Kevin Pho, M.D. @kevinmd

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A stage four diagnosis is a fact about one disease. It is not an explanation for a new emergency that follows it. An internal medicine physician watched what happens when those two things get confused. Her sister went into the hospital with epigastric and abdominal pain. She had a history of stage four breast cancer, but that was not why she was admitted. Staff tried to place an NG tube in her room, could not, and took her to place it under anesthesia. The next morning her sister arrived with a room number and worked out in the elevator that the number was inside an ICU. Her sister was intubated, on a ventilator, on a cardiac monitor, unconscious. A young physician stood at the foot of the bed. He never looked at her and never gave his name. Asked how a patient goes in for an NG tube and ends up on a ventilator, he said: she has stage four breast cancer. Told that this was not an answer, he said it again. It was not an answer. The metastases were in distant lymph nodes, not the viscera. And nothing about a preexisting malignancy explains acute respiratory distress in the immediate aftermath of an invasive procedure under anesthesia. That is the diagnostic error, and it is worth naming precisely: a chronic diagnosis was used to explain an acute change of state that it could not possibly have caused. Her abdomen had been distended for over twelve hours. The eventual CT showed free air. Surgery found a tear in the posterior fundus of the stomach, a recognized, rare complication of the procedure, with gastric contents spilling into the peritoneal cavity. In that situation every second is precious. Nothing happened for almost 18 hours, and it happened then only because a physician who was also a family member escalated it in the room. The surgeon told her afterward she did not think the patient would survive the night. She survived that night and the next. She never came off the ventilator and died several days later. Months later, the hospital reported that the investigation found no one had done anything wrong and had been closed. The clinical lesson, in the physician's own words: a patient with advanced cancer can have other things wrong with them, things that are not cancer, things that are imminently treatable and even curable, and if we assume otherwise, certainly in the absence of proof, we do our patient a profound disservice. The reasoning failure is anchoring. A known malignancy is the most available explanation in the room, so it gets applied to a presentation it does not fit, and the search stops there. The cost of stopping is measured in hours. Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What is the anchoring diagnosis in your specialty that most often stops the workup early? #ThePodcastbyKevinMD

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Bone fell out of a patient's foot wound, in the office. The kind of clinic that saves limbs like that is disappearing. The office belongs to Devin Zarkowsky, a vascular surgeon in solo practice in Fallbrook, California, an unusually underserved corner of San Diego County. He chose it on purpose. In training he studied the barriers that keep people from vascular care, and a mentor's 2013 map showed the parts of the country carrying heavy amputation burdens from peripheral arterial disease and diabetes. He landed in one of them, and stayed. Two things are true about his patients at the same time. There is vascular care 20 miles north and 20 miles south of town, a drive they could make. And a dying limb is exactly the thing that makes that drive not happen. The condition that needs the trip is the condition that takes the trip away. Separately, he sees people in his own town who will not drive more than 15 or 20 minutes for care, even with a toe that has already turned black. Staying close to home is a pattern he first saw in residency. It holds. He breaks access down into four things a patient has to have all at once: 1. Enough savvy to know the care exists. 2. The resources to get it. 3. The mobility to physically reach it. 4. The wherewithal to navigate a complicated system once they arrive. Peripheral arterial disease attacks the third one directly. Which is why a specialist inside the town changes what happens to a limb in a way a specialist 20 miles away does not. There is a line in the episode that stays with you because of how small he makes it sound. By being in the town he is in, he says, he provides that resource without much effort. Without much effort. The entire difference between a saved limb and a lost one, in some cases, is a door that happens to be close enough to reach. Fallbrook's medical fabric has been worn thin by consolidation in the region. Zarkowsky moved into the gap, the way his father ran a solo dental practice in a small town for 40 years. When Kevin Pho asked where his patients would go if he were not there, his answer was the whole story: "The answer in many cases is they won't." Not to the clinic 20 miles north. Not to the one 20 miles south. Nowhere. Listen to the full conversation on The Podcast by KevinMD. Link in the replies. #ThePodcastbyKevinMD #PeripheralArteryDisease

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When a heart stops, the person restarting it is working from memory. Looking it up means stopping. Stopping makes it worse. That is the actual design of cardiac arrest care in 2026, and it is worth sitting with how strange it is. Anesthesiologist Michael Peck spent a career leading codes, sometimes after midnight in an operating room as the one person who had to take charge, calling for help. No one was coming. What he describes is a task that would strain any unaided human operator: multiple medications, timers, rhythm changes, communication demands, and documentation, all at once, with the algorithms timed in minutes and every step pulled from recall. And where does that recall come from? A recertification course that might have been a week before. Or a year before. Aviation looked at this exact class of problem and solved it decades ago. Pilots run emergencies with checklists and decision support. Nuclear operators do the same. Nobody calls that weakness. It is how high-reliability industries treat human cognition: as a known-limited resource you design around. Medicine made the opposite bet. Peck pitched building the resuscitation algorithms directly into the monitor in 1991. The manufacturer said no. The technology was not ready then. Today it is not the barrier. More than 30 years later, the person running a code is still expected to hold the whole sequence in their head. The trap is self-sealing. You cannot pause a cardiac arrest to consult a reference, because in Peck's words, "Once you stop something, the prognosis gets worse." So an aid that requires stopping will not get used, and hospitals have not put one that avoids stopping into the room. Even the learning loop inherits the flaw. Hospitals review their cardiac arrests, but the reviews rely on documentation and memory, and memory is unreliable after extreme stress. The lessons from the failures and the successes both degrade before anyone captures them. Peck's deeper reframe: we talk about errors in a crisis as individual failings, when many are the predictable consequences of human cognitive limits under stress. That single sentence moves the problem from "train harder" to "design better," which is where aviation and nuclear power already live. "Medicine works best when we stop pretending that we are superhuman as clinicians." Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What is one high-stakes task in your field that still runs entirely on recall? #PatientSafety #ThePodcastbyKevinMD

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A doctor heard what one prescription cost: $250,000. His first words: "You must be mistaken." The drug is from 1950. Here is the whole story, and it is worse than the price. The drug is Acthar Gel, an old hormone first used in 1950. All it does is tell your adrenal glands to make more steroids. When synthetic steroids arrived in the 1980s, it was nearly dead. No market, no reason to exist. Then a company used an old FDA loophole to relabel the same drug a "biologic." No new trial. A biologic faces no competition, which means no price ceiling. One course of the same old drug now costs $250,000. That covers supply. The demand side is the part worth sitting with. The sales reps who push it show doctors a zero or 20 dollar copay card. They never say the cost. The neurologist who wrote that $250,000 prescription thought he was ordering a cheap old generic. When Bharat Desai, an internal medicine and pulmonary physician, told him the real number, he could not believe it. The rep had never told him. The marketing says steroid-sparing. Desai's correction, on the show: it is not even a substitute. All it does is make your body produce more steroids. And it is still being pushed right now. A rheumatologist told Desai the drug reps keep pressing him to write it. Desai's advice was three words: don't do that. And the payers cannot stop it. A lot of the Medicaid budget is being drained into this one drug. Medicare is bound by rule: if a drug is approved and a physician writes the indication, it has to pay. It cannot even bargain on the price. How does a drug like this keep moving? Four ingredients, every one of them from this episode: 1. An obsolete drug with an old approval still on the books. 2. A loophole relabel with no new trial. 3. A copay card that hides the real price from the prescriber. 4. A few key opinion leaders, paid with research money, speaking fees, and industry-financed CME, whose word a time-starved field takes on trust. Desai calls the result "corruption dressed as science and woven into the culture of medicine." He compressed the whole mechanism into one line: "The shepherds were bought and the flocks followed them into the ditch." What would actually force the real price in front of the prescriber before the signature: regulation, payer rules, or the profession policing itself? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. #DrugPricing #ThePodcastbyKevinMD

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Your clinical knowledge does not protect you from depression. If anything, it gives you the tools for denial. That is not a slogan. It is what it took Kenneth Scott Burnham 23 years as a board-certified emergency physician, and one night in a hospital parking lot, to learn. He knew the signs and symptoms of depression intimately. He had described them to patients his entire career. Loss of enjoyment. Poor sleep. Shifting moods. A dark cloud. When they showed up in his own life, he rationalized every one: long shifts, no sleep, getting older. As long as he could still work in the emergency room, he told himself he was doing fine. The rationalizing ended in a hospital parking lot after a long shift, unable to start the car and go home to face another day. So he asked for help, the thing he had watched patients do his whole career. He made an appointment with a family physician. He had never had one. The doctor he saw was one he had trained when she rotated through his ER. Sitting in that waiting room was exposing. When she asked what brought him in, everything he had planned to say vanished. All he could manage: "I am in a really bad spot, and I need help." Then came the part he thought he understood: recovery. He wanted the Zithromax treatment: five days, then better. Recovery was two years of medication adjustments, therapy, and cycles of ups and downs. He knew clinically that exercise mattered. It still took two years before he could walk around his own neighborhood on a regular basis. The gap between knowing what helps and being able to do it is real, and we do not account for it when we discharge patients into it. He saw the system from the other side of the gurney, too. Very good at stabilizing people. Very poor at helping them figure out what comes next. Discharge instructions, follow-up advice, a list of phone numbers, and we call that a job well done. That gap between stabilization and being well is enormous, and it is where the relapses happen. And the culture. He had the vocabulary to describe what he was going through the entire time. We all do, he says. But the professional risk is too great, so the suffering stays silent. When he finally spoke, the surprise was how many colleagues texted, "Hey, I have been there." His story became a permission slip: if this guy, 23 years in the ER, ends up in a parking lot unable to start his car, maybe I should be honest about where I am at today. He left clinicians three things. One, you are not immune. Your clinical knowledge does not protect you. Two, the patient experience is not what you imagine from the other side of the table. There is shame at discharge, paralysis at the pharmacy counter, a gap between knowing what to do and being able to act, and we do not account for it. Three, asking for help is a clinical act, not a personal failing. Give yourself the same grace you give your patients. The physician who gets help is not the weak one; he is the one who is going to be around in 5, 10 years. And if any of this lands close to home, 988 is available 24 hours a day. What would you say to the colleague you suspect is holding the line the way he was? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. #ThePodcastbyKevinMD #PhysicianMentalHealth

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A 47-year-old woman went to her doctor in pain. Exam, X-ray, six weeks of physical therapy. No improvement. Her doctor ordered an MRI. An insurance company said no. Not medically necessary, not until she finished six weeks of physical therapy. Her doctor pushed back: not only had she already finished the six weeks, the insurance company itself had paid for them. The denial stood. The appeal took 38 days. When the insurance company finally reversed itself, she got the MRI immediately. It found a sarcoma in her hip. Memorial Sloan Kettering told her that a month sooner, chemotherapy alone would have treated it. Instead they amputated her leg, her hip, and her pelvis. She died two years later. Now the part most people never see. The insurance company had published its own criteria for approving an MRI: pain, a doctor's visit, six weeks of physical therapy. She met them. They did not follow their own criteria. By law, the reviewer who denies your scan is supposed to be a doctor in the relevant specialty. A federal Inspector General report found reviewers often are not, or have minimal experience in the specialty they are ruling on. That is against the law. A pediatrician deciding a radiology appeal. The family sued. In court, the case collided with two walls. Wall one: the statute books. Doctors, nurses, podiatrists, dentists, and hospitals are all held accountable for bad medical advice, and it is written into law. There is no law in New York holding an insurance company accountable. One might infer insurance companies have clout. They are big lobbyists. Wall two: ERISA. Most insurance plans fall under the federal ERISA law, where the bar for bringing an action is far higher than in state court. Almost nobody can even get these cases in front of a judge. This one slipped through only because the plan covered public employees, outside ERISA, so it could be brought under state law. A federal judge threw it out anyway. "This is tragic, but there's no law in New York that holds an insurance company accountable when they give medical advice that's wrong." He said he was not about to make new law. The appeal went to the Second Circuit. The lawyers asked the court to certify the question to New York's highest court: does existing New York case law already cover this? And the profession showed up. The American Medical Association and the medical societies of New York, Vermont, and Connecticut filed friend-of-the-court briefs. This is not just one family. What attorney Steve Cohen, who brought the case for Mrs. Valenti and her family, wants patients and physicians to do in the meantime: appeal every wrongful denial and stay with the appeal. They count on you wearing down. Get the denial in writing with the reviewer's name and specialty. Physicians: write it in the chart. Dr. So-and-so from this insurance company denied the MRI. It builds the record for the appeal, and for the lawsuit nobody expects. And the frontier: tortious interference. When an insurance company steps between a doctor's recommendation and a patient's care, is it interfering in the doctor-patient relationship? The courts, he said, have never squarely ruled on it. Has an insurance denial ever changed the course of care for you or someone you love? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. #ThePodcastbyKevinMD #PriorAuth

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Food allergy deaths are rare. The mistakes that cause them are really, really ordinary. Medicine keeps reassuring people with the first sentence and moves right past the second. A teenager in California went to a school dance. She took a bite of a cookie that was said to be safe. It wasn't. Her auto-injector had allegedly been left on the party bus, and the bus was gone. Reports said the other kids were doing CPR on her in the parking lot. A girl in Florida took a bite of the wrong chocolate chip cookie at a friend's house. Same brand. Same red packaging. Peeled back, so she couldn't see it was the peanut butter one. A parent offered it to her. Tragedy ensued. Lianne Mandelbaum, founder of the No Nut Traveler, tells both stories. Then she tells one on herself. She is a diligent parent of a teenage son with a severe allergy, and she once clicked the wrong brand of ice cream cones in an online grocery order. Her husband called: "Are you trying to kill Josh on my watch?" The cones came studded with peanuts. Her argument is aimed at how clinicians and journalists frame the risk. Comparing anaphylaxis deaths to a lightning strike sounds reassuring and reads as dismissive, because the comparison hides the denominator. Nobody encounters lightning all day, every day. Someone with a food allergy encounters food all day, every day, and every encounter carries the potential for a fatal error. The deaths are rare. The exposures are constant. The analogy erases exactly that. The stigma compounds it. In a Northwestern study she co-authored, with almost 5,000 respondents, more than 13 percent of people reported hiding their food allergy from airline crews out of fear of repercussions or ridicule. Hiding the condition from the people who would treat you is the predictable product of being laughed at, doubted, and called hysterical. And the tools lag behind the rhetoric. Every commercial flight carries a defibrillator. There is no requirement for epinephrine auto-injectors. A physician described her own life fading in front of her mid-flight because the emergency kit held only vials and, at first, no doctor could be found. Meanwhile, she notes, stock epinephrine in schools has mostly been used on kids who never knew they had an allergy. Nobody's first allergic reaction should be a fatal one. Blaming the person who made the mistake is a cop-out. Nobody chooses a food allergy. Nobody chooses a fatal error. The families sharing these stories have just buried a child or an adult. As she puts it: "We don't get a do-over." Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What's the ordinary mistake you've caught yourself making with something high-stakes? #ThePodcastbyKevinMD #FoodAllergy

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There is now a name for a growing kind of medical malpractice: wrongful prolongation of life. Keeping people alive against their clearly written wishes. Under the Patient Self-Determination Act of 1990, a patient has the legal right to refuse treatment. Hospitals are learning in court that a signed directive is an order, not a suggestion. In 2011, a dentist in New Rochelle, New York was diagnosed with early-onset dementia in his fifties. He immediately wrote his advance directive with one clear provision: if he ever reached the point where he could not recognize anyone, comfort care only. No IV fluids. No antibiotics. Let him go peacefully. Five years later he fell, did not recognize his wife or his two adult sons, and was brought to the hospital. His wife held his healthcare power of attorney. The family handed over the advance directive and the POLST. It said comfort care only. The doctor gave him antibiotics, a CT scan, and IV fluids anyway. The antibiotics kept him alive an extra month. His family had to witness the suffering. For years, courts threw these cases out. Providers had a kind of blanket immunity. They kept the patient alive, so how could it be wrong? Plaintiff lawyers would not take them. Then Georgia. A grandmother made it clear she never wanted to be intubated or put on life support. Her granddaughter, in her twenties, was her surrogate. They intubated the grandmother anyway. Years of appeals followed, and the courts in Georgia ultimately ruled the patient had the right to say no to treatment, even lifesaving treatment. The case settled for a million dollars, one of the first of its kind. The floodgates opened. Why does it happen? A new doctor arrives in the ER and never asks the code status. Documents are inaccessible. And sometimes it is ego. As patient advocate Althea Halchuck, EJD puts it: the doctors are trained to keep people alive, they are not trained to let them die. What protects a family: only about 30 percent of Americans have an advance directive, so choose a surrogate who will actually go to bat for you, not just the next closest relative. The New York case has not settled. The defendants just exhausted their last appeal, which means it is heading to a jury. Who in your life would actually go to bat for your wishes if you could not speak for yourself? Listen to the full conversation on The Podcast by KevinMD. Link in the replies. #ThePodcastbyKevinMD #PatientRights

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The classic ADHD checklist had 59 questions. Seven were about inattention. That is most of the story of why a generation of women got missed. It was built in the sixties, seventies, and nineties, around a picture of ADHD that looked like a boy who couldn't sit still. Very visible, impossible to ignore. In girls it looks different. Not rambunctious, but restless. Fidgety, talkative, rapid speech, a mind that drifts mid-task. The inattentive kind is more common in women, and it is exactly what those old tools were worst at catching. So a lot of girls read as fine on paper while struggling their whole lives. Then the recognition came from an unexpected place. During the pandemic, women started seeing themselves in each other's posts, and new diagnoses in adult women nearly doubled from 2020 to 2022. People named it for each other before the system named it for them. Here is the part worth saving. Estrogen is made by the brain itself, not only the ovaries, and it helps regulate dopamine, serotonin, and norepinephrine. It rises and falls across the month. When it drops, in the days before a period, women with ADHD can hit real dips in attention, memory, and focus, and they appear to feel it more than women without ADHD. Same brain, different week. Researchers are only now studying what that means through perimenopause and beyond. So a woman can spend years being told she is inconsistent, when the truth is that a neuromodulator of dopamine is cycling through her on a schedule and nobody ever charted it. Arti Lal, a pediatrician who has spent 14 years diagnosing and treating ADHD, put the gap simply: hormones have been entirely left out in 50% of the population, and we are only coming to that now. Even after 14 years of this work, she says: I wish I had known this before. ADHD has been trivialized and stigmatized for a long time, more so in women. Recognition isn't a diagnosis. If this sounds like your life, that is a conversation for a real assessment with a clinician. Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What did it look like in your life before anyone named it? #ADHDinWomen #ThePodcastbyKevinMD

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An ICU nurse wrote one sentence about her job and it was shared 59,000 times: "I am an ICU nurse. We are drowning." What the essay never captured is what the years after it did to the nurses in it. Lauren Powers is a critical care nurse at a small community hospital. At two in the morning there, she says, there is no perfusionist. The nurse is the perfusionist. Every medication and every device on the unit can save a patient or kill them, and she is the one managing all of it. There is no backup specialist to call down the hall at that hour. The judgment is hers, in real time, with a life on the other end of it. She remembers a patient whose balloon pump, seated in his aorta, was supporting his failing heart. At shift change the alarm sounded that means the pump is seconds from powering down. A stopped balloon can shower clots. She wiped the line with alcohol swabs to read whether the blood was inside the device or outside it. Five nurses were already at the bed, each doing the next thing before she could say it. They FaceTimed the device rep at two a.m. The patient was okay. Then the pandemic's first months arrived. Her unit surged to five ICUs with the staff for two. There is not 150 percent oxygen, she says, there is only 100, and some nights you watch that math play out and can do nothing about it. Of the six or seven nurses who worked her unit's hardest night, three are still there. The unit is now, by her estimate, roughly 80 percent travel nurses. She has watched the light and the spark people had for this profession leave them, and calls it what it is: heartbreaking. What she holds onto is that she gave everything she had, and sometimes it still isn't enough. The essay did something she never expected. Strangers wrote to tell her she had said the thing they could not: thank you for saying the words that I can't. That is the part a nursing-shortage chart never shows. Not just how many nurses left, but how many are still there carrying a night they will never put down. The number that went viral was five words on a hard shift. The number that matters is three of seven. What kept her was never the staffing or the schedule. It was her coworkers. She says she could not have survived that night without them. You don't know how much your work family means to you until they start to leave, and no one will ever be able to replace that bond. Listen to the full conversation on The Podcast by KevinMD. Link in the replies. Nurses, and everyone who works a job like this: what is the one shift you know you will never forget? #ThePodcastbyKevinMD #Nurses