Posts by vividsailor7

George Doyle9 said:Can someone please give me some advice? Should I be looking into more tests because my prolactin is elevated (704.4 mU/L, while the normal range is 72-511) and my free testosterone is at 0.0227 nmol/L (normal range 0.004-0.039)? This is actually my third time checking hormones, and it’s the first time I’ve had my free testosterone checked. In all my previous tests, my prolactin has always been high, but my doctor just brushed it off as stress. Everything else seems fine.
I'm 28, and I've been dealing with excessive hair on my stomach, chest, face, and back since puberty. But lately, the hair is getting longer (like 5mm) and darker. From a gynecological standpoint, everything is supposedly "fine," which is why my primary care physician hasn't referred me anywhere. There isn't a single person in my family with this kind of hair growth issue, but it's driving me absolutely crazy. For years, I was plucking the hair around my nipples with tweezers, and now I've been using depilatory creams on my stomach based on a dermatologist's suggestion—but they just give me breakouts, and I feel like I have to redo it every other day because it grows back so fast. I honestly feel like I'm making things worse. Am I just going to keep getting hairier? Is there any way to actually fix this permanently?

It wouldn't be a bad idea to check in with a gynecologist about whether you need hormone therapy.

Chloe Thompson66 said:So, I was looking back at my specialist endoscopy report from about two and a half years ago, and it says right there: "Endoscopic hiatal hernia, HP newg"
But I only just noticed that part in the report! I mean, I remember the doctor who did the procedure mentioned there was "something small"... he didn't really say anything specific, just kind of implied everything was fine??
Now I'm totally confused about what his actual diagnosis was. Like, what even is this hiatal hernia thing if he didn't bring it up as a big deal? He just told me to stick to a certain diet and that was it.

I think I figured out what it is on my own, but I’m wondering—can it actually get worse over time, or maybe shrink or just disappear? And do I seriously need to go in for another endoscopy?
The thing is, I haven't actually followed up with the doctor since then because I was supposed to get some other tests done that I just never ended up going to...

That’s a clean report.
Just keep living your life exactly like you were before.
No follow-ups or extra testing required.
Everything else they told you is all there is to it.

Jeremy Grant said:Hey everyone,
Has anyone dealt with acute pancreatitis before? Also, wondering if you can start the process for disability benefits.

That really depends on what underlying conditions you have, as well as how severe the actual attack itself was.

Karen White4 said:Where can I get a 2-hour OGTT done along with insulin levels?
I need to know where—specifically looking for fasting and postprandial testing.
thanks
It's urgent! Where am I going to face the shortest wait times for this??

Mayo Clinic,
SK Vuk Vrhovac,
Mount Sinai.

stormytinker4 said:Thanks so much for the reply!! He’s been taking one Lasix tablet a day for three days now, but honestly, there hasn't been any improvement whatsoever regarding the swelling... I'll definitely suggest those tests you mentioned to his doctor...

I have no idea what his serum electrolyte levels look like right now, but let’s be real—it's highly unlikely he's going to see any actual relief from just taking Lasix.

melloworca6 said:vividsailor7, take a deep breath and actually try reading what people are saying to you for once.

First off, you’re talking trash about your own colleagues. 👎 Second, you’re asking the AMA to turn against their own superiors. Look, Medicare is the one calling the shots for them, so they have to follow those guidelines. Since you’re so hell-bent on having them defy their bosses, tell me—are you going to go against your department head? Or the hospital director? See, going against a director or a boss is hard enough, but trying to fight the entire Institute? That’s just suicide.

I know plenty of cases where specialists acted like cowards and refused to push back against their bosses, even when they disagreed and we were dealing with serious illnesses. I won’t get into specifics because I’m not exposing people close to me online, and since it’s specific, anyone would know who I’m talking about, but there it is. A few of them didn't agree with the boss's decision, so they’d pull a patient aside and informally mention they didn't agree, but at the end of the day, the boss made the call and they had to roll with it. Then these same people come crawling in here, acting like primary care doctors aren't fighting windmills, as if they aren't up against an entire government agency and the whole system. 🤣 Give me a break.

Honestly, they aren't just paper-pushers, no matter how much they get belittled. They have to manage the Institute on one side, furious patients on the other, and doctors who do whatever they want and couldn't care less about anything else. It isn't easy.

First off, I have absolutely nothing good to say about the PZZ.
I honestly couldn't care less about whatever drama is happening between Medicare and the American Medical Association. That's their business. They need to act exactly how we tell them to, because that’s where the real story begins for us. Period.
Look, you're talking to me here—which is standard for a forum like this since it’s just you and me hashing this out—but let's be clear: I'm following the guidelines set by my professional association. Every specialist who actually respects the standards of their medical society does the exact same thing. So, this isn't just about my personal opinion; there's a whole lot more at stake here than just my two cents.
Thirdly, regarding the whole "bad boss" argument—those situations are way more nuanced than people realize. Honestly, if you don't actually work in a hospital setting, you really shouldn't be commenting on it. As for the kind of generalizations you just made, Nicholas Myers already pointed out how pointless that is unless we're talking about specific, concrete incidents. Now, look, I’m NOT suggesting you go out of your way to list them all right now, but if you aren't ready to get into the actual details, then don't bother bringing it up at all. It’s just plain stupid to claim someone was "denied" something without any proof to back it up.

Morgan Morgan5 said:Sir,
I honestly don't understand why you feel the need to use such a tone. I will admit, I agree that "that dentist" is mostly just blowing smoke because he can't actually do anything to hospital specialists (other than, of course, the state adjusting your on-call pay slightly)—but this affects all of us working within the system in one way or another. If I—someone working in the pharmaceutical industry—am saying this to you, who is right there on the front lines, it isn't because I'm trying to play the hero. It's simply because I know how hard all of you work and how much of yourselves you pour into these patients. So, what does it cost you to meet them halfway when the system fails them?

So, what kind of tone am I supposed to be using? Honestly, compared to some of the people on here, I think I'm doing just fine.
As for meeting people halfway—and I assume you're talking about the patient here—I’ll go out of my way for them. In fact, I can honestly say I probably go too far sometimes.
Take that first column example. Where I noted "IBD vs. prescribing Salofalk, Cipro, and Budosan"—I could have just bluntly stated that you’re stuck waiting two weeks for pathology results, plus another two weeks just to get an appointment at a GI clinic. I could have written that with a completely straight face! And then the Medical Ethics Board wouldn't have issued a single thing. I also brought up managing other chronic conditions, like Diabetes or HIV diseases.

copperlynx22 said:It seems we aren't quite on the same page here.

vividsailor7 mentioned a situation where a primary care physician refused to prescribe a more expensive therapy to a patient who arrived with a specialist's recommendation, but if I understood correctly, that wasn't actually about generics. Back before the current reforms, Medicare eventually sided with the specialist.

I believe his concern lies in the possibility of such a scenario recurring. It isn't a matter of whether someone receives Bayer Aspirin or Pfizer (to use a loose analogy), but rather whether a patient can access an insulin analog if their endocrinologist determines it is necessary over standard insulin—or if a GP will deny the prescription simply because they deem the switch unnecessary.

I won't get bogged into the technical nuances between analogs and non-analogs, but the crux of the matter is that analogs lack generics and cost twice as much, even though they are all included on the essential drug list.

As for what you said about that, you're spot on.
And regarding the insulin issue, unfortunately, Medicare didn't approve it; I already wrote about that in another thread. To reiterate, we're talking about Lantus, which the endocrinologist prescribed twice in one year for a patient previously on NovoMix—I believe it was twice daily plus Metformin—with an HbA1c that I recall being around 8.0 or 8.5%.

Kimberly Richardson56 said:Thanks.

Don't mention it. If you need anything else at all, I'm right here.

Peter Reyes63 said:I'll share my story then... I'm allergic to G3, G4, G5, G6, and G8... ragweed, field poppy, cocklebur, meadow grass, and timothy.
..I got tested once... They took blood and on a scale of 01 to 17.5 (anything over 17.5 is extremely high), I scored 72.2..

What should I do... do I need to start taking pills or what? I didn't even know I had an allergy until I started sneezing like crazy this summer. It's not a massive problem, just irritating when I can't breathe through my nose.

I'm clueless about allergies and how to manage them. So, I figured I'd ask for some advice here. About two months ago, I went to the doctor because my nose was totally stuffed up. I don't remember which spray I used. Diagnosis: Allergic rhinitis. He told me to get Nasonex and spray it twice a day, morning and night. He also said to use Quixx a few times a day. Honestly, I felt better immediately.

Anyway, two months have passed, and for the last few days, breathing has been hard again. Should I just follow exactly what he told me and stick to the same spray routine, or...?

Thanks in advance!

Nasonex is probably your best bet. For antihistamines, you could try Alerdin 5mg, either on its own or paired with a leukotriene antagonist like Monlast 10mg.

Dana Smith13 said:The questions you’re asking are strictly medical. Honestly, unless you're talking to your own doctor, nobody else can truly grasp the specifics of your treatment or the actual progression of the disease. That said, I want to shift your focus toward things you *can* actually control—actions you can take right now that will show results fast, regardless of where the illness is hitting you:

First off, I strongly suggest cutting out anything from your diet that weakens the body and fuels disease progression. We're talking refined junk: margarine, processed oils, white flour, and more. Toss out the meat and deli meats, milk and dairy products, and all kinds of simple sugars—refined white sugar, honey, and even raw fruit.

Second: ramp up your intake of whole grains (brown rice, buckwheat, millet, barley, oats, amaranth, etc.), legumes (lentils, chickpeas, beans, peas, navy beans...), leafy greens, and root vegetables.
Fall is coming. Pumpkin can be prepared in a hundred different ways and absolutely should be part of your daily menu.
Don't forget spices. Ditch those standard industrial seasoning blends, paprika, pepper, and whatever else; swap them for natural spices instead. I highly recommend using plenty of miso (fermented barley or rice).
And definitely use high-quality supplements: Immune support formulas, various probiotics, green magma, spirulina, and so on.
If you manage to implement these changes, your health status should improve rapidly. You might even find yourself forgetting why you were even waiting to restart therapy.
Regards

Regarding the bloodwork—that's just not true. There are clearly defined protocols being followed, not just doing whatever someone feels like doing.
As for the diet, while it isn't inherently "bad," there's zero benefit to it if you aren't following it properly. Is it any different than, say, cutting out meat, dairy, or olive oil?

Kimberly Richardson56 said:Thanks, but unfortunately, we already know all about that whole relapse into drinking business.
During my very first hospitalization last November, things were looking incredibly grim. I don't have the lab results on hand right now, unfortunately, but the situation was dire: I was dealing with arrhythmias, high blood pressure, and fluid buildup in my abdomen—I think they specifically used the term "ascites."
So, I’m sitting here wondering: did he just make that up on the spot? Or is it actually physically impossible for those levels to bounce back that quickly? Honestly, there's a third possibility that's even more frustrating—maybe things have taken a turn for the worse, and that's why the numbers only dropped to 170 instead of going down further. It doesn't add up.
Are we talking about days here, or are we looking at months? I mean, how much time does it actually take for a lab result like that to swing back into the normal range?

I also want to know: does having just one glass of red wine a day actually count as abstinence? I’m asking for someone who used to go through these intense benders—we're talking about six times a year where they'd drink non-stop for weeks on end without any breaks. During those stretches, they were knocking back at least a liter of wine, plus several hard liquors and maybe a few beers here and there. Then, during the periods when they weren't "drinking," it was still "only" a few drinks every single day. Does that one glass even move the needle?

He hasn't touched a drop in 12 days now. Tomorrow, he’s heading to a private lab to get that GGT retested because—get this—he actually doesn't trust the results from the hospital. (Are you kidding me???!!!)
As for the fallout, walking has become a real struggle right now—it feels like some kind of alcoholic neuropathy given how weak my legs have been feeling lately. On top of that, there's this overwhelming sense of lethargy. I'm currently on four different medications prescribed by an internist back when I had my first hospitalization; one is for blood pressure, and I’ll have to double-check the names of the other three.
He’s currently taking Vitamin B (Neurobion, two tablets—he just started this), Vitamin E, Milk Thistle (for his liver, a herbal supplement), and Ginkgo.

Right now, what I’m actually most curious about is the pace at which that GGT level drops—specifically, how fast it usually goes down if it's even possible to estimate.

Ascites is nothing more than free-floating fluid buildup in the abdomen. Period.
Based on the meds, it looks like they’re likely on a regimen of Lasix, Aldactone, and maybe some Inderal or Carvelol, among other things.
Neurobion and Milk Thistle can stay, but everything else is completely pointless.
If his neuropathy is really getting to him, we could look into starting him on Katena or Lyrica.
When we're talking about abstinence—if we're being strictly technical—this isn't actually true abstinence. But, honestly? Given everything else that's going on, you can be relatively satisfied with where things stand.
GGT is incredibly volatile. It’s all over the place because it depends on so many different factors—everything from the specific stage of liver or kidney failure to just how much stress your system is under. You can't just look at one number and call it a day; there's way too much going on behind the scenes for that.

Robert Adams88 said:Dr. Harvey, everything else looks fine, except for my uric acid being slightly elevated and, of course, that total bilirubin which is absolutely going haywire.

I can only restate exactly what I said in my previous post.

Jamie Barnes15 said:embryonal 95% + 5% immature teratoma
The markers look normal, everything else seems fine except for what I just wrote.

wanderingcobra76 is right, but since the labs are stable, I seriously doubt we're looking at a primary disease here.

stormytinker4 said:on top of that, his feet and ankles are swelling😢 ...

The coughing—it started bloody, then turned black, then gray, and now it’s lighter, sometimes even yellowish, almost like smoker's cataracts.

If his legs are swelling, you need to check heart function first (EKG, TTE, chest X-ray, NT-proBNP, CK, CK-MB, arterial blood gas) and kidney function (urea, creatinine, urate, 24-hour creatinine clearance, proteinuria), because he might be struggling to breathe due to heart failure and potential respiratory insufficiency.
And if he's coughing up yellow stuff, it could be an infection (if he has COPD, it could be a COPD exacerbation), so regardless, getting a CBC and CRP done would be smart, along with starting an antibiotic like Amoxicillin 500mg once daily for 10 days.
But obviously, before any of that, you actually need to perform a meaningful physical exam.

swiftbear86 said:It isn't about misleading patients; it's about following the official lists and Medicare guidelines.

The real question is why specialists aren't taking these issues to the drug commission to influence Medicare, rather than letting the hospital get penalized by having their budget slashed just because they didn't follow Medicare's specific rules.

After all, there are doctors sitting on that commission.

http://www.medicare.gov/guidelines

Felix - that's an excellent point you made at the end.
Once Medicare starts holding specialists accountable, things will actually start to change.

In my view, a patient should receive the best possible treatment based on medical standards. Specialists in certain fields should sit down with the commission and work it out, because right now, it feels like it's just a group of doctors who aren't even sticking to professional medical standards!!

Look, I couldn't care less about Medicare's guidelines. Honestly, their rules don't affect my life one bit, and frankly, I have zero interest in whatever kind of relationship they have with the American Medical Association. It’s all noise to me.
As for actually punishing these specialists? Honestly, it’s just not going to happen. You might be able to squeeze some accountability out of the smaller local clinics, sure, but trying to go after someone at a major institution like the Mayo Clinic? Forget about it. There isn't a damn chance.
On top of that, they’ve had that option to enter the LOM code since around November of last year, and as we can clearly see, absolutely nothing has changed. Not a single thing. That dentist is just all bark and no bite—nothing but empty threats.
And if—by some miracle, which I find absolutely impossible—they actually go through with it, I’ll be more than happy to send every single patient scheduled for a colonoscopy or an EGD straight to Medicare, just like they do with that insignificant dentist.

melloworca6 said:I don't want to drag this debate out on that other thread since it's already blowing up here, so I'm moving the quote over.

And this isn't being "okay" toward your colleagues. 🤷 Sorry, but Medicare is king here. It's not like we have some other independent agency to turn to, so we're stuck with them, and apparently, you think you can just pick favorites. If they are the authority and they say a drug can't be covered without paying out of pocket, and you intentionally write prescriptions for drugs you know aren't on the basic free list—and then you go as far as telling patients to sue the medical board—then you're just being disrespectful to your peers. Honestly, it doesn't surprise me that they hang up on you or act rude.🤷

We all know how drugs get added to the Medicare list. You should all get together and pressure them to include what the experts actually recommend instead of screwing over the patients. As if being sick isn't enough, we don't need doctors fighting amongst themselves and pitting people against each other.

Look, Hrvoje, I get that you write what you think is best, but damn it, we don't live in a utopia. You can't just take the "not my problem" approach. How are you supposed to collaborate with other specialists when things get serious and require a team effort if you're busy bickering over fucking medications?😢

It’s not that I’m being unreasonable—it is actually exactly the opposite. They are the ones being completely reckless and irresponsible because they refuse to dispense the medication.
I honestly don't get it—how on earth can a doctor just accidentally prescribe a medication? Seriously, how does that even happen?
My own family can't even get online anymore—they've basically degraded themselves to the level of an SKZZ clerk.
I’m going to say this one more time: Medicare and its endless, bureaucratic rules have absolutely nothing to do with me!
When it comes to how everyone is working together on this, first off, the SKZZ is completely unified. As for the meds and those internal prescriptions? Honestly, only a few smaller hospitals are even handing those out—I’m not even sure if anyone in a major city like New York does that anymore.
To answer your original question: honestly, when I deal with most doctors, clinics, or medical institutes, I rarely run into any issues at all. It’s just a matter of finding the right people.

restlesspanther42 said:Moving this quote over here too.

I've had enough.
The whole damn Mayo Clinic is talking about my post, and now it’s been tossed straight into the trash.

Nicholas Myers said:Well, I see what you mean ( : OKP : ), but I have no idea how to split or merge posts without making a total mess of things.

The topics are clearly linked.

I think it’s best to just leave it as is for now. We'll see how it plays out.

That said, I agree with your observation; actually, I wrote something very similar on another thread.

vividsailor7, I hear you, but I think you're missing the mark on one point. This isn't about the AMA being stubborn (though, granted, some of your examples involve both stubbornness and unprofessionalism, but that's beside the point)—it's about the fact that they'll be penalized if they don't follow orders.

Think about it this way: if you were supporting a family on your salary and someone threatened to cut your pay in half or fire you, would you still pick a fight you can't win, or would you just do what you're told?

Suppose Medicare decided that any specialist who doesn't prescribe medication strictly according to their specific guidelines would face a pay cut. How would you react then?

Honestly, let them face the consequences. I couldn't care less.
And honestly, I see that termination notice as nothing more than a "eat or be eaten" ultimatum. If you aren't performing perfectly, they’ll come for you. It's pure predatory behavior. Trying to actually enforce any kind of disciplinary action through the SKZZ is basically impossible anyway—maybe you could get away with something minor at an OB, but trying that at a local Clinic or the Mayo Clinic? Forget about it. They wouldn't stand a chance.
And some run-of-the-mill dentist over there is going to end up handling colonoscopies, EGDs, EUS, treating GI bleeds, and all that? Unbelievable. I mean, seriously? The waiting list for a basic colonoscopy in my area is already stretching into its second year! It’s absolutely ridiculous.
And don't even get me started on interventional cardiology—we haven't even touched on TEE, TTE, coronary angiograms, and all that other heavy-duty stuff yet.
Regarding that last point—I already told you guys about my colleague, the diabetologist over at Holy Spirit. She reported the Januvia and Inegy prescriptions to Medicare, and the Institute confirmed she did everything by the book. Of course, the LOM went absolutely ballistic about it. Typical.

velvetmoose9 said:Medicare basically holds the keys to the vault.
With that kind of power, Medicare gets to decide what’s covered and what isn't.
The problem is that Medicare doesn't always play by the same rules as the actual medical professionals.

Just because something is "legal" doesn't mean it's actually fair.

Well put.
Look, I couldn't care less about Medicare and their endless, suffocating guidelines. Honestly, who actually gives a damn?

Morgan Morgan5 said:This is absolutely true. A general practitioner shouldn't be prescribing something that goes against Medicare guidelines. A hospital specialist should be fully aware of those protocols; instead of passing the buck to a GP and saying, "Well, let them deal with the headache and explain it to the patient," they should be warning the patient that while they believe a specific therapy is better, it unfortunately isn't covered for free under current rules. If you truly believe the Medicare guidelines need to change to match modern treatment protocols, then send a formal petition to Medicare—or better yet, write to the medical boards and get a story out in the news.😁

Not one single bit of that should be handled by some hospital specialist or the SKZZ.

Robert Green93 said:How long does it actually take from the moment the lab techs finish drawing my blood until they ping the doctor with the results online? And I’m talking about a scenario where there isn't a massive line out the door—just me sitting there waiting.
Regarding that doctor I have to see after my bloodwork comes back.
I’m asking because I just spent seventy minutes standing around waiting with someone the other day. ☕
We were the only ones there! Alone!

If an emergency search at HSBC returns results within an hour or two regardless of whether you’re a client or a stranger, I honestly don't see what the big deal is. It seems like everyone here is under this massive delusion that the second a technician draws blood into a vial, the results just magically pop up on a screen instantly. Real life doesn't work that way.

I can't even begin to wrap my head around this level of incompetence. It’s absolutely infuriating! Every single time I think we've hit rock bottom with these ridiculous policies, someone finds a way to dig even deeper. It is pure, unadulterated chaos, and frankly, I'm sick of pretending it's anything else. How much more of this nonsense are we supposed to just sit here and take? It's an absolute joke. kaže:
If you’re heading in for a full hematology workup, should you be eating beforehand, or is it a no-go? I’ve been scheduled for an appointment in the afternoon, and honestly, I don't know if I can actually make it through the entire day on an empty stomach. To make matters worse, nobody at the hospital is picking up the phone to give me a straight answer. Does anyone here happen to know the drill?

For heaven's sake, why on earth wouldn't you be able to eat it? Where on earth do you even get a question like that from?

Nicholas Wells74 said:I have a question regarding my intake for psychiatric treatment.
If I submit a request for inpatient psychiatric treatment, and we’re looking at a situation where dozens of people are filing those same requests every single month while hospital capacity is already razor-thin—how does it actually work? What specific criteria are these psychiatrists using when they sit down to decide whose application gets approved and whose gets tossed in the trash?
Does anyone actually publish those departmental waiting lists publicly? And if the answer is yes, does that list just lay out everyone's full names for the whole world to see? Or is there some actual privacy involved where patients get assigned a code—something only they and the doctors can use to track their spot on the list?

Whether or not you need inpatient treatment isn't up to anyone else—it’s entirely at the discretion of your attending physician. In this specific instance, that means the psychiatrist makes the call.

bluecrane16 said:I’ve got a question to toss out here, but I’m not entirely sure which thread this belongs in. Can a moderator please move this to the right section?
Does a patient actually have the right to request a referral for a second opinion from a specialist? Or are we strictly limited to just one single opinion? I’m also wondering if there’s a specific list of diagnoses where a primary care physician is required to hand over a referral, versus cases where they can just flat-out refuse. Does it all just come down to whether the doctor feels like being helpful, or is there an actual protocol in place?

It does.

restlesspanther42 said:If anyone actually cares, this explains what the new guidelines mean and how you're supposed to handle them.

@vividsailor7
Sure, you can tell a patient they have a right to a specific drug, but you're required to include a clause on every single one of your findings stating that Medicare has the authority to issue a different drug of equal strength from the same class.

Here’s the directive as well.

That "clause" is just another ridiculous fabrication.
As for that memo, I don't recall reading it myself, but back then (early March), my colleagues and I were basically making fun of Varga and the American Medical Association, so that was probably what we were talking about.
And as for the actual document? It’s probably been shredded or used as a coaster by now.

Kyle Lee7 said:1. She admitted herself that she doesn't know certain things; when I ask her directly, she looks me in the eye and tells me she doesn't know. Even regarding Vitamin D and its impact on MS, I had to find all that information online myself. When I brought it up, she told me she'd never heard of it and wasn't even sure if Vitamin D testing was even performed anywhere in the US...
Since I'm living with MS, I'm personally invested, so naturally, I dig deep, read up, and educate myself from every possible angle—which means I'm at least one step ahead when it comes to new research and developments. Of course, I don't know everything better than she does; I'm certainly not an expert on brain anatomy, but it really bothers me that if she treats patients with MS, she should at least stay current on the latest news...

2. Given that asthma either stays quiet or results in an acute attack, the question becomes: when and why should you go to a pulmonologist? When it's dormant, I stick to the regular prescription I've had for over 12 or 13 years; when an attack hits, then it's an emergency.

When it's quiet, I don't need a specialist, and when it's active, I'm physically unable to make it to a specialist's office.

My pulmonologist doesn't work out of a hospital and doesn't have a small clinic once a week; she works at a community health center in the pulmonary department where there are about ten of them, seeing patients five days a week during all working hours. Essentially, her entire job is seeing patients. So why can't she see a sick patient?
Naturally, I'll go wherever they are willing to see me. I tried once to see the pulmonologist when things weren't quite critical yet, because I wanted to understand why my stable condition had suddenly started worsening. She would have been the best person to tell me, but the people in the ER are just there to put out fires, and Urgent Care acts the exact same way in those situations.
The situation was such that she could see in "real time" how my lungs were behaving and hear it firsthand, rather than me having to recount everything that happened a month after the fact.
I truly don't understand why a pulmonary specialist would have an issue with someone coming in during a flare-up, instead of letting someone who *isn't* a pulmonologist deal with it by calling 911—is that how it works?

Or, if you mean the specialized pulmonary emergency units, like the ones at major city hospitals—unfortunately, I've had the chance to assist someone who was practically dying there a couple of times. I swear, I will NEVER set foot in that hospital or deal with those employees again, no matter the cost. What we experienced there, multiple times, was enough to warrant a lawsuit. The only reason I didn't pursue legal action was that I just wanted to forget the whole ordeal; otherwise, I would have ended up in a massive multi-year court battle. I'm drifting a bit from the topic, but I seriously believe those people are responsible for the death of someone close to me. The behavior of certain staff members, the lack of equipment, and letting a person who is suffocating wait in a hallway while the ER doctor and technician enter five times to literally beg the attending physician to start the exam... all while she and the nurse respond rudely, acting like they're just waiting to go paint their nails. Even today, it still makes me sick.😠
The worst part about it is that in NYC, Jordanovac is the only pulmonary emergency center, so...🙂

1. She DOESN'T have to know about Vit. D. As far as I'm aware, it hasn't been included in any official neurological society guidelines yet, even if the research exists.
2. An acute asthma attack is treated with two puffs of Ventolin, and if that fails, you go with 80mg IV Medrol. For severe cases, it's Aminophylline 250 IV along with Oxygen. Why on earth do you need a pulmonologist for that?? There's zero point in changing therapy over a single attack.
Furthermore, you don't go to the municipal hospital for emergencies; you go to the local hospital based on where you live for internal medicine or HS. Every time I'm on call, I have at least 2 or 3 asthma or COPD patients.

Jessica Chavez4 said:What exactly is the PZZ?

Primary health care.

swiftbear86 said:We’re currently hitting the same topic across two different threads, so I’ll leave it to the moderator to decide which one stays active for the discussion.
I really don't get why there’s this constant friction between the AMA, the specialists, the patients, and the pharmacies.

My approach is always the same: I tell patients that the specialist prescribes the specific therapy they believe is best for the diagnosis. Then, the AMA has to figure out if they can authorize an Rx under Medicare or if they have to issue a private prescription, which means the patient pays full price out of pocket.

The tension would be a lot lower if specialists warned patients upfront. Sometimes people simply can't afford the medication, and when that happens, the entire treatment plan just goes down the drain.

The whole "argument" boils down to one thing: the pharmacist refusing to fill the Rx. That's the bottom line.
As for the rest of this nonsense, it feels like nothing more than misleading the patient.
A specialist doesn't need to provide a warning label for every script; they prescribe the appropriate therapy, period. The pharmacist's job is to dispense it exactly as written.

swiftbear86 said:So, does this mean Medicare is going to tell hospital specialists they have to write down the generic name, while leaving it up to the primary care doctor to decide which specific brand actually gets prescribed?

Otherwise, there’s just no point in specialists bothering with the brand names at all.

Right now, we’ve got a situation where specialists aren't even following the Medicare guidelines for prescribing therapy. It leaves the patient stuck in a loop—the doctor tells them they don't qualify for the recommended drug under Medicare coverage, so their only option is to pay full price out of pocket using a private prescription.
Take stuff like Plavix, Preductal, or Singulair, for example...

Why on earth shouldn't they be allowed to write the brand name??
Patients have every right to be pissed off because they were given medication based on professional guidelines, and they have a right to receive it at no cost.
As for why the American Medical Association is denying them—honestly, I should probably say it's none of my business, but lately, we’re constantly having to call out the AMA regarding medications. To make matters worse, they’ve become incredibly arrogant recently; for instance, they won't even listen if you tell them $167 you're spending a fortune on meds every month—they just don't give a damn about what happens down here.

swiftbear86 said:I agree that a specialist should prescribe based on medical standards, but they also have to keep Medicare guidelines in mind (since the healthcare facility is a contracted partner of Medicare). They need to explain to the patient upfront that for a specific diagnosis, Medicare won't cover it, meaning the patient will have to pay the full price themselves.

The guidelines for the Medicare drug list are located at the end of the list, where a code consisting of letters and numbers is decoded.

For example, the Plavix or Pigrel mentioned above are covered by Medicare for a period of 3 to 12 months following a procedure.

Guideline RB01
For treating patients after a bypass or stent placement, per the hospital specialist's recommendation, lasting from 3 up to a maximum of 12 months, depending on the type of stent.

Code ATK B01AC04 111

Brand name: Pigrel

Prescription Type: RS

Manufacturer:
Johnson & Johnson

Generic name - INN: clopidogrel

Method of administration: O

DDD and unit: 75 mg

Price per DDD / $: 5.31

Dosage form: film-coated tablets 28x75 mg

Price per unit without tax: 5.31

Price per unit with 5% tax: 5.58

Price for original packaging without tax: 148.78

Price for original packaging with 5% tax: 156.22

Price in $ without tax for single unit paid by the agency:

Price in $ with 5% tax for single unit paid by the agency:

Price in $ without tax for original pack paid by the agency:

Price in $ with 5% tax for original pack paid by the agency:

Co-pay in $ without tax paid by the agency:

Co-pay in $ with 5% tax paid by the agency:

Co-pay in $ without tax for original packaging:

Co-pay in $ with 5% tax for original packaging:

Main therapeutic group ATK: Drugs acting on the blood and blood-forming organs

Subgroup ATK: Platelet aggregation inhibitors (excluding heparin)

List: basic

NOTE indication / guideline: / RB01

I don't have any interest in following some arbitrary set of rules, and frankly, I don't want to. The only guidelines I care about—the only ones that actually matter—are the official standards set by my profession. Period.
Period. Full stop.
I am being crystal clear when I tell my patients: you need to listen. Does someone actually have a right to demand prescription medication?
Look, if the insurance company denies the claim and blocks a patient from getting their medication again, I’m going to call them out directly. I'll make it crystal clear: I couldn't care less about Medicare's little guidelines or their threats of penalties. I don't care if they want to fine me. Period. I treat my patients based on the standards set by the American Medical Association, not some bureaucratic checklist. If I recommend a specific medication, then that is what gets prescribed. It’s that simple. You and Medicare are following the exact same playbook used all over the world, and because of that, a patient could literally die. It's reckless. I don't give a damn about Medicare's protocols; you are the ones denying the patient their medicine. Why even bother sending the claim in the first place if you're just going to block life-saving treatment?
And there they go again, blathering on about those guidelines like they actually know what they're talking about. They act so incredibly condescending, too—half the time they just slam the phone down in your face before you can even get a word in edgewise. Typical.
I only ever caved once, and that was only because she told me she couldn't care less if I decided to step up. $333 Monthly medication coverage for patients? Give me a break. They act like I’m living in some twisted Wonderland instead of reality. It's absolutely absurd.
I’ll tell them they should just go ahead and change their insurance provider or, better yet, file a lawsuit or report the whole thing!
Since we’re on the subject of cardiac medications, I have to bring up my own situation involving my father. It’s been a nightmare. He’s dealing with uncontrolled arterial hypertension and diabetes, plus he’s a post-MI patient with unstable VT and COPD. His current regimen includes Januvia, Clopidogrel, Preductal, Losartan, Foster, Sorits, Ramed, Nexium, and Nebilet. To make matters worse, the doctor actually refused to prescribe the first five of those! I had to step in and intervene myself just to get him what he needs. Honestly, it is an absolute disgrace.

Nicholas Myers said: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. 🙂

To be perfectly honest, I don't get it. I really don't. This whole idea of what exactly is being tallied for whom? It’s completely unclear to me.

melloworca6 said:Unless they start slapping on more restrictions—like strict mandates or tracking exactly how many times a doctor checks in on a patient—I highly doubt the primary care office is going to shoulder that much liability just to go against what a specialist recommends. 🤷

I don't see any reason why anyone would bother doing that unless Medicare is breathing down their neck and throwing penalties left and right—but hey, we'll see how that plays out.

Morgan Morgan5 Asks:
It honestly makes me sad when people who don't have a clue about the profession start posting their opinions without doing any actual research first. Whether they’re doing it on purpose or just being lazy, they end up spreading nothing but misinformation. You see it all the time with journalists today—the hacks at the local news stations and those big cable networks. As far as medications go? Nothing. Absolutely nothing important is actually changing. For the patients.I'm talking primarily about prescription drugs—not the stuff they just hand out to you in a hospital ward. If prices actually drop, the pharmaceutical companies are going to take the hit first. And that’ll ripple right down to the doctors, too, since those big pharma outfits are the ones footing the bill for their "educational" seminars (or, let's be honest, just paying for their trips).

Look, we patients all read the same sensationalist garbage in the papers. The way they write things makes everything sound so murky just because they need clicks. I’m not exactly an expert—I'm definitely a layman—but I know enough about how things work to realize I totally misread the text. What do you think it’s like for someone who hasn't a clue how any of this works, especially when their only source of info is some tabloid churning out the same nonsense?

We’ll just have to wait and see how much this new policy ends up crushing the patient. All this back-and-forth between specialists and the insurance providers—it’s the patient who ultimately pays the price. It’ll be interesting to watch once the insurance companies get the final word on everything. Truth is, plenty of things are already being swept under the rug. Terrible stuff that people mostly stay quiet about. You know how it goes: there are limits on certain tests and caps on specific medications. You end up waiting two or three months for a basic lab test because they ran out of reagents or blew through their monthly budget. Or you have oncology patients sitting around waiting weeks for their treatment because the monthly quota was hit and the funding for those drugs just ran dry. It happens.
You aren't going to convince me that we won't feel the fallout of this. Every single time they roll out some new reform or set of regulations, it’s the patients who end up paying the price.

Unbelievable. Apparently, this new regulation kicks in on September 1st, so let's just sit back and see what "wonderful" surprises they have in store for us. And look, I'm with you on one thing: I honestly don't care what a drug is called as long as it works and doesn't wreck my body. I couldn't care less if it's the brand name or a generic, unless that cheap version actually performs worse.

edit: And get this—over on the other thread, people are saying exactly what I've been hammering on about here. They're claiming Misar hits harder than Xanax or Helex. Yeah, I get it, it's the exact same medication under a different name, but clearly, for some reason, certain people respond better to one brand over another in the same class. How? Why? Is it a placebo effect, or are they lying to their doctors? 😁 I don't know, but it's not the first time I've heard someone swear that a version from a different manufacturer works significantly better.

See? I told you! This proves that if they had actually stepped up and enforced the mandatory generic substitution policy earlier, oncology patients wouldn't be struggling to get their medication right now. It’s exactly what I’ve been saying all along.
There is no such thing as "the best" or "the absolute worst." Period.
See? This is exactly what I’m talking about (honestly, half the time I believe these stories and the other half I think they're total nonsense). It turns out the generic version actually outperforms the brand-name original.

swiftscout8 said:Exactly. They started shutting down labs in community health centers, diagnostic departments, and things like that. For instance, the lab at the downtown clinic just closed its doors. What is that even supposed to mean? Now everyone is being bounced around from one lab to another; they sent me all the way out to the Railroad district.
When I see an attending physician, everything they do boils down to antibiotics, referrals, or maybe some vague guidelines. Though, in my case, they actually put in some effort. There are plenty of doctors out there who won't even look at you; they just process whatever paperwork you bring them.

With all due respect, specialists sometimes go overboard with diagnostics and treatments. My latest headache is a CSR in my right eye that’s been dragging on forever. They literally ran me through the wringer: neurologists, head MRIs, optic nerve scans, vertebral artery imaging, visual field tests—you name it. They kept swearing it was a neurological issue. And all this happened without anyone performing a basic, and I mean basic, ophthalmological exam. They harassed me for two years, and then my primary doctor simply told me he wasn't going to dig any deeper because we weren't getting anywhere. I couldn't let it go, so I went to a private eye clinic. They did the basic diagnostics and I walked out ninety minutes later with a diagnosis and a treatment plan. It’s a perfect example of how aimless wandering hurts the patient, and how an attending needs to realize when a path is counterproductive and leading nowhere.

Since you guys decided to quote my post, I honestly have no idea what I'm even supposed to say in response.

I can't even begin to deal with this level of absolute nonsense right now. Honestly, it’s exhausting. Every single time I think we’ve hit rock bottom with the sheer incompetence on display, someone finds a way to dig even deeper. It’s pathetic. Truly. I’m sitting here staring at this mess and I just want to throw my laptop out the window. How does anyone function like this? It's a joke. A complete and total circus. kaže:
Can someone please clear this up for me? I’ve been managing my thyroid issues with an endocrinologist in a different city for two years now. Am I allowed to just keep seeing my current specialist, or am I going to be forced to handle all my checkups and tests at the hospital closest to home?

In my opinion, it all boils down to your individual LOM.

Kyle Lee7 said:I have a follow-up question regarding this whole "residency" issue.
I live in Brooklyn, but I see specialists at various different hospitals depending on what I need—sometimes it's an appointment, sometimes it's just where I end up needing care.

For example: Neurology is at Mayo Clinic plus some private doctors; Neuro-ophthalmology is at Mayo Clinic; Pulmonology is over by Barun Filipović; Ophthalmology (for contacts and glasses) is at Vinogradski; Gynecology involves my records being kept in Silicon Valley plus a private specialist; and my dentist is in Savica.

Does this residency rule mean I’m suddenly going to be kicked out of Mayo Clinic where I've been a patient for years, or from my dentist's office too?

Regarding the idea of primary care physicians taking on more work—it isn't a bad concept in theory. However, after decades of them writing prescriptions and referrals while juggling upwards of 90 patients a day, how can we honestly expect them to suddenly transform overnight into Renaissance doctors who know and manage every single niche detail?

My own doctor is actually really nice, but she honestly doesn't know nearly as much about MS as I do! Just a few months ago, she didn't even know where in NYC one could get Vitamin D tested or what specifically to write on a referral. I ended up looking it up online for her, including finding the location where I could go (at Vinogradski, without an appointment, where they email the results a few hours later, versus waiting three months for an appointment at Mayo Clinic and then waiting even longer for the results). She basically just waits for me to show up with a list of tests—tests that I track myself, because if I don't remember them, she won't either...

As far as where we actually live goes, I honestly don't think this is going to affect anyone living in NYC.
Look, her waiting around for you guys to show up with a complete list is one thing—I get that. But claiming she has no idea what's going on? That is a flat-out lie.

Kyle Lee7 said:In principle, the idea behind this is actually quite good because there are so many logical gaps in the current system. Of course, new ones will pop up, they'll just be in different places.

The worst part, though, is the patients themselves—people who visit doctors, get a whole stack of prescriptions, and then just DON'T TAKE THEM. Or they don't finish the course, or they take them incorrectly. I actually overheard a guy bragging to a pharmacist the other day about how he keeps his medication sitting right in his desk drawer, yet he still makes sure to pick up one or two boxes every single month regardless!

Then you have the patients who get a tiny little twinge in their ear and suddenly demand a full-body CT scan and every diagnostic test known to man.
Or the hypochondriacs and people with severe anxiety who spend YEARS cycling through doctors, running enough tests on the healthcare system to cover ten people, when all they really need is for someone to finally refer them to a psychiatrist. But no, these same Primary Care Physicians insist on writing referrals for heart checks, blood work, thyroid panels, brain scans, this and that... even though the patient is clearly just anxious. It’s like these PCPs should be psychiatrists instead, because every single one of these patients just wants physical proof of a disease. Do we realize how much that costs us?

As for asthma, it’s just "lovely" to hear people dismiss it as some minor, insignificant condition that doesn't require a specialist.
I’ve been on the brink of death a couple of times—struggling to breathe, my oxygen saturation levels tanking... but heaven forbid I actually see my own pulmonologist!
Generally speaking, it feels like the shortage of pulmonologists isn't even a result of this new reform; it's been bad for a long time. Specifically:

I have my own pulmonologist. She sees me maybe once every two or three years just for routine maintenance. My asthma is under control, and my PCP handles my prescriptions. However, if my condition starts to take a turn for the worse—I CANNOT GET TO HER!!!!
I can get an appointment in a month. Wtf? The nurse tells me, "If it's an emergency, call 911; if you're feeling slightly worse, go to your primary care doctor." So what is the point of having a specialist pulmonologist managing my care? If I can't see her exactly when a flare-up happens, what's she there for?
Is she just there for routine checkups when I'm feeling perfectly fine? I don't even need her for that!

The only time I actually want to see a pulmonologist is when I feel my asthma worsening, but BEFORE it reaches the point where I need to call an ambulance!!!!!

It was the same thing back when I was a student and had my records at the campus health clinic; they had a habit of scheduling appointments a month out.
The only way you got seen the same day was if you had a high fever or active bleeding.

That just isn't normal. Even if you have a minor inflammation or something is aching or burning... what is the logic in waiting a month for an appointment, letting everything get worse, spread, and complicate itself, and just suffering through it for thirty days???
Especially since gynecological issues aren't things you should wait on, aside from regular screenings.
It’s like going to a PCP with a throat infection or a bladder infection and being told to come back in a month because it's "not an emergency."

That’s actually how I ended up finding a private gynecologist whom I can see the same day or the next. And that was the first time in my life someone actually asked me, "Have you had your swabs done?" What do you mean, swabs? Heaven forbid a government doctor would suggest that a sexually active person might actually need to get tested once in their life.
☕

I absolutely agree with you. Let me give you a real-world example of how this plays out in the clinic: A patient comes in complaining of some mild abdominal pain. I run the standard blood work, order an ultrasound, check their family history, perform a physical exam—everything looks perfectly fine. Everything points to nothing being wrong. But no. This gentleman insists on having a full abdominal CT scan just so he can "be sure" everything is truly okay. Of course, I take the time to explain exactly why that scan is unnecessary and clinically unjustified. What does he say? He tells me straight to my face that if anything happens to him—say, an acute abdominal issue crops up or he gets hit by a truck anytime soon—he’s going to sue my ass. So, now what? How are we even supposed to move forward from there?
Of course, the CT scan came back clean, and now they’ll just drop that one little fact on the forum. But they won't mention the actual reason why the doctor ordered the scan in the first place! And then, predictably, everyone—and I mean everyone, myself included—is going to start throwing stones and pointing fingers, asking what idiot sent you in for a CT just to soak up unnecessary radiation for no damn reason.
Look, she gave you a perfectly fair answer, and honestly, I have no idea what you're even looking for from us right now.
I honestly lose my mind when I see someone with what looks like a genuine emergency—we’re talking severe abdominal pain or bloody stools—just sitting there waiting in an ER hallway or outside an ambulance bay. It drives me absolutely insane.
What on earth am I supposed to do about this? Honestly, just send them straight to the ER—which is exactly what they could have done themselves if they had any sense. When I’m dealing with an ambiguous situation like this, they simply CANNOT be running emergency cases or taking walk-ins. It’s impossible.
That’s exactly why HS—or what we call LOM—exists.
So, let me get this straight: it’s somehow easier for you people to track down a pulmonologist than it is to just get your own primary care doctor to prescribe some Medrol? You’d rather hunt down a specialist than wait for the one day a month they actually have an opening at the hospital? Give me a break.☕😕

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

Nicholas Myers said: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.

I agree with you, adding to that last point I mentioned in my examples above—basically, PCPs are already doing this, even though I'm mindful that there aren't specific indications or guidelines for Alvesco. This brings up the question: why is the PCP sending the patient to a specialist in the first place if they're just going to override everything?

Nicholas Myers, a question regarding your recent post—what's your take on generics, specifically regarding this new model for prescribing meds? I'm thinking about what Morgan Morgan5 said about people not even knowing which drug is the originator; it's essentially what I pointed out earlier.

Nicholas Myers said: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.

Honestly, I haven't a clue because whenever I need to prescribe triple therapy for eradication, I just write
Zithromax or something for HP.
But then again, it’s the same story with things like Lipitor, Nexium, Controloc, Concor, or Tritace. You can't just write the name and call it a day!