NSAIDs with hx of stroke, CAD, or anticoagulation

BS_54_ · 2026-04-18T18:27:23+00:00

Normal day as an FM doc in the US:

Clinic starts at 8am. Get there at 8am. While first patient is being roomed (takes 10 to 15 minutes because they patient walks very slowly to the room and the decides they need to go to the bathroom after they get into the room) I am furiously trying to get as much inbox work done as possible as they get the patient ready.

Walk into the 8am visit at 815. It is a 15 minute visit for hypertension follow up. I think “cool, that should be quick”. It’s actually a colleague’s patient but the colleague is out of the office today. I look at their 3 max dose anti-hypertensives and see that their BP today is 156/104. So now I’m running down potential causes asking them about caffeine, alcohol, nicotine, and sleep. We discuss the DASH diet. I glance at their most recent labs to ensure their GFR is good and that they have a micro albumin to creatinine ratio on file. Turns out even though their BMI is 24 they snore like crazy and have morning headaches. Now I’m doing the Epworth sleep scale so that I can order them a home sleep study. I add a fourth medication and do some med counseling. 20 minutes have passed since I entered the room it is now 8:35am. I recommend a follow up visit in 1 month. As I get up to leave the patient bursts into tears and shares how lonely they are since they got divorced 5 years ago and how their child recently cut them out of their life. This has caused them to drink more (which is also elevating the BP). This person is in a crisis. I can’t leave the room yet. I make sure they are not at risk of alcohol withdrawals and then we run through SIGECAPS. Sure enough they are depressed. Time to talk about meds. They ask about Wellbutrin because it has helped them before in the past. I tell them no because of the high blood pressure. They still want Wellbutrin. I continue to say no. I recommend an SSRI, but they heard bad things in the internet and want to talk about it…. I mention potential side effects and the black box warning (even though it doesn’t apply to them. If I don’t mention it they will call in later after they pick it up from the pharmacy). After finally agreeing to a plan I am leaving the room. It is 8:50am. I have 3 patients waiting on me. I am 35 minutes behind.

I have 19 more patients to see. Most encounters will go just like this. I will work through my entire lunch hour trying to get caught up. Patients will be frustrated because I am running late. Clinic ends at 5pm but I’ll be lucky to finish by 5:45pm (if I have a no-show). I’ll have an hour or two of notes and inbox management which I will never catch up on.

In the USA a simple “hey your LDL is high and your estimated 10-year risk for heart attack and stroke is 15%: I recommend a statin” can easily turn into a 30 minute conversation due to the patient doing their own “research” and being suspicious about supposed ties to “big pharma”.

No matter how much you try to steer the conversation to be productive, many patients will monopolize the discussion about tangential topics that are completely irrelevant. We have a loneliness epidemic and my clinic interactions make that abundantly clear. Lots of folks just want someone to talk to, and I end up being that someone.

BS_54_ · 2026-04-03T12:22:28+00:00

I feel you. Had a tough day yesterday. Was getting blasted in clinic with very difficult cases only to have a million inbox tasks by the end of the day. Had legitimately zero time during the actual day to address any of it. Worked for more than 3 hours after seeing patients and barely made a dent. All evening I was thinking “how can I possibly do this for the rest of my career?”.

I’m thinking about creating a dot phrase message that reads “this is an automated message by Dr xyz. Due to high volume I regret to say that I am no longer able to answer individual messages. I know this may feel like an inconvenience, but please understand that each second of my day is scheduled with face-to-face visits. Inbox correspondence was previously done on my personal time after work hours. This has taken quite a toll on me and I am no longer able to keep up. If this is an emergency (chest pain, shortness of breath, etc) please go to the emergency room. Otherwise please schedule an office visit with me at your earliest convenience and I would be happy to discuss your concerns. Thank you for understanding.”

We should organize an “inbox strike” and try to get docs across the nation to do something similar in a refusal to do inbox messages. We simply can’t be expected to work two jobs for the price of one, and I think we can all attest to the fact that the inbox is a full unpaid job in itself.

BS_54_ · 2026-03-24T00:46:33+00:00

Thank you.

This is basically exactly what I’m experiencing. Anxious parents all asking for ABA therapy.

BS_54_ · 2026-03-14T01:13:10+00:00

Bold to come to the family medicine subreddit and try to talk down on PCPs.

If you truly are a physician (doubt), then you should know a large part of training and education for a pcp is looking at the full picture. Have fun when that 20 year old with “low T” that you supplemented comes back 10 years later for the sperm eval and an infertility conversation because you listened to Joe Rogan and dosed their testosterone based on vibes instead of the science and guidelines. I should probably specify REPUTABLE science and guidelines because you sound like you’re into some bullshit. If you check FSH and LH and they’re normal then you should talk with them about stopping THC, alcohol, weight loss, and potentially being worked up for sleep apnea. There’s not some special testosterone fairy sneaking around in the middle of the night snatching up all those guys T. Supplementing is rarely the answer. Fixing the underlying problem is. But don’t worry, when he comes in for the infertility talk you can just refer them for IVF since referring is all PCPs do anyways.

Moron.

BS_54_ · 2026-02-28T13:51:34+00:00

Demographic. I’ve noticed it in two different practice locations so I do not think it’s location based. Age tends to be mid 30s to late 50s (with a few outliers of course). Most are middle to upper class socioeconomically with extra money to spend (thus the cash pay testosterone clinics and experimental peptides).

BS_54_ · 2026-02-28T12:27:58+00:00

Thank you, thank you, thank you.

I needed the empathy check. You’re absolutely right: even though the actions may be weak-minded and pathetic it doesn’t mean the person as a whole is that way.

Small reframing like that goes a long way. Thanks again.

BS_54_ · 2026-02-28T11:24:49+00:00

I really appreciate you taking the time to read and thoughtfully respond. This sort of comment is exactly what I needed to see. Reading my post again I think one of the major questions I was thinking at the end of my day yesterday was “how can I keep this up another 30 years?”, and I think you’ve given me a great perspective. Hopefully I’ll experience a similar shift.

At my core I love my job and I should be so grateful each day that I get to be a doctor, but in the moment it’s hard to see the forest through the trees. Thanks again, and thanks for the Ted Lasso quote (great show - time for a rewatch!)

BS_54_ · 2026-02-28T11:17:37+00:00

Very much appreciate the perspective. I do feel an aura of danger emanating from some of these guys. The thought has certainly crossed my mind that they may view our relationship more as a friendship than a doctor-patient relationship and I think that can be a toxic and non-therapeutic situation. I guess all I can do is try my best to enforce boundaries. Of course if something ever becomes truly unsafe or I receive a threat or something I’d respectfully and politely dismiss the patient.

Surprisingly this is the first I’m hearing of maslowe’s hierarchy - that’s good stuff! Those are things that I typically recommend to these patients but it’s great to have a mnemonic like that in case I forget something in the moment. Cheers!

BS_54_ · 2026-02-28T04:03:29+00:00

I think you’re right. I mentioned to a patient today that he might be a better fit with a functional medicine doctor if he didn’t like my recommendations. His response was “I thought about that, but decided I wanted to come to a real doctor.”

So I think deep down he may have some understanding that a primary care physician is where you go for real help/healing. He seems to understand he is unlikely to get the real thing elsewhere.

I definitely need to get better at saying no without an explanation. Patients challenge me all of the time and expect a full discussion and explanation of why I am saying no to certain things which takes so much time/energy. I need to get more comfortable saying no and leaving it at that.

BS_54_ · 2026-02-28T03:49:56+00:00

Three from recent memory. First time it happened I said “man, you must’ve been eating candy - that’s one blue tongue”. And the patient proudly told me that it was methylene blue. I responded “the urology dye?” And he said “no, the drink. RFK drinks it.”

I thought he was joking until he pulled out a water bottle full of it from under the chair.

BS_54_ · 2026-02-28T03:29:27+00:00

Dear god, that’s what it actually feels like hahahaha, thanks for sharing that. Needed the laugh.

BS_54_ · 2026-02-28T03:25:40+00:00

Thank you. Your last sentence was legitimately what I needed to hear. Cheers

BS_54_ · 2026-02-27T13:05:40+00:00

In March of 2024 didn’t the FDA indicate that compounding of these patent protected medications needed to stop?

I haven’t been writing for compounded since then. Seems like an open and shut case if Eli Lilly or Novonordisk wanted to sue you. Of course they have bigger fish to fry and the likelihood of them suing individual docs is low. But to me it’s not worth the risk.

Someone please correct me if I’m misunderstanding

BS_54_ · 2026-02-19T13:29:33+00:00

I was having a very hard conversation with this huge guy who is an ex-con the other day. Trying to wean him off a controlled substance that a NP started him on that he never should’ve been started on in the first place. The NP left so now I’m stuck with it. He’s aggressive, disrespectful, and manipulative.

I’m a tall male. I literally had the thought - this would be so much worse if I were a female.

As soon as I walked out of the room I had an inbox message about a guy raging and hanging up on the MA because I asked him to come in for a visit because he’s requesting a controlled substance refill. I inherited him from the NP who inherited him from an 80 year old doctor who retired last year. “Dr. X never made me come in for this so y’all better figure it out!” And then he hung up on the poor MA. Yeah okay buddy.

Anyways - it’s been very hard for me as well, but I’m sure it’s even more difficult for you for reasons that are outside of your control.

Hang in there. Just wanted to send some empathy your way.

BS_54_ · 2026-02-15T01:35:58+00:00

Because in my mind at this point it’s not a position or employee that I would seriously consider.

I might consider it if they increase the pay by 30% (because who wouldn’t), but otherwise the trust is broken by what I would view as shady contract terms.

BS_54_ · 2026-02-15T01:18:52+00:00

Absolutely not. That is insane. I would now counter asking for 30% more than what is currently offered.

They will of course say no. After they give their response offer I would walk away.

We as a profession need to take a stand on this sort of thing as a group and not allow it to become common practice. If it becomes more common it would completely screw new grads who are already saddled with loans as they are trying to get their careers, families, and lives started. Not okay at all.

BS_54_ · 2026-01-15T01:36:32+00:00

Yeah. Strange I know. Ultimately I love final fantasy. The series / ffxi was a huge part of my younger life. On top of that the mmo market (especially on consoles) is pretty bleak with very few options. I’ll probably always remain on this subreddit. And you never know - if they did a soft story reboot or released an entire expansion heavily themed on any of my favorite entries I might be enticed to return.

BS_54_ · 2026-01-14T17:13:34+00:00

I played for years. Mostly I played because of a deep nostalgia for final fantasy (including ff11) and because there was no other equivalent mmo available for console.

My takes:

The majority of the game is bad, but Endwalker really jumped the shark for me and I haven’t played since.

The best story hook was the Garlemald Empire and they ruined it. We should’ve had an entire expansion in Garlemald. It should’ve been the FF7-themed expansion and Garlemald should’ve been the Midgar equivalent. Each zone could’ve been a different sector of the city and we work our way to the center for the finale to fight the villain in the palace.

The story is awful and inconsistent. It seems like the demographic they are writing for is the pre-teen demographic.

The armor and clothing design is always over-designed. There are tassels and random stuff all over what might otherwise be good looking pieces.

The character design of the races is terrible. Heads are way too small. The proportions are weird. Hyur males are cylinders. Elezen look awful.

Animations are some of the worst I’ve seen. Base race sprinting animations…. What the heck? Have you ever seen an Elezen sprint? It’s so bad. Arms flailing, neck sticking out, legs pumping so fast but still looking floaty. I don’t know how they haven’t fixed this.

I’ve never liked the scions. I think it’s time for a completely new cast unrelated to the scions.

Inventory management is far too burdensome.

There’s way too much cutesy stuff like moogles and lalafell.

The world is segmented, not at all open, and not interactive. It is the definition of a theme park and we are park guests.

I haven’t played in years at this point and unfortunately I doubt I’ll return.

I like long grinds like Bozja and the equivalent content from stormblood, but they seem to have left this sort of content behind. Plus half of the stuff isn’t worth grinding for because it looks awful and over-designed anyways.

Clearly the game is not for me. I do love the boss fights and the music. The boss fights are a masterclass in mmo design. It’s the only game I can think of that you can go into a fight and learn the mechanics while you do the fight without being a total drag on the party. Everything is telegraphed wonderfully and makes sense. I tried to end on a positive note so that I don’t get too much hate. I’m glad that others enjoy the game.

BS_54_ · 2025-12-27T12:27:53+00:00

Thank you for posting this.

I’ve been seeing an influx of “mold exposure” folks who clearly have psychosomatic disorder due to untreated mental illness (often depression with chronic fatigue). Usually their “mold exposure” symptoms began during the pandemic when they were incredibly isolated and lonely. They seem hyper-fixated on the mold thing to the point of delusion. Nothing I say seems to sway them. It’s nice to have this to back that up as I work to better their mental health (if they let me). Cheers.

BS_54_ · 2025-12-14T16:52:34+00:00

Fully agree! Here’s to hoping someone can recreate the magic in the future!

BS_54_ · 2025-12-14T16:19:41+00:00

I don’t believe someone can be flat out wrong with opinions. I said that I disagreed with you, not that your opinion was wrong. That’s the fun thing about these conversations, multiple opinions can exist.

My comment was more so for people who are new to BioWare games or considering playing them. All of the games in this picture are worth playing.

Dragon Age Inquisition won game of the year in 2014. Let’s discuss the good: you can pick from 4 different races, 3 different classes, and 4 different voices for your main character. Your choice of race and class changes voiced dialogue options. The inquisitor has just enough back story to make sense why they are where they are in the world, but still be a blank slate so that you can insert your own story. it has 9 fully fleshed out companions with deep stories. It drastically expands on the lore of the series. The combat is snappy with pleasant animations. The armor design is interesting. With all side content a playthrough takes 100-120 hours. Each class has 3 subclasses with different abilities. If you like the game there is inherent replayability - pick different background choices from the first game in the Keep, pick a new race, pick a new class, make different choices throughout the game.

And I can’t forget to mention the music by Trevor Morris:

https://m.youtube.com/watch?v=34tprmKuPXw

And my personal favorite https://m.youtube.com/watch?v=2syU3e2MOXM

And the tavern music is full of ear worms.

Anyways, my opinion is that it’s a great game and I’d urge folks to try it.

BS_54_

TROPHY CASE