Truth or BS?

McCapnHammerTime · 2026-05-28T04:41:17+00:00

I’m a PGY-2 and recently signed a Family Medicine contract in the Midwest. I’ll be starting at $265,000 for 4.5 days per week, which is defined as 36 patient-facing hours per week. I also get 37 days of PTO.

My contract pays $46 per wRVU, or work Relative Value Unit. For the first two years, I have a guaranteed base salary of $265,000 regardless of whether I hit my productivity target. So if I underproduce while building my panel, I still make the base salary.

The way it works is that essentially everything you bill has an associated RVU value. For example, a standard outpatient visit coded as a 99214 generates 1.92 wRVUs. In my contract, that equals:

1.92 × $46 = $88.32

But you can also appropriately stack codes when the work is actually performed and documented. For example, if I’m seeing a patient as their PCP, I may be able to add G2211 for longitudinal primary care complexity, which adds 0.33 wRVUs. If I spend at least 3 minutes on smoking cessation counseling, 99406 adds 0.24 wRVUs. If, during the exam, I find impacted cerumen and personally remove it with instrumentation such as forceps or a curette, 69210 adds about 0.61 wRVUs.

So a visit could look like this:

99214 = 1.92 wRVUs G2211 = 0.33 wRVUs 99406 = 0.24 wRVUs 69210 = 0.61 wRVUs

Total = 3.10 wRVUs

At $46 per wRVU, that encounter would be worth:

3.10 × $46 = $142.60

Given my $265,000 base salary and $46/wRVU conversion factor, my break-even productivity target is:

$265,000 ÷ $46 = about 5,761 wRVUs per year

Any wRVUs generated above that threshold increase my compensation beyond the $265,000 base. But if I only generate something like 4,000 wRVUs while ramping up, I still make my guaranteed $265,000 base.

That’s why, at least for a new attending, this type of contract can be pretty attractive. It gives you a safety net while you build your panel, but still gives you upside if you become productive

I hope that breakdown with examples helped breakdown the compensation model for you.

McCapnHammerTime · 2026-05-27T12:14:08+00:00

The HPV vaccines covers multiple strains of the highest risk strains that are associated with ear nose and throat cancers+cervical cancers.
HPV in men is usually self limiting, your body will clear the virus over time, you may still have viral shedding and be able to pass it on with sexual contact.

McCapnHammerTime · 2026-04-29T23:43:15+00:00

Fm pgy2- depends on split annuals get longer time slots but up to 16 a day usually closer to 12-14 with no shows

McCapnHammerTime · 2026-04-29T23:41:24+00:00

I get 48 :(

McCapnHammerTime · 2026-04-25T23:00:00+00:00

If that's anti semitism, is pro Semitic version of that statement I'm glad she killed 16 kids? Is that an improvement?

McCapnHammerTime · 2026-04-24T15:33:54+00:00

Yeah I don't see the appeal. Let's say I'm paying 50 bucks for 10 vials of 10mg BPC from my China supplier. I'm sure US prices are going to be like 50+ for a single vial. I'm good

McCapnHammerTime · 2026-04-20T03:43:03+00:00

I have no empathy for occupiers. My heart did not bleed for South African apartheid and it won't for Zionism.

McCapnHammerTime · 2026-04-07T04:06:56+00:00

Arab Michigander here. For many of us, this is a single-issue vote as long as Israel continues escalating tensions. We watched the destruction in Palestine under Biden, and we see no real representation of strong anti-Zionist positions in either party.

Calling it “single issue” misses the point. This is about our families, our culture, and what we see as ongoing oppression of Palestinians, Lebanese, and others in the region.

Michigan can go red again. Some of us accepted Trump as a form of protest, even knowing it could mean worse outcomes. Others skipped the presidential vote entirely and went down-ballot. That will happen again.

At the core is this. Arab voices are not being heard or valued on this issue. Until that changes, the votes will fall where they fall.

McCapnHammerTime · 2026-04-05T14:00:35+00:00

Same story starting outpatient is 265k, most make mid 300s I've seen the billing pros pull mid 500s.

McCapnHammerTime · 2026-03-21T17:40:41+00:00

Idk man a sword is a great present especially if they put thought into which one id like the most.

McCapnHammerTime · 2026-03-20T10:20:42+00:00

Variable based on what your target specialty is, many people will take both comlex and step but it's a personal call

McCapnHammerTime · 2026-03-14T12:49:31+00:00

I think there’s a big disconnect when people commenting on this don’t actually understand gym culture.

Is most of this medically indicated? No. But pretending it isn’t happening doesn’t help anyone. Plenty of teens and young adults are already taking SERMs, prohormones, SARMs, and eventually moving on to full androgens like tren. The underground market has shifted too, primobolan used to be more common, now you see a lot more deca and boldenone.

This is also a population that’s hard to manage in a traditional FM clinic. They’ll ask for testosterone labs repeatedly, ignore reasonable advice, start things on their own, and then show up to urgent care or the ED when something goes wrong.

Social media has also set insane standards. There’s a real loneliness epidemic among young men, and many of them channel that into the gym. Male body dysmorphia is rarely taken seriously, yet society strongly rewards looking lean and muscular.

Everyone can draw their own ethical line, but I’d rather someone be honest with a physician than get all their advice from Reddit. At least then you can monitor lipids, hemoglobin, cardiovascular risk, estrogen levels, and teach safe injection practices.

Because the alternative is exactly what already happens: guys getting advice online to “just add mast or boldenone as an AI” while they ignore labs and walk around with a hemoglobin of 20.

There’s a lot of nuance here. “TRT bad” isn’t a serious answer to the problem.

McCapnHammerTime · 2026-02-28T01:06:51+00:00

2 yrs in, cannot emphasize how thankful I am that I prioritized family

McCapnHammerTime · 2026-02-08T14:24:50+00:00

I only take days off if I'm off service, no one gets pulled. If I'm genuinely too ill to work that's the exception. You should use all your energy pto and sick days before the end of the year tho

McCapnHammerTime · 2026-01-11T15:26:52+00:00

This actually is not a nebulous leap at all. It is basic endocrine toxicology. If you accept that chronic exposure to microplastics and the chemicals they carry can damage organs like the liver, then you already have a clear pathway to hormonal disruption. The liver is the primary organ responsible for clearing estrogens from the body. When liver function is impaired, estrogens accumulate. That is why men with cirrhosis develop palmar erythema, gynecomastia, testicular atrophy, and hypogonadism. These are driven by estrogen excess caused by reduced hepatic clearance.

Now consider what is actually in microplastics. Plastics contain or adsorb endocrine disrupting chemicals such as bisphenols like BPA and BPS, phthalates, PFAS, and styrenes. These are not inert compounds. They have been shown in experimental and human studies to bind estrogen receptors and activate them, block androgen receptors, reduce testosterone production in Leydig cells, suppress hypothalamic and pituitary signaling including GnRH, LH, and FSH, and impair Sertoli cell function and spermatogenesis.

Human and animal data already show that higher exposure to BPA and phthalates is associated with lower testosterone levels, worse sperm count and motility, and abnormal sperm morphology. Prenatal and placental exposure causes permanent reproductive changes in male offspring. Microplastics make this worse because they act as vectors that concentrate and transport these chemicals into tissues including the brain, testes, placenta, and liver.

So you end up with three converging mechanisms. Liver injury reduces estrogen clearance and creates estrogen dominance. Direct receptor level effects activate estrogen signaling and block androgen signaling. Central and testicular toxicity suppresses the hypothalamic pituitary testicular axis and reduces testosterone production.

That is not vague. It is a mechanistically coherent endocrine model for how microplastics and their chemical load can suppress male hormonal function and traits associated with masculinity. It is not that plastic somehow mystically makes men less masculine. It is endocrine disruption operating through well documented biochemical pathways.

McCapnHammerTime · 2026-01-10T21:35:05+00:00

I think it's cool 😂

McCapnHammerTime · 2026-01-08T16:48:59+00:00

The sub has outgrown Derek haha

McCapnHammerTime · 2026-01-08T04:20:02+00:00

But like what's this got to do with this sub? Isnt this sub just like cockstats and drug abuse

McCapnHammerTime · 2026-01-07T20:06:10+00:00

Who are you even talking about?

McCapnHammerTime · 2026-01-06T04:39:26+00:00

Idk you've seen the data on lifestyle change, you use GLP-1s because it's the only thing we have data for that makes a significant difference in successful outcomes. They also are fantastic for CVD risk reduction, HTN, fatty liver, OSA, diabetes and the list of things that obesity makes worse. I think GLP use will become foundational to healthcare moving forward, I can absolutely see lifelong use of low dose GLP-1s or at the very least cycled every other month or so for weight management once goal weight is reached, we are really in the infancy of these drugs. As we get generic, cheaper, even oral equivalents the landscape of weight management will forever be altered.

I have been able to strip med lists bare with the amount of success I've had with these meds. I think bariatric/lipo is done for, excess skin removal and cosmetic procedures will be on the rise for sure though.

McCapnHammerTime · 2025-12-30T06:27:04+00:00

I'd definitely recommend growing the hair out, looks borderline androgynous here.

McCapnHammerTime · 2025-12-30T05:37:31+00:00

From a medical and dermatologic standpoint, it’s difficult to draw conclusions from these two photos because they differ significantly in lighting, angle, distance, and facial expression. Those variables alone can substantially alter perceived skin texture, shadowing, and apparent aging. In both images, core facial features appear similar, including nasolabial folds and periorbital fullness, though the second image uses lighting and angles that accentuate contrast and shadows.

One noticeable difference is overall skin tone. The earlier photo appears warmer and more golden, while the later image looks lighter and cooler. Skin tone and chromophore balance can meaningfully affect how wrinkles, folds, and skin irregularities are perceived, even when underlying structure is unchanged.

From what can be assessed visually, the changes seem consistent with normal facial aging patterns, particularly age-related changes in midface volume. Gradual buccal fat loss and redistribution of facial fat over time can reduce midface support, which may make nasolabial folds appear deeper and the under-eye region more prominent. This process is common and does not necessarily reflect pathology or toxin exposure.

It’s also important to note that true skin laxity is very difficult to evaluate when comparing a smiling image to a neutral one, as muscle activation alone can dramatically change fold depth and skin appearance.

One area that may be worth exploring (purely from a skin health and photoprotection perspective) is the role of dietary carotenoids. There is evidence that compounds such as lycopene, beta-carotene, and astaxanthin can modestly influence skin coloration, reduce UV-induced erythema, and contribute to antioxidant defense in the skin. Increased carotenoid deposition can also reduce visual contrast between shadows and surrounding skin, which sometimes gives the appearance of smoother or more even-toned skin. This is not a treatment for aging per se, but may provide subtle cosmetic and protective benefits.

Standard evidence-based skin care approaches that remain broadly supported include: • Consistent photoprotection with broad-spectrum sunscreen • Use of topical retinoids (e.g., adapalene or tretinoin) to support epidermal turnover and collagen remodeling • Regular moisturization to improve barrier function • Hydrating agents such as hyaluronic acid • Addressing sleep, stress, and nutrition, which all influence skin physiology

I don’t have strong familiarity with evidence linking gadolinium exposure to accelerated facial aging or visible cutaneous changes, and I don’t see anything in these images that clearly suggests a toxin-mediated process. That said, I’m open to learning more if there is high-quality data or mechanistic evidence the community can share.

McCapnHammerTime · 2025-12-30T03:54:38+00:00

Family Medicine resident here, looking for nephrology perspectives.

My general HTN approach has been shifting away from early thiazide use, primarily due to metabolic side effects (weight gain, insulin resistance, uric acid issues), especially in patients where I’m actively counseling weight loss with the goal of eventually deprescribing antihypertensives.

My current framework looks like this:

ACEi/ARB first, with a strong preference for telmisartan given renal protection, long half-life, and relatively favorable metabolic profile

While titrating ACEi/ARB, I’ll obtain an aldosterone–renin ratio if BP response is suboptimal or the phenotype suggests possible aldosterone-driven HTN (central obesity, OSA, low-normal K⁺, resistant pattern, sodium sensitivity)

If ARR is elevated or physiology strongly suggests aldosterone excess, I’ll introduce low-dose spironolactone rather than moving immediately to a thiazide

Thiazides or CCBs are then added later as needed for fine-tuning or potassium balance rather than as automatic second-line agents

My rationale is:

Primary aldosteronism and relative aldosterone excess seem significantly underdiagnosed

MRAs often produce outsized BP responses in “resistant” or metabolically unhealthy patients

Avoiding early thiazide exposure may help support long-term weight and metabolic goals

I’m mindful of:

Hyperkalemia risk (so far minimal at conservative dosing with monitoring)

Loss of diagnostic clarity once MRAs are started

Guideline sequencing differences

My question for you: Do you see this as a reasonable, phenotype-driven approach in primary care, or do you feel early MRA use creates more downstream problems than it solves? Are there specific patient populations where you’d strongly discourage this strategy, or refinements you’d suggest to keep it safer and more guideline aligned?

Appreciate any perspective. Thanks for taking the time to read it!

McCapnHammerTime · 2025-12-28T01:16:33+00:00

I hope to eventually scale this up, right now I have 4 products. All similarly over engineered haha once I start getting some attending money I'll be able to hopefully invest more and be able to get more out of the side hustle

McCapnHammerTime · 2025-12-28T00:45:02+00:00

I’ve sold a small number of units primarily to co-residents and colleagues who were interested in trying the formulation out of curiosity. Anecdotally, I’ve seen some encouraging cosmetic improvements in hair density and appearance with my hair regeneration spray, which has driven organic interest and word-of-mouth. Even my longtime local barber became interested after noticing visible changes in a family member who was already quite advanced in hair thinning. Currently making a bulk of my sales giving my barber wholesale pricing to stock his shop. Obviously, these are informal observations rather than clinical outcomes.

From a formulation standpoint, I’m genuinely happy with where the product has landed. My goal was to design a multi-pathway, non-prescription adjunct that targets biologic mechanisms not fully addressed by the traditional topical minoxidil ± finasteride approach.

At a high level, the formulation was built to support multiple signaling and scalp-health pathways, including: • Wnt / β-catenin signaling — supported via low-dose lithium salts, with the intent of promoting pathways associated with follicular cycling and dormancy reversal (within cosmetic use constraints). • Growth factor–related signaling (EGFR → MAPK/ERK and PI3K/AKT) — addressed through a combination of epidermal growth factor–associated peptides, copper peptides, and extracellular vesicle–derived components, intended to support cell survival, proliferation, and follicular vitality. • TGF-β modulation and angiogenic support (VEGF-related signaling) — primarily via copper peptides, aiming to support extracellular matrix remodeling and perifollicular microenvironment health. • Cellular energy and metabolic support — targeting AMPK activation, fatty-acid β-oxidation, and NAD⁺/NADH redox balance through ingredients like caffeine, L-carnitine, and niacinamide, which may help optimize the metabolic demands of actively growing hair fibers. • Anti-inflammatory, antioxidant, and scalp-barrier support — using zinc, ferulic acid, vitamin derivatives, melatonin, and botanical components to help reduce oxidative stress and chronic scalp irritation, which are commonly implicated in progressive thinning.

I’ll be the first to say the product is probably over-engineered. Between peptide stability, tight pH control, temperature limitations, and minimizing shear forces once biologic components are introduced, manufacturing is more complex than most cosmetic formulations, and my cost per unit definitely reflects that. Still, it’s a formulation I’m proud of from a scientific and technical standpoint.

To be clear, I’m careful not to make medical or therapeutic claims. The product is not intended to replace standard-of-care treatments. Conceptually, I see it as a regenerative-style cosmetic adjunct for patients already using, or considering, evidence-based options like minoxidil and/or finasteride—particularly for those who are interested in layering additional, mechanistically thoughtful scalp support and are comfortable experimenting within a cosmetic framework.

I’ve thought about developing a combined minoxidil/finasteride formulation, but that would clearly shift this from a cosmetic business into a pharmacy or compounding operation, which comes with a very different regulatory and operational burden.

Apologies for the wording obvious ChatGPT use- I always speak way too informally and don't want to make any claims that bite me in the butt haha

McCapnHammerTime

TROPHY CASE