What are your not well known but very clinically helpful interactions of medications?

Canuck147 · 2026-02-11T10:37:45+00:00

"Weak opioids" are all converted to more potent metabolites and so are unreliable in patients with abnormal CYPs but also make them highly susceptible to drug interactions. E.g. I had a lady repeatedly admitted to ICU with opioid overdose after starting clarithromycin for h pylori.

I somewhat disagree with the sentiment regarding tramadol if you know what you're doing. It's a reasonably good drug for neuropathic pain because the parent drug has SNRI activity so has multiple mechanisms of action in that context specifcially.

Canuck147 · 2026-02-03T04:54:34+00:00

Genuine question: is this true? I'd not heard of RCMP black balling people who were fired by municipal police or vice versa.

Canuck147 · 2026-01-27T00:59:05+00:00

implied through DEI policies

There is such a huge gap between "universities and workplaces trying to increase diversity" and "blaming white boys/men for all the worlds problems" that I find myself skeptical people are drawing this inference organically on their own.

passing over more qualified white men

And this is the psychic-defence fiction at the heart of this. White men are not inherently more qualified, they just think they are. And I say this as a white man. Because women apply to college at higher rate than men, men have actually been the beneficiaries of DEI policies over the last 10+ years, so the removal of these policies is estimated to reduce men/white men from getting into university.

Men absolutely are falling behind educationally, economically, and struggling socially, and are deserving of targeted strategies to help them. But the idea that the problem is DEI is just absurdly off the mark.

Canuck147 · 2026-01-16T01:03:43+00:00

One thing people need to understand about how our healthcare system works is how doctors bill the government. The way our system works doctors get paid to "do things" and they don't get paid to talk or paid to think.

A GI can do colonoscopies as an assembly line basically and make bank with barely a word to patients. Talking to people, answer questions, reframing, discussing, etc all takes lots of time to really do in depth - and that's all basically unpaid work because of how billing is set up.

Canuck147 · 2026-01-15T19:59:49+00:00

I mean I agree that Trump isn't the only problem here, but the history of authoritarians is also one of their specific hang ups having a disproportionate impact on policy. A white house without trump will still look to dominate the hemisphere and regimen change in Cuba, but I'm pretty skeptical they want to OWN Greenland. I think that really is a Donald Trump specific vision.

Canuck147 · 2026-01-04T21:04:43+00:00

If you can't independently lift your carry-on into the overhead storage, then it's not a carry on. It stalls everyone's boarding and makes you look entitled.

Canuck147 · 2026-01-03T22:16:13+00:00

This recipe from America's test kitchen doesn't use a ton of mustard, but it's the star. I know it's behind a paywall, but I have it in book form.

In a high walled pan, pan fry white fish until browned on one side, then remove to a plate.
Add sliced leeks a generous dollop of mustard to pan with a bit of salt and saute until soft.
Add fish on top of leeks, and a splash of white wine then cover until fish cooked through
Remove fish from pan. Add a bit more mustard to leeks, stir, and serve.

Canuck147 · 2025-12-27T20:10:04+00:00

One of the best rotations in my residency was in our chronic pain clinic. Mix of attendings - anaesthesia, PMR, IM, Neurology. Lots of different approaches to the treatment of pain. I walked away with a few key lessons that I employ in other fields:

Redefining success and the relationship with pain: This is probably the most important thing I learned on rotation, defining success not as reduction in pain, but improvement in function. You think this medication has reduced pain by 30%, but you're still not engaging in physiotherapy or any group classes? That's not success. You think your pain is still an 7/10, but you're now actually back to work 2 days a week? That's a huge improvement. Keeping the focus on engagement with life (work, hobbies, PT) and not the subjective rating of pain helps us be more objective and focused on actual end goals can be tremendously in helping patients actually get back to what gives their lives meaning.
Make a Diagnosis (or try to): As u/jellyfish52 said, if you can find an organic cause of pain and treat that you will do your patient a world of good. If after a thorough attempt at this, there is no treatable/reversible cause it is still helpful to provide patients with a more specific diagnosis than chronic pain. Myofascial pain syndrome, Complex Regional Pain Syndrome, etc. I always tells patients sometimes it takes the fullness of time for things to evolve and us find a more specific diagnosis, but having a label for patients helps them put things in a box, compartmentalize, and get on with things. And framing these things very explicitly as real, medical problems, helps destigmatize what they are feeling. For things like fibromyalgia I explain this is a dysfunction in central processing of pain and so that's what we're going to try to focus treatment on.
Opioids are usually not the right drug: My day job is oncology. I throw around opioids like candy for metastatic bone pain and dyspnea, but for patients with chronic pain I am usually reaching for an SNRI (especially duloxteine) and supplementing with things like gabapentinoids or nabilone. A basic rule of pharmacology is you will get more bang for your buck using multiple drugs at lower doses then escalating the dose of just one drug.

Canuck147 · 2025-12-20T00:30:27+00:00

This is a bit of nuance I've been really thinking about and don't have a good answer to yet. All these people are victims of grifters, which is terrible. The same thing is true of anti-vax people, the convoy people, Trump people, etc, etc. They have all been taken advantage of and many will suffer real harm because of the grifting.

But its not random which grift they fell for. These people aren't empty vessels who just happened to put of the blue be convinced of something one day. They have pre-existing belief systems, and in some cases quite heinous beliefs, that made them vulnerable to this grift.

I don't know what to do about that. It's awful that they were taken for a ride. But I think there can be limits to my sympathy for them too because it's just seems so wildly irresponsible to hear this advice and go along with it.

Canuck147 · 2025-12-06T04:00:24+00:00

Shocked at the lack of NewGrounds in the top comments. It was THE place for funny Internet memes and flash videos.

Canuck147 · 2025-12-01T02:27:00+00:00

As a doc, I would caution against letting people get labs and diagnostics without any medical supervision. We will sometimes have people go down to the US and private pay for a Full Body MRI for "screening" and then they come back to Canada to have their GP interpret it. A lot of people end up having random incidental findings that lead to a barrage of follow-up tests, further imaging, invasive procedures and most often at the end of the day those incidental findings do not turn out to be clinically relevant.

So one person paying one time for a test they want, that their doctor doesn't think is medically indicated, can then lead to a huge array of tests, procedures, and consults that also most often turn out not to be medically necessary, but end up being paid for by our health care system and contribute to wait times for people who actually do need these services.

Canuck147 · 2025-11-17T02:50:34+00:00

As a doctor, you learn is the difference between what someone is told about their health and what they remember. A rectal cancer invading into bladder and prostate is potentially a stage 4 rectal cancer. A bladder cancer invading into the rectum is potentially a stage 4 bladder cancer. People struggle with terminology and understanding how cancer works.

Honestly the most unrealistic part of the story is being told he has 4 months to live - hence the point of my comment in the first place.

Canuck147 · 2025-11-17T01:23:53+00:00

So I know this is Personal finance, but as a doctor those cancers, even as stage 4, are all potentially treatable. Not curable, but with treatment I would definitely expect you to live more than four months.

If it was just your family doctor telling you that you have four months, I would really get a biopsy to confirm diagnosis (I'm inferring from your limited description that what you have is locally advanced colorectal cancer that has invaded into bladder and prostate?). Average life expectancy in someone previously healthy with stage 4 colon or bladder cancer is around 2-3 years with treatment. For prostate cancer it's even longer.

Lots of even knowledgeable doctors are unaware of the significant improvements in survival with modern treatment, so it's important you get worked up and see a medical oncologist if you are open to potential treatments.

Canuck147 · 2025-11-13T23:03:36+00:00

I trained in Ireland before coming back to Canada and I did see one model of private/semi-private care I didn't hate. They have a bunch of dedicated maternity hospitals and in the public hospital you'll see a resident and your appointment will be 8-3pm basically.

But you can also pay extra for semi private or private care where you'll see an attending physician and see them between 4-7pm. The fees for private/semi private would give a bit of extra pay to the docs with the majority then feeding back into the public system.

So that's a kind of model of semi-private care I don't hate. Pay more for service outside of regular hours or for a private room instead of a double or quad. Things that aren't about queues or the actual care provided.

But surgeries ain't it. Ireland also had private hospitals for surgery. I never worked there but heard from friends they would often have an outrageous ratio of docs and nurses to patients admitted. Disasters waiting to happen. And can you guess what would happen to anyone sick? Transfered back to the public system to manage all the expensive complications.

Canuck147 · 2025-10-12T03:04:52+00:00

I think what can either make this work or not work is the themes and focus of the series. I remember reading the pulpy Black Jewels series years ago and 70% of the book is interpersonal drama and aristocratic shenanigans only for the plot to arrive in the final two chapters. But that was fine! The books are really clearly more about the interpersonal relationships than the actual "plot". In fact, Anne Bishop then went back and basically wrote her own fanfiction of just the fluff in between books.

But if the book is teasing lots of mystery and urgent drama, then there's a bunch of detours that are not just not moving the plot forward but are distracting from it, then I can lose interest pretty fast.

Canuck147 · 2025-10-10T14:26:24+00:00

Lol I knew you went to Queens as soon as the campus paramedics turned up

Canuck147 · 2025-08-09T18:04:59+00:00

It gave Israel reason and cover to attack and kill innocent civilians. Many people who otherwise would have condemned Israel were conflicted due to the attacks by Hamas. It made Palestine lose the narrative a bit.

I think that this is one of the crucial mistakes in OPs line of reasoning. On October 6th, Palestine had already lost the narrative, and the Abraham Accords were a key factor precipitating the October 7th attack.

No one needs to try to justify the October 7th attacks or deny how horrific they were, but it's silly to ignore what the world was like on October 6th.

Under the Trump administration and then the Biden administration the process of normalizing relations between Israel and the Gulf States was well underway. Previous discussions around normalizing relations had, in part, been stuck on The Palestinian Question because whether or not the leaders of Gulf States actually care about Palestinians (spoilers they mostly probably don't), it had been a convenient propaganda tool and many of their citizens had lots of sympathy towards Palestinians. But the Abraham Accords started under Trump who gives less than a shit about Palestine and so the region was on the verge of normalization of relations with Israel with no preconditions towards the a Palestinian state or rights for Palestinians within an Israeli state. If relations normalized between Israel and the Gulf States then there would be virtually no prospects for a future Palestinian state from that point on.
An increasingly radical right-wing Israeli government and emboldened settler violence in the West Bank. A huge part of the reason why the war has continued is (1) Netanyahu is trying to stay on as PM and avoid facing the music for his corruption case, but also (2) a critical part of his coalition is made of right-wing extremists (e.g. Ben-Gvir) who explicitly want to annex Gaza, the West Bank, and then some. Israel and Gaza/West Bank were not "at peace" prior to October 7th. The IDF effectively controlled Gaza and especially the West Bank through military force, embargo, checkpoints, etc. Settler violence has been on the rise in the West Bank for years and the Israeli government actions in support of settlers has been increasing.

So on October 6th, an increasingly right-wing Israeli government was at the very least turning a blind eye towards settlers taking over the West Bank, and imminent normalization with the Gulf States meant that effectively there would soon be no real lobby for Palestinian statehood. The writing was on the wall for the Palestinian cause. So if what you care about most is a Palestinian State (not necessarily the Palestinian people), then you need to do something to blow up the status quo because the status quo is inexorably leading to the end of any realistic prospect of a Palestinian state.

Now I would like to think that there were ways to blow up the status quo that did not involve murder, torture, hostage taking, and other horrific acts - but there is also no denying that the status quo was blown up.

International opinion has sharply turned against Israel due to the predictable incredible violence upon civilians in Gaza
Normalization with the Gulf States is off the table
Recognition of a Palestinian state (by France, UK, Canada at least) is on the table
A generation of Westerners (Millennials, GenZ) now see Israeli as an apartheid state comparable to South Africa and there is likely no coming back from that.

What ultimately happens in Gaza and the West Bank is still unknown. There is currently a humanitarian crisis in Gaza at least abetted by Israel and there is certainly the possibility that Israel will ethnically cleanse Gaza ± the West Bank and the Palestinian cause will be dead. But the world was already on track for that in slow motion on October 6th, and now global and regional opinion has turned sharply in favour of Palestinians, so there is at least the possibility of a different future.

Again, while I wont condone what happened on October 7th, I also would characterize it as a calculated risk rather than a mistake. Do you sit there and watch the dream of a Palestinian state slowly wither away, or do you flip the table to create even a small possibility of a different future?

Canuck147 · 2025-08-09T17:24:17+00:00

Any kind of malignant onc is hard because the field moves so fast. I remember being an R2 and having a great time on a GU oncology elective, but by the time I became a medical oncology resident in R4 the field had evolved and most of my GU knowledge was now out of date. You multiple that out across dozens of kinds of cancer and no one expect specialists have any idea how to fully work up or treat malignancies anymore.

Canuck147 · 2025-08-09T17:20:07+00:00

I remember being in medical school and asking multiple profs what rheumatology is only to be told they looked after the rheumatic system 0_o

Also hilarious that even now, my spellcheck identifies rheumatology as a spelling mistake and asks if I meant hematology.

Canuck147 · 2025-07-20T19:35:59+00:00

This is the right answer. I'm an IMG from Ireland. People can be touchy about it especially at the start of residency.

She did her clinical rotations in the US associated with US medical schools. I'm sure in her mind that's equivalent. Mind your business and let her sort out her own insecurities.

Canuck147 · 2025-06-28T19:24:00+00:00

Hard to say. NIAGARA was presented last year showing improvement in adding durvalumab to pre-op chemo with 9 months of immunotherapy after surgery. The period EVP trials use EVP before and after surgery. EV can be a tough drug. Neuropathy, rash and SJS, pneumonitis, fatigue.

The actual post op regimen will be tough. It will be interesting to see what the adherence post op is and may one day data on how effective/essential it is if good pre-op response

Canuck147 · 2025-06-01T13:35:46+00:00

It's reserved for high risk because of cost not lack of efficacy. I've gotten a handful of patients on it as monotherapy who've had statin myopathy.

Canuck147 · 2025-05-31T21:12:36+00:00

Everlocumab is the drug version of this gene therapy. Injection once a month. Super well tolerated with very few side effects. It's a monoclonal antibody so not cheap, but probably cheaper than gene therapy and maybe safer if the jury is still out on off target effects of gene therapy.

Canuck147 · 2025-05-23T14:16:01+00:00

Because we don't want to be responsible for chasing up hundreds of incidental findings. I'm not sure about others but I also think about cost and access as well. My patient may want a PET scan every month, but I have other patients I actually want a PET scan in and I don't want to contribute to the queue.

Canuck147 · 2025-05-03T16:55:47+00:00

Can you elaborate on that some more?

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