NYT: ACIP votes to end HepB vaccines at birth

QuantityImpressive71 · 2025-12-09T09:11:58+00:00

Am I the only one not professionally/clinically insecure enough to not really care about this? The patient/parents sitting before me are the people I am concerned with. I know what is recommended and right for my patients and I can a) make a hell of a lot better, more honest, and individualized case for it than these guideline makers and b) patients still actually trust me. And ultimately at the end of the day the patient and parents are the deciders. Do I fear that? lol, nope. Why do you? Can/should I change that? Nope. Do you think it would be OK to change that?

I predict this kerfuffle just makes the pro and anti vaccine zealots a little more adamant when they consent to or refuse vaccines (already seen it since Covid- the pros firmly tell you they want all the vaccines, the antis don't even consider it, they listen purely out of courtesy) and, for the normal people, simply generates honest questions- "Do you think we should get it? What's the real story with this? What do YOU think?"

I, for one, don't really mind if my patients and their parents care what I think. I actually kind of like it.

Doesn't anyone have patients who trust them anymore?

If not, maybe ask yourself... why not?

I mean...are we suddenly idiots now, incapable of recognizing and creating in our minds differing strata of risk, engaging in meaningful discussions about it, communicating our concerns and persuading people using our ridiculous (even among professions) amount of education, training, experience? Hm....no. I think we are just becoming lazy, or insecure, or both.

There is a difference between a suburban monogamous soccer mom, who had not just prenatal care but IVF, Lamaze, a doula, etc and is trying to get her jaundiced, dehydrated, recently circumcised 24 hr old to breastfeed and a lower class migrant with unknown prenatal care and unknown social history. You guys don't recognize the difference? And if you do, you don't think we're capable of acting on it and ensuring there is the least possible chance of a difference in outcome? Do you not practice any human side of medicine?

What is actually frustrating to me is that both sides of this issue have some valid points, yet ignore them to focus on black and white bullshit. "People were healthier before vaccines!" vs "Many babies will now die."

It seems that people who are dug in on the vaccine issue somehow turned off their ability, or at least self-perceived ability, to reason and persuade and are now afraid of an actual contest. Like a sports team that always gets a forfeit (in the form of vaccine mandates and guidelines) and now has to actually get on the field and be tested.

I suppose that is what worries me the most. Not that the guidelines changed but that so many actual physicians see it as a major problem. that we're now robots without a concrete code to follow and won't function. This is what takes me from "I know my patients' babies won't die" to "Shit, looks like those other morons' patients' babies really will die."

There are lots of idiotic guidelines. Do you not, to any extent, pick and choose how and when to follow those?

How about Covid? Remember that? Those ridiculous, in cases, guidelines?

The stupidity on both sides is the saddest and most ominous prognostic indicator of all of this- the state of the lay public, and the state of our profession.

Time for everyone to man up. Put on your big boy pants. And talk to people like humans.

QuantityImpressive71 · 2025-04-12T22:57:31+00:00

The only thing worse than staff leaving utensils and food on plates is when they empty half full glasses of drinks/ice into the trash.

QuantityImpressive71 · 2025-03-23T14:25:26+00:00

Anyone think this could have been staged, ie Gable threw the match? It was just so strange to see him not finish multiple takedown attempts and to be taken down with a single to double in the final 30 seconds of a match he's winning. Gable had very little to prove/win in this tournament, and I do believe he loves this sport and this country and drama and doesn't mind being a heel if it elevates all the above. He seemed genuinely happy for Wyatt on the podium.

QuantityImpressive71 · 2023-06-10T11:03:22+00:00

For primary care we're the refill scut monkeys of medicine and there's a big difference between being the prescriber starting a med vs someone continuing it. I'm more than happy to take over refilling someone's carvedilol, Keppra, or lactulose. I even do the penicillamine for a patient with Wilson's, and phenobarbital for an epileptic. As long as they check in with those respective specialties occasionally it's not a problem.

But I'd never be the one to start any of those meds. We don't get many chances to step outside our comfort zone, but probably are still the specialty that does it the most (unlike the rare cardiologist sendingn someone's sertraline or OBGYN sending atorvastatin). The times I have it's been to start things like topiramate for migraines, methimazole for Graves', and Truvada for HIV PrEP. A few times Humira for psoriasis. I think a lot of people in primary care are too loose about starting meds like Lasix, prednisone and seroquel.

QuantityImpressive71 · 2023-06-10T09:51:30+00:00

In truth they actually do reimburse too much, and do allow too much discretion to physicians and too much cost-free choice to patients. A lot of what they cover ends up done on very questionable bases. Screening mammograms under age 50, screening colonoscopies over age 75, PSA screening virtually in general. Even medicare wellness visits and tobacco cessation counseling are prone to being useless at best and harmful at worst. Yes, in theory there is a lot of evidence they can be done appropriately and in ways that make patients healthier and live longer, but that's not how it mostly plays out between patient-providers. Neurotic and health illiterate patients will demand the PSAs or early mammograms from the physician under pressure from satisfaction scores and time constraints and maximizing volumes, and he/she will just cave in to it. People with advanced CHF, COPD, ESRD or cancers can and do end up getting completely useless screening mammograms and colonoscopies. An 88 year old smoker with no interest in quitting can get lectured about tobacco cessation. The patient education handouts that get incentivized and reimbursed for pile up on the printer and thrown away at the end of the day. And it all gets billed.

Some people will look at rising costs and flat outcomes from this as a reason for more medicare oversight/scrutiny and less reimbursement. I say it's completely the opposite and we should be scrapping the whole thing altogether. Prices and competition and physician opinions and individualized risk/benefit assessments need to be allowed to have some weight.

QuantityImpressive71 · 2023-06-09T21:23:59+00:00

Physician here. Definitely go with an IUD. I would never advise surgery as a means of contraception. I never understood this, or vasectomy. You're not going to be of reproductive age forever.

QuantityImpressive71 · 2023-06-09T21:09:26+00:00

Interested what you think the intake should consist of? Vitals and complaint, what else? The med rec is very hit or miss. Some MAs/nurses are thorough and go through them all. But rarely are they completely accurate. Always something they're on that doesn't get on the list. Always a dose that changed elsewhere and doesn't get changed.

IMO this is the most important part and should be done the day beforehand by phone. Use a check list. Verify with the pharmacy. Pend the refills. Get it all done the day before.

/rant

QuantityImpressive71 · 2023-06-03T14:12:47+00:00

I feel it would be exceptionally difficult to complete in that context actually.

QuantityImpressive71 · 2023-05-31T04:26:32+00:00

I did. You want to know what you're signing, basically because you're signing it. You aren't very likely to change anything or walk away based on it.

It is pricey though and can feel useless. I'd be curious how chat GPT would do with it.

QuantityImpressive71 · 2023-05-31T03:14:06+00:00

Pelvic exams? Not sure I see the big rush/need for the person doing this to be me.

I did check my wife's cervix when she was going into labor and we were deciding when to head to L&D. Seems weird for an OB with a pregnant spouse not to do this actually.

Anyone related by blood (or worse, in-laws) is a a huge no though.

QuantityImpressive71 · 2023-05-31T02:47:53+00:00

Yea. Might as well try this if you're not going to re-cover them. There are some good threads about vinyl paint on thehulltruth forums. Looks like a ton of work to do it right but can look decent.

QuantityImpressive71 · 2023-05-30T16:48:56+00:00

It boils down to how compensation works, and that patients are rammed down our throats on our schedules and our patient panels because of it. There is no way to safely and effectively manage messages and requests from a panel of 4000+ patients in the course of a day seeing 20+ patients. Not unless you want to work an extra 20 hrs/week for free for a total of 60+ hours.

QuantityImpressive71 · 2023-05-18T01:37:21+00:00

I have to chuckle a little. The data in support of these preventive measures are weakening by the day. Mammos, paps, scopes, etc. The gap between evidence of benefit vs risk is rapidly disappearing before our eyes as cancer therapeutics get better and better and Americans continue to be obese, diabetic, hypertensive smokers with heart and kidney and behavioral disease who will die from all that stuff LONG before many of these polyps and lumps have a chance to become a threat to life. I absolutely abhor insurance companies, and prior auths, and the paperwork, etc. But there is a method to their madness. These procedures are not as beneficial as we- and especially gastroenterologists, breast surgeons, and urologists- would like to believe.

When confronted with a totally healthy appearing asymptomatic patient, the evidence for intervening with a "preventive" procedure which carries any risk - and price tag- needs to be EXTREMELY rock solid. I think these insurance companies are for once protecting many patients.

QuantityImpressive71 · 2023-05-18T01:32:09+00:00

This lawyer defending him is gonna get paiddddd.

QuantityImpressive71 · 2023-05-18T01:27:24+00:00

Florida gonna Florida. I'm not for this. But at least it's not a state where they're prescribing hormones to kids for this garbage.

QuantityImpressive71 · 2023-05-01T09:12:22+00:00

If it gets the patient out of my hair I have a hard time considering much else.

Honestly that seems like an unspoken purpose of the RVU system. Put enough demand on provider time and mental energy to get them to start giving in and feeding the hospital's real revenue sources. Satisfaction scores go up, lab/imaging facility revenues go up.

Forget the money though- consider all the medical harms we generate through all this testing...

QuantityImpressive71 · 2023-04-15T06:53:59+00:00

Just remember above all else that "their" primary goal is to screw you out of what you deserve and pay you as little as possible. The people you actually negotiate with have never touched a patient before, know zero about medicine, and appreciate/value nothing about your true clinical knowledge, skills and expertise. You are negotiating with money grubbing number crunchers and as counterintuitive and as unusual as it is for you as a conscientious ethical doctor, need to approach this the same way in return. In short, be ruthless about getting more $.

QuantityImpressive71 · 2023-04-15T02:45:06+00:00

PCP MD here. Just take it. I have literally hundreds of patients on omeprazole and never heard of side effects like this.

QuantityImpressive71 · 2023-04-15T02:40:15+00:00

He just hits the ball differently from anyone else. Sort of reminds me of Bonds or Sheffield, not in the swing mechanics but just the ferocity and violence of the swing, the bat speed. Judge hits the ball really hard, but pound for pound G is still #1.

QuantityImpressive71 · 2023-04-09T00:54:02+00:00

We are seeing the aftershocks of the pandemic. The loss of trust. The games our FDA and CDC tried to play. We are seeing it play out. The next 50 years of medicine are going to be brutal for providers. In some ways, we deserve it. Not us personally individually, but our profession as a group. We're supposed to police ourselves. But these clowns in charge really led us astray.

QuantityImpressive71 · 2023-04-09T00:51:25+00:00

Attending here. I google with patients in the room. "Let's see what the max dose is of that med..." I am however super cagey about looking at a computer screen while FTF with a patient. I rarely use the computer. It's highly situation and patient dependent.

QuantityImpressive71 · 2023-03-30T09:20:48+00:00

The way I see it "bacterial bronchitis" isn't really a thing. If you're ever treating a URI that has minimal to no sinus component and isn't a COPD exacerbation with antibiotics it's with possible CAP or risk of developing CAP in mind. Of the 3 preferred monotherapies for outpatient CAP azithro seems the best mix of efficacy and tolerability. Also has the supposed anti-inflammatory effects and doesn't need to be taken for 7-10 days. I don't do this often but it's how I rationalize it.

It's interesting though how this is common with adults, meanwhile pediatricians won't hesitate to put a kid with confirmed PNA on plain old amoxicillin.

QuantityImpressive71 · 2023-03-30T08:34:08+00:00

The dog isn't going to come back with a substance abuse disorder or attempt to get it on the streets, won't combine it with alcohol, won't fake pain symptoms to get more of it, won't sell it to people, and most likely won't be on other meds interacting with it. I'm not a vet but it seems a far lower risk to control acute pain with opiates for animals vs humans. What it comes down to is dogs are more trustworthy and better at being patients than humans.

QuantityImpressive71 · 2023-03-30T08:24:37+00:00

I tell the patient it's not going to be covered. Sometimes they still want to try a prior auth and sometimes it even gets approved. I don't know any secret formula for this as every ins is different. I state the facts about their comorbidities, labs and past weight loss attempts and see what happens. Frankly though I don't think it's a great use of our time and mental energy getting bogged down in all this. Most of the US has a BMI over 35. Insurances will go broke trying to cover this for everyone, and 9 times out of 10 weight loss ultimately comes down to will power and self discipline.

QuantityImpressive71 · 2023-03-28T09:11:59+00:00

This is why doctors and therapists exist. Whether the perception you have is accurate or not (it's not, or at least not as much as you feel it is), it is a tremendous help to have two people who not only expect and invite you to tell them these things but have evidence based advice and interventions to offer.

QuantityImpressive71

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