Re left atrial appendage closure 💯 👇🏻
Today is the 55th anniversary of a war crime with no precedent in the modern era: the mass rape of Bangladeshi Hindu women by the Pakistani Army that was only stopped by the Indian Army.
Sadly, the US Administration (Nixon/Kissinger) sided with Pakistan but thankfully, the Indian army moved too quickly for them. 🧵
Daughter needs an ambulance — bill for this when company believes family has no insurance : $600.
Once they find out family has insurance , ambulance company sends insurance company bill for $2300. Insurance company “only” pays ~$1000, leaving balance of $1300 for patient.
More on “AI generated slop”
It was 1480, when 18,000 Ottoman Turks invaded Otranto in Puglia, Italy 🇮🇹, devastating it
800 young martyrs (male, over 15 years) refused to renounce Christianity and were beheaded
Today, their bones can still be seen in the beautiful Otranto Cathedral
This is wrong. I know because I finished after 1995. Someone does have an accuracy problem. And it isn’t @MaryBowdenMD
x.com/DrDiGiorgio/status/203…
This gets at a real frustration people feel, but I think it misidentifies where the pricing power often sits.
A very large share of Americans with private insurance are actually in employer sponsored self funded plans. In those arrangements, the employer is the one ultimately paying for the MRI, the surgery, the delivery, and the office visit. The insurance company listed on the card is often functioning mainly as a claims administrator, not the true purchaser of risk in the way people imagine.
That matters because it means the story is not simply “big bad insurer versus powerless hospital.”
In many markets, there are actually many purchasers of healthcare services, including employers, union plans, third party administrators, and insurers, but only a small number of dominant hospital systems selling care. So the hospitals have all the leverage.
When a hospital system controls enough beds, enough specialists, enough outpatient sites, and enough geographic territory, it can demand all or nothing contracts. Employers and plans are told to accept the entire system’s rate structure across the board or lose access altogether. That is consolidation driven pricing power.
So yes, insurers is an easy villian. Prior auth, denials, narrow networks, and opaque benefit design are all real problems.
But they are not the whole story, and they are not the main driver of high prices.
If you want to understand why an MRI at one site is a few hundred dollars and at another is many thousands, or why routine hospital based care is so expensive, you have to look at seller market power, especially large consolidated hospital systems that can command prices far above anything resembling a competitive rate.
There is plenty to criticize about insurers.
But on cost, the bigger issue in many places is that the purchasers of care have weak leverage and the sellers do not.
And the sellers know it.
To confirm, this “100% AI generated” passage is the opening of chapter 5 from Mary Shelley’s Frankenstein
💯
Allow the market to function by allowing balance billing (yes, I know that’s a scary word) , or allow Medicare dollars to be spent on direct primary care and seniors will suddenly have a lot more options.
Price controls lead to scarcity. Every time.
I just had 2 MRIs at @HoustonMedImage.
I was in and out in about an hour.
I paid $1250.
Katie the technician was kind, professional and efficient.
Parking was incredibly easy.
Same tests would have cost $3032 at Houston Methodist Hospital.
Do we have a physician shortage problem ? Yes, but it’s a created one related to incentives the system sets up.
Take residency spots— if you’re a health system executive of a small or large health system you would be dumb not to take advantage of a federal program that pays you for each trainee you enroll. The solution is not to build more medical schools to fill these residency spots.. it’s to significantly reduce or eliminate the federal subsidy. Make health systems pay for trainees. If you ask folks to put up money, you’ll immediately eliminate many poor quality residencies that exist as foreign medical graduate mills.
But what about the shortage of family practice physicians / nephrologists etc? This is created by a system that has completely devalued seeing patients in lieu of doing procedures on patients.
Medicare policy which is basically controlled by health systems and health insurance donors has essentially been boosting payments to hospitals and relative to inflation has actually cut payments for the the part of the visit where physicians talk to patients. If you participate in Medicare you are also not allowed to balance bill patients to make up for this.
The most successful health systems are ones that can efficiently label patients with a diagnosis that can translate to a billable procedure code. This means there’s a huge demand for talented proceduralists because they generate massive revenue for health systems. That demand translates to high wages for proceduralists which in turn makes procedural specialties and specialties that support procedures very high demand (orthopedics/neurosurgery/dermatology/opthalmology), and the non-procedural specialties (1º care, nephrology, psychiatry, infectious disease) low demand.
If you value procedures highly.. you get a lot of procedures. This has a good side : no one can touch American cancer mortality rates or per capita organ transplant rates. But the bad side: 50% of Medicare patients that get left atrial appendage occluders are dead in 5 years. This means we have tied up some of our smartest/most capable physicians in doing procedures on seniors in the waning years of their life.
So yes, that means we have a dearth of US trainedphysicians that will spend the time in an office to make sure grandma won’t get some meaningless drug or device.
Unless we fundamentally change the system we will continue to have a misallocation of physician capital that artificially creates a demand for non-U.S. citizen foreign medical graduates, and no amount of additional medical schools or loan forgiveness will help.
When you look at the escalation of healthcare costs, it's all tied to government intervention.
The biggest leap in bloat:
Omnibus Budget Reconciliation Act (OBRA) of 1989 and 1990
When you have enough cardiologists to have "pregnancy heart teams" do you really have a shortage of cardiologists ?
A informative thread that sheds light on physician shortages in the US .
In 1480 viel een Ottomaans leger (18.000 man, onder Gedik Ahmed Pasha) de Zuid-Italiaanse stad Otranto aan. Na 15 dagen beleg werd de stad ingenomen. De overlevende mannen (boven de 15) kregen een ultimatum: bekeren tot de islam of sterven. Ongeveer 800 weigerden. Ze werden naar de heuvel buiten de stad gevoerd (nu de Heuvel der Martelaren). Daar werden ze één voor één onthoofd.
De eerste was kleermaker Antonio Primaldo, die riep: “Nu is het tijd om voor onze zielen te vechten voor de Heer.”
De aartsbisschop werd voor het altaar van de kathedraal onthoofd.
Andere priesters werden doormidden gezaagd.
Vrouwen en kinderen werden als slaven verkocht of vermoord. Totaal: tienduizenden doden en duizenden in slavernij.
Dit was geen “normale” oorlog maar een religieus gemotiveerde slachting van weerloze christenen die weigerden hun geloof af te zweren.
Na de herovering in 1481 werden de lichamen (die maandenlang onbegraven op de heuvel hadden gelegen) verzameld en naar de kathedraal gebracht. In de Cappella dei Martiri staan vandaag de dag glazen vitrines vol met hun echte schedels – rij na rij, honderden stuks.
Een stukje geschiedenis dat zelden in de schoolboeken staat…
Anno 2026?
Kerken organiseren vrijwillig iftars wereldwijd..
Hebben die 800 martelaren hiervoor geleden?
Voor kerken die nu vrijwillig weggeven wat zij met hun bloed verdedigden?
The U.S. government invests over $21 billion annually in Graduate Medical Education (GME) to support ACGME-accredited training, primarily through Medicare.
Medicare provides the majority of funding, averaging $112,000–$129,000 per resident annually, with additional funding from Medicaid and the VA.
~2 out of 3 American applicants to medical school don’t get in. Given that medical schools have actively been discriminating against white and Asian citizens because of explicitly racist affirmative action policies, there are likely to be a fair number of perfectly capable American citizens who want to be doctors that don’t make it through the process.
Hospitals sees medical trainees as cash cows - federally funded labor — they dont care where you were born. It’s yet another nice arbitrage for your friendly non-profit that may be advertising in the next Super Bowl while sending uninsured patients to collections.
We need accelerated pipelines for American citizens to practice medicine. But as long as there is a constant supply of foreign medical graduates which hospitals are cashing in on, nothing will change.
Yes!
Too often physician solutions are bandaids that don’t address structural problems.
Stark is a huge competitive advantage for health systems, and basically forces physicians to operate under single npi’s which usually means 1 emr / 1 scheduling pathway/ etc.
End it.
Haven’t looked into this myself. But given recent history, certainly believable.
I really enjoy reading posts from Sergei. He provides an unvarnished peek under the hood of so many health tech companies.
He unpacks the @doctronic story here. It’s worth a read.
TL/DR: too many companies business models are built on threadbare data, glossy pitch decks and fawning press releases.
I was rooting hard for Doctronic, the self-proclaimed “AI doctor,” when it secured a contract with the state of Utah earlier this year for automated AI prescription refills.
But as it turns out, sometimes a Cinderella story is just what we want it to be perceived as. In reality, @doctronic appears to have quite a few dirty secrets and outright red flags, which I dig into in my latest investigation:
https://www.fixhealth.ai/p/doctronic-the-ai-doctor-with-a-dirty
That’s 9 zeroes and a lot of fraud!
18 states have passed legislation streamlining the licensing process for internationally-trained physicians to work in the US, and another 23 states are in the process of passing legislation.
This effort is being funded by @AFPhq and @ckochfoundation.
Fascinating case series and discussion of the rise in severe cutaneous adverse reactions (Stevens Johnson Syndrome / Toxic Epidermal Necrolysis ) that happened in the COVID era.
Interestingly cases rose even as new COVID cases receded.
Everyone in the case series was vaccinated.
Authors posit causes as Covid/vaccines/both.
https://www.sciencedirect.com/science/article/pii/S0305417923001286
No lies detected.
Also doesn’t cover the massive amount of Medicaid fraud unleashed with Medicaid expansion.
The secret recordings: Texas Tech's senior official admits that they lied about me in the official documentation leading up to my medical school dismissal
For months after I began writing about how wrong the medical and scientific communities had gotten the COVID-19 response, senior Texas Tech administrators had been engaged in a flurry of internal activity about my public speech. They did not debate my views. They only discussed what to do about the attention.
My right to free speech is protected under the United States Constitution. Texas Tech is a taxpayer-funded agency that must guarantee its students First Amendment rights. Its Student Handbook promises to uphold them.
Senior administrators, including deans of multiple schools, held several meetings about what I wrote online. They instructed administrators to compile surveillance dossiers -- screenshots, PDFs of my articles and tweets, negative emails and hearsay. They instructed faculty not to say good things about me. They assigned me a "professionalism coach," Cheryl Erwin, who posed as an impartial advisor but privately wrote that I engaged in "intellectual narcissism" and believed in "conspiracy theories."
In one passage, she compared my case to the Trump indictment and his denial of the 2020 election results. She wrote that I was exercising my First Amendment rights to "make an idiot of himself."
I questioned the wisdom of lockdowns and the effectiveness of masks. This warranted, it appears, my very own Stasi dossier.
I was aware of none of this until I exercised my statutory right to inspect my educational records. After dozens of email exchanges, months of delay, and a federal complaint to the Department of Education, I was finally able to inspect them two months ago.
Dr. Erwin had accused me of believing in conspiracy theories. I did not.
But I should have.
Shortly after the dean of the medical school demanded my signed Honor Code and asked "what rotation is he on," I began receiving evaluations from Texas Tech faculty that were false and misleading. This went on for months. Something on the order of fifty discrete complaints were made against me. Prior to that, the number had been zero.
I filed seven detailed complaints according to the Student Handbook and under the guidance of several administrators. I alleged that my evaluators had fabricated evaluations. I demanded hearings to hold them accountable.
On November 4, 2023, senior administrator Simon Williams signed a document removing me from campus on the pretext of being dangerous. A BOLO was issued telling students, faculty, and employees to call 911 if I was seen. Mass emails warned that I was dangerous.
An incident that continues to be cited to this very day, more than two years later.
On November 5, Dr. Williams invited me to a sandwich shop. He confessed that he knew I was not dangerous. He admitted that Texas Tech faculty and administrators felt threatened by my complaints -- and took it out on me.
In other words, Dr. Williams confessed that he lied in Texas Tech's official documentation and that the campus removal was retaliation for constitutionally protected speech alleging wrongdoing by Texas Tech faculty.
Here are just some of the things he told me:
"This profession expects more of everyone. And if you choose to enter it, by definition you choose to live by those professional rules."
"And you know, free speech is free speech. We've actually had a lot of talks. Our lawyers are doing works with us. Just yesterday when I was at the meeting, they were talking about free speech. I mean I'm 100%. I want you to be able to say whatever the frick you want. And I won't get -- I usually will not get in any way triggered by it. But when you're in a position that's such a trusted position in society -- then your standard has to be a little bit. And that's one of the places this is becoming a problem." [Timestamp: 00:34:48]
"Can I say in my appeal letter that Dr. Williams seems to believe that I'm not [nervous laughter] homicidal?"
"I... I have said that. I don't think you are. I don't think there's -- I've never sensed threat or danger or anything like that." [Timestamp: 00:34:48]
"But it's important for me that I do this. In fact, that's why I moved back from Seattle a day early. Because I needed to be here today. I want you to know that because I never felt [inaudible] bad here. I've always enjoyed my interactions with you. I wish other people could see it that way, but apparently that's [inaudible]." [Timestamp: 00:34:48]
Yet in his letter authorizing my removal just the day before, he wrote:
"You have engaged in behavior that may constitute violation(s) ... specifically, but not limited to ... 'Physical harm or threat of harm to any person.'"
Then an appeal hearing was held.
A Schrodinger's Administrator of sorts, just as soon as Dr. Williams was observed to speak publicly, he immediately asserted that I was indeed dangerous and should be kept off campus, flip-flopping back from the position he communicated privately.
The timeline:
November 4: "Physical harm or threat of harm to any person"
November 5: "I've never sensed threat or danger or anything like that"
November 9: Kevin is dangerous actually
To be clear. Under 18 U.S.C. § 242, it is a federal crime to willfully deprive a person of constitutional rights under color of law.
A federal crime.
And that is exactly what Dr. Williams did.
Dr. Williams's decision to remove me was not impulsive. Nine months earlier, two days after my Newsweek article was published, he wrote in internal emails:
"It is obviously protected speech but also quite concerning in the way he appears to speak for the medical community. We need to discuss an appropriate response." -- February 1, 2023
"I am not surprised that there was backlash. I think it will be best to hear what legal says we should do." -- February 2, 2023
The "appropriate response" took nine months to execute.
It was relentless, and it came from all directions.
This "appropriate response" was precisely the one I filed grievances to confront.
And I was met with calls from the campus police.
I am not the first one Texas Tech has done this to.
How do I know? An administrator told me.
At least one other student had false allegations leveled against him because the administration wanted them gone.
And if they win, I won't be the last they do this to either.
I only discovered these emails because I exercised my right under FERPA to inspect my educational records.
Now Texas Tech's litigation counsel, Assistant Attorney General Scott Smith, has recently blocked all further access to my records -- in writing.
If Texas Tech does not fulfill its FERPA obligations, it could lose all federal funding.
Texas Tech, apparently, is getting very nervous.
Smith also ordered me to stop contacting the Registrar and to route all requests through him.
That's right.
The attorney defending Texas Tech against my lawsuit is now trying to establish gatekeeping control over my education records.
That's illegal.
A federal complaint is pending with the Department of Education and other federal agencies.
@TheFIREorg @glukianoff -- crickets
@CivilRights -- you have my complaint
@KenPaxtonTX @OAGTexas -- your AAG is doing a terrible job; borderline sanctionable; I don't get it
@GovAbbott -- this your university
@TexasTech -- Williams was not the top of the decision tree; I know that for a fact
@Newsweek -- help me publish my story
@ACLUofTexas -- do you know about this?
@dojphofficial @HarmeetKDhillon @PamBondi -- theoretically, this is prosecutable under 18 U.S.C. § 242. I'm not a prosecutor, but it does theoretically fulfill the elements. Willful.
@CreightonForTX -- you are the chancellor. Do something.
My case is a strange one. It gets stranger everyday. It will get stranger still. Of that I am sure.
Here's something strange: the defending Assistant Attorney General and two colleagues are getting hammered on the docket by a pro se plaintiff.
They seem utterly incapable of following court rules, making coherent arguments, or even properly citing their own exhibits or authorities.
I suspect that they just don't know what to do with my case.
In the next post, I will begin telling that story.
You won't believe it.
Texans, your government is setting your taxpayer money on fire to defend a university that set out not just to destroy a medical student's career, but his personal and professional reputation as well.
Remember. They destroyed me because I was damn good at what I did.
Now I'm an order of magnitude better.
And I don't bluff.
Horror and laughter.
Those come next.
For Indian cardiologist colleagues - travelers from the U.S. who could recently have been bitten by the lone star tick may have symptoms everytime they eat any mammalian meat (pig/beef/goat/lamb)
31-year-old woman with repeated anaphylactic reactions 3-6 hours after eating mutton:
https://pmc.ncbi.nlm.nih.gov/articles/PMC12357717/
Unexplained perioperative anaphylaxis?
Great thread on an emerging pathogen👇🏽
Who can blame him? He was 8xing his odds of admission!
R to @anish_koka: The good news: alpha-gal sensitivity can fade over time IF you avoid further tick bites.
The bad news: one more bite resets the clock.
A detailed exposure history — including where your patient has lived and what's been biting them — is still the most powerful diagnostic tool we have.
R to @anish_koka: A special note for cardiologists and surgeons:
In the landmark UVA series, 24% of alpha-gal positive patients had severe allergic reactions to heparin during cardiopulmonary bypass. Higher IgE titers predicted who reacted.
Hawkins et al., Annals of Thoracic Surgery 2021 https://pubmed.ncbi.nlm.nih.gov/33031779/
Intraoperative anaphylaxis during aortic valve replacement has been reported with undiagnosed AGS - https://www.jacc.org/doi/10.1016/j.jaccas.2025.106033
Unexplained perioperative anaphylaxis? An important addition to the differential: undiagnosed alpha-gal.
R to @anish_koka: Why should this be on every clinician's radar?
The CDC has flagged alpha-gal syndrome as an emerging public health concern.
Cases are rising fast — tracking with the expanding range of the Lone Star tick, now well beyond the Southeast into the mid-Atlantic and Midwest.
The July 2023 MMWR mapped ~90,000 suspected cases from 2017–2022 and flagged it as an emerging public health problem: https://www.cdc.gov/mmwr/volumes/72/wr/mm7230a2.htm
42% of 1,500 healthcare providers surveyed had never heard of the syndrome, and another 35% weren't confident in their ability to diagnose or manage it CDC: https://www.cdc.gov/mmwr/volumes/72/wr/mm7230a1.htm
R to @anish_koka: You send a serum alpha-gal IgE level.
It comes back markedly elevated.
The combination of the clinical story + elevated IgE level cliniches the diagnosis.
You tell him: no more beef, pork, lamb, or venison. Poultry and fish are fine.
You prescribe an EpiPen and refer to an allergist.
His nocturnal episodes stop completely.
R to @anish_koka: What selective pressure drove the loss of alpha-1,3-galactosyltransferase in the Old World primate lineage?
The leading hypothesis is pathogen-driven selection. Several major pathogens exploit alpha-gal on host cell surfaces as a binding target — certain strains of Plasmodium (malaria), trypanosomes, and various enveloped viruses can use alpha-gal as an entry point or display it on their envelope after budding from host cells.
The idea is that losing alpha-gal gave our ancestors two advantages: it removed a pathogen docking site from our cells, and it allowed the immune system to produce natural anti-alpha-gal antibodies (which we all have in large quantities) that could target pathogens displaying alpha-gal on their surfaces. It's essentially a form of innate immunity — you preemptively make antibodies against a sugar you don't express yourself.
This would have been strongly selected for in Africa and Asia where malaria and other alpha-gal-exploiting pathogens were endemic.
New World monkeys, evolving in South America with a different pathogen landscape, never faced that same selective pressure, so they kept the gene.
Compelling hypothesis, but not definitively proven.
R to @anish_koka: Back to alpha-gal syndrome
What makes alpha-gal unique among food allergies:
→ It's a CARBOHYDRATE allergy, not a protein allergy → The reaction is DELAYED — typically 3-6 hours after eating → This delay is why it's so often missed
A steak at 8 PM = anaphylaxis at 2 AM.
R to @anish_koka: You may have caught the Old-World monkey part.
What's that mean - you ask ? (Skip this and the next reply if you aren't interested.)
Old World monkeys are from Africa and Asia — think macaques, baboons, mandrills.
New World monkeys are from Central and South America — howler monkeys, spider monkeys, marmosets.
The evolutionary split between Old World and New World primates happened roughly 35-40 million years ago when South America was still separated from North America and drifting away from Africa.
For the alpha-gal story, the relevant point is that the loss of the alpha-1,3-galactosyltransferase gene happened in the common ancestor of apes/humans and Old World monkeys — so both groups lack alpha-gal on their tissues. New World monkeys actually do still produce alpha-gal.
Technically a marmoset burger could also give you the same syndrome - luckily, no one eats marmoset or gorilla burgers so this is mostly a really fun academic interlude to torture medical students with.
R to @anish_koka: Alpha-gal syndrome is correct. It is an IgE-mediated allergy to galactose-α-1,3-galactose — a sugar molecule found in virtually all non-primate mammalian meat.
It's caused by bites from the Lone Star tick (Amblyomma americanum).
When the tick bites, it transfers alpha-gal into the person's bloodstream, and the immune system produces IgE antibodies against it.
Then, when that person later eats red meat (beef, pork, lamb, venison), they can have an allergic reaction, typically 3-6 hours after ingestion of the meal.