Learn what physicians think about the real issues.

On Sermo, physicians collaborate on everything from patient care and medical ethics to healthcare reform and practice management. We’ve highlighted some of their most vibrant discussions on the Sermo Blog.





The most popular clinical discussions on Sermo this week


Best test for epidural abscess
Healthy young man. Fever and percussion tenderness of the spine. In the ER at 3am...
Authored by an Emergency Medicine Physician

Patient cannot lose weight - I'm puzzled
I see a lot of patients for weight loss and am generally not at a loss. A little basic calorimetry and it all makes sense. I just saw a patient at the end of last week that baffled me, however.
Authored by a Family Medicine Physician

Ulcerative proctitis: patient acceptance of topical therapy
Let's start with the guidelines. Both the American College of Gastroenterology (ACG) and the Crohn's & Colitis Foundation of America (CCFA) recommend topical mesalamine, such as suppositories and enemas, as first-line treatment of distal colitis.
Authored by a Gastroenterology Physician

Vitamin D Deficiency: Still underrated. Why?
From personal, anecdotal experience, the clinical significance and manifestations of the 'hormone', Vitamin D, in humans, continues to be underrated, unappreciated and largely ignored by a lot of physicians in clinical practice.
Authored by an Internal Medicine Physician

Keflex for UTI??
I just got an "on call" page...pt was in ER yesterday dx with UTI (maybe pyelo but not sure).
Authored by an Internal Medicine Physician

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The most popular practice management discussions on Sermo this week


Anesthesia residents and surgical attendings
I am a senior anesthesia resident at a major medical center and had a pretty infuriating experience last night on call.
Authored by an Anesthesiology Physician

What's the ICD-10 code for banging my head against the wall?
"The federal agencies that developed the system—generally known as ICD-10, for International Classification of Diseases, 10th Revision—say the codes will provide a more exact and up-to-date accounting of diagnoses and hospital inpatient procedures, which could improve payment strategies and care guidelines. "
Authored by an Anesthesiology and Pain Medicine Physician

AAFP Demands Primary Care Pay Raise
"Primary-care physicians are pressing the agency that oversees Medicare to change a payment system they say places a higher value on work done by specialists."
Authored by a Family Medicine Physician

HIPAA and contact with other providers
I'm wondering if someone could clarify the HIPAA rule(s) regarding sharing proected health information (PHI) with other providers. Here's my situation: ...
Authored by a Psychiatry Physician

Medicare to pay doctors $10,000 to renew contract?
UAW is renogtiating contracts with automakers. UAW pledged not to raise labor 'fixed costs' in new contract (ie, hourly wages.) But, they apparently want automakers to fork over $10,000 up front per worker as a "signing bonus" (well, it's a 'renewing' bonus, but that's just words.) Sweet!
Authored by a Rheumatology and Internal Medicine Physician

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The most popular clinical discussions on Sermo this week


Blood sugar 524. Would you send him home?
I know of another doc sending a 19 y/o athlete to the ER with a c/o myalgias, fatigue, polydipsia and polyuria. BS in his office was 438. No known h/o DM. Pt sent to ER for fluids/bloodwork/management and possible/probable admission.
Authored by a Family Medicine, OBGYN Physician

Clonazepam and Diazepam plus alcohol for sleep - what to do?
70 yo old very robust, educated white male taking no medications for HTN, cholesterol, etc. Type A, successful businessman, still working some. Broadly allergic to many herbal compounds such as melatonin and valerian root (skin rash). Was prescribed clonazepam for sleep problems 30 years ago and has continued use.
Authored by an Ophthalmology Physician

Cardiac Arrest in an 81yo Female
In the aftermath of "Hurricane" Irene, nearing the end of my ED shift, EMS called in that a BLS crew was bringing in an 81yo female in cardiac arrest from home, no ALS available. I cynically told the other docs who were on that I would take this one since...
Authored by an Emergency Medicine Physician

Need help with necrotic fingertip
4 yo healthy male saw dermatology 13 days ago for a wart on the tip of his right 5th finger. The wart was destroyed chemically with cantharin application per mom. The next day a brown blister began to form at the area of the topical application.
Authored by an OBGYN Physician

Superficial vs deep vein and what would you do?
there is acute occlusive DVT in two pairs of Gastronemius viens, from the pop fossa to the proximal calf. The gastrocnemius veins are dilated and non compressible. The pop vein is not invovled.
Authored by an Internal Medicine Physician

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The most popular practice management discussions on Sermo this week


Physicians Required to Re-Enroll in Medicare in 2013
Nearly all physicians must revalidate Medicare enrollment by 2013 Doctors are concerned that enrollment problems could lead some in good standing to get kicked out of the program.
Authored by a Family Medicine Physician

Just told "Primary care is dead Open and Urgent Care Center
I have been working on a business plan for a new Primary Care/Sports Med Clinic. I was talking with a vendor for equipment and he expressed that primary care is dying and encouraged me to open Urgent Care Center. He cited the lack of access to priamary care as a source of declining use.
Authored by an Emergency and Family Medicine Physician

Getting paid for after hours phone calls
How do all of you feel about using a 900 number after hours and on weekends?
Authored by an Internal Medicine Physician

Surgeons responsibility regarding CRNAs
While surgeons commonly order nurse anesthetists to give anesthetics, surgeons have no affirmative obligation to control the substantive course of the anesthetic process. To the contrary, a surgeon may rely upon the nurse anesthetist as the anesthesia expert.
Authored by a Family Medicine Physician

leaving solo practice
I currently have a practice 3 days a week at my main office, and 1 day a week at a secondary office that I sublet. I would like to end the solo practice at my main office and get a part-time salaried position, and yet maintain 1 day at my secondary office in solo practice.
Authored by a Psychiatry Physician

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The most popular clinical discussions on Sermo this week


Priorities- Please Give Some Input what to Tx 1st.
Corporate executive type patient w/ h/o morbid obesity, HTN, ankylosing spondylitis, obstructive lung disease of undetermined etiology, he calls it "adult onset asthma" (but I suspect it's actually due to GERD). He takes Benicar HCT, Mobic for back pain, Singulair and Advair (on and off if sx get worse) presented in the late winter for assistance with weight loss.
Authored by an Internal Medicine Physician

FDA recommending Celexa not be used at over 40 mg
The U.S. Food and Drug Administration (FDA) is informing healthcare professionals and patients that the antidepressant Celexa (citalopram hydrobromide; also marketed as generics) should no longer be used at doses greater than 40 mg per day because it can cause abnormal changes in the electrical activity of the heart.
Authored by a Psychiatry Physician

iConsult - Otolaryngology
When you take out a retained tube there for years with small surrounding small hole, is it really worth doing a paper patch? I have not been impressed with paper patch success Any tricks on keeping the patch on??
Authored by an Otolaryngology and Pediatric Physician

Pain management conundrum.
Patient with chronic pelvic pain being evaluated for possible diagnostic lap.
Authored by an OBGYN Physician

13 yo male w/UTI
pt is a 13 yo male who in july had several weeks of GI sxs ie "gassiness", swollen stomach, intermittent vomiting, stools loose and "explosive"; exam shows hypoactive BS and epigastric and LUQ tenderness w/o peritoneal signs; checked KUB, cbc, lytes, urine-all nl...
Authored by a Femily Medicine and OBGYN Physician

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The most popular practice management discussions on Sermo this week


Starting A Cash Only Family Practice. Anyone want to watch?
I am currently starting up a cash only family practice with my wife, a P.A. She and I have decided that our experience with managed care, insurance, government plans, etc is less than desireable.
Authored by a Family Medicine, Emergency Medicine, Osteopathy Physician

Am I coding wrong?
I work in a hospital owned family practice office and we have quarterly visits with a coder who continues to tell me that I am overcoding my visits.
Authored by a Family Medicine Physician

Can The "Mommy Track" Physicians Provide Excellent Care?
Controversial. Maybe offensive. No offense is meant, either to part-time physicians, or those on the "mommy track", usually women.
Authored by an Anesthesiology Physician

Concierge Anesthesia?
I was reading an article on Medscape about concierge medicine, and it got me thinking... How can I create a way to be a concierge anesthesiologist?
Authored by a Anesthesiology Physician

Exclusive question for small private practice Ophtos ONLY
This is a very serious question to fellow opthalmologists who are part of small private practices only and understand their practice finances. This does not apply to anyome else so please dont bother to read further.
Authored by an Ophthalmology Physician

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The most popular clinical discussions on Sermo this week


How would you handle this pain patient?
40's female, 7 years out from MVA which led to chronic MSK (no fxs) pain on opioids coming to your clinic for the first time. States she has been weaning opioids due to gastroparesis and now has significant increase in pain. Comorbidity obesity, anxiety, depression, fibromyalgia, on disability.
Authored by a Pain Medicine, Anesthesiology Physician

Eleven year old can't eat.
An eleven year old hispanic male has been having stomach aches for two years. Initially, he was seen and told it was due to stress/anger and to be more calm. Bloodwork done then was nl, including LFTs, CBC, h.pylori. .
Authored by a Pediatrics Physician

Hypertensive urgency, when to send to ER?
Do you have a certain threshold blood pressure value where you will reflexively send a patient to the ER for admission? Assuming an asymptomatic patient, would you send someone with a blood pressure of 250/110 to the emergency room?
Authored by a Internal Medicine Physician

"Do you smoke crack?"
I have 2 of these patients on service, one in the burn unit (pictured). They both smoke crack, one is neutropenic. What are your thoughts?
Authored by a Dermatology Physician

Unusual Case - Acute Retinal Necrosis from CMV?
She is an 81 yo F with an ocular history including advanced glaucoma OU s/p failed trab OD. She is phakic with a mild cataract OD and pseudophakic OS. No recent eye procedures or surgeries.
Authored by an Ophthalmology Physician

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The most popular practice management discussions on Sermo this week


Facebook use by staff--how can we end this?
Our staff has struggled with staff using facebook which "on the clock". We are told this, and believe its true, by our teenage children who work part-time and observe this behavior, especially by our front desk staff. They use it on our computers and on their cell phones.
Authored by a Family Medicine Physician

Do you charge patients for copying their charts?
Part of the answer has to do with business, and part with the complexities of the doctor-patient relationship. I know plenty of us honor a physician-to-physician transfer of a copy of a patient's chart with no fee at all.
Authored by a Pediatrics Physician

IT issues
I have been in solo practice almost 5 years. I have had an EMR from the get-go. I am on my second IT tech and I pay him by the hour ($100/Hr). There are pluses and minuses to every IT tech.
Authored by a Internal Medicine Physician

starting an LLC
After speaking with a business-minded colleague of mine, I've been thinking of starting up an LLC. Not sure of my exact plans, but toying around with the idea of some sort of "consulting group". From what I understand, I can get this going for a few hundred bucks by using LegalZoom.com (I imagine there are other similar sites as well) and can potentially make/save a decent amount of cash by doing this.
Authored by an Endocrinology Physician

No-shows and cancellations
Just curious how people's practices deal with no-shows and cancellations. Do you have a policy where pts are allowed a certain number of no-shows and cancellations, and then those pts are "fired" from the practice?
Authored by a Rheumatology, Internal Medicine Physician

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The most popular clinical discussions on Sermo this week


Newborn with skeletal abnormality
This 34 week gestational age female infant was born to a 21 yo G2P1 mother whose first child was normal. Delivery was by induction for worsening polyhydramnios.
Authored by a Pathology, Pediatrics, OBGYN Physician

Brown recluse identification and bites (Educational)
So, a gentleman in his mid thirties presents to you with this wound on his elbow. It is centrally fluctuant, with a little purulent drainage. He first noticed pain about 2 days ago. He might have had some subjective fevers, but otherwise no systemic symptoms.
Authored by a Emergency Medicine Physician

Five Days Old baby girl with blood in diaper!
The attached picture of diaper show fresh red blood on a diaper of a 5 days old baby girl. The material tested positive for blood. She has been having it for the last three days, mother brought diapers along with.
Authored by a Pediatrics, Psychiatry Physician

Facial papules in a 9 year old, molluscum?or other?
This 9 year old girl has had these flesh colored papules since age 3. Have been calling it molluscum but I'm not so sure, have never gotten inflamed,none have ever disappeared.
Authored by a Pediatrics Physician

Foreign body ingestion in a child
A 5 yrs old ingested a coin. No tracheal compromise. No acute issues. Serial X rays ordered. After more than 24 hrs hrs its still in stomach. Should the patient have an upper GI endoscopy to retrieve the coin or can it be watched closely for another day or two?
Authored by a Family Medicine Physician

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The most popular practice management discussions on Sermo this week


How Do You Measure Physician Productivity
Physician productivity in medicine is a controversial topic at present. The usual measures of number of hours worked or number of patients seen may be oversimplifying a very complex situation. Considering there is no agreed upon number of hours that is both safe and maximally efficient for physician...
Authored by an Otolaryngology, Pediatric Physician

Free Rx Pads
I am starting a new job and the electronic Rx , as we all know, is ok, but not the best. Is there a place online to order free Rx pads, i think i ordered from mediscript in the past for free, but it doesn't look like they still offer that. Anyone aware of any websites where i can order free Rx pads?
Authored by an Emergency Medicine Physician

How do you sell a medical practice?
I have been a solo family doc for 13 years. I am sure that like most of you the challneges have been numerous and every time more difficult. I am considering switching my career and look for an employed position.
Authored by a Family Medicine Physician

EMR cost analysis
Are there any spreadsheets/formulas out there to help determine the economic impact on individual private practice? I was going to start on my own but wanted to check and see if anyone else has done it already.
Authored by an Ophthalmology Physician

Help with incorporation
I'm starting a corporation for liability and tax purposes and have a couple of questions for the Sermo docs who have done this before: Any general advice?
Authored by an Internal Medicine Physician

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