Alex D. Bibbey, MD
@thats_bone
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Diagnostic radiologist, opinion haver, runner. Health policy, economics, law and finance. Partner, Greensboro Radiology, Duke Radiology '17. Opinions my own.
Durham, NC
Joined March 2014
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Patient in the ED with post-operative pain, discharged from the hospital yesterday, called surgeon's office this morning and nobody called back so they were forced to go to the ED. Don't be this surgeon, y'all.
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It is difficult to express how funny something like the "world record for reducing epigenetic age" coming from a tech bro sounds to a medical professional
Bryan Johnson spends $2 million a year to be 18 years old again.
In 2021, he reduced his epigenetic age by 5.1 years in 7 months (a world record)
His 13-steps for a long healthy life:
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@quality_nguyen
@AshleyGWinter
Imagine you are the grad student that had to take blood draws on a hibernating bear
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Good morning to everyone except people who insist that it is incorrect to say "right middle lobe" and you should only say "middle lobe" because there is no left middle lobe
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Literally everything about EPIC EMR makes more sense if you understand that it was built from the ground up as a billing engine and incidentally happens to have a bunch of bolted on patient care documentation and communication features
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@DougJBalloon
Christopher Columbus, who I do not support, was the most important free speech hero of the 15th century | Glen Greenwald, NYT Opinion
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Based on the ER notes I see on a regular basis, I feel like there is a certain segment of the population that is in quite a bit of denial about marijuana induced cyclical vomiting
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By age 30 in radiology, you should have:
-PTSD from the sound of the phone ringing on call
-had barium sprayed onto you during a fluoro case
-accidently said "period" at the end of a sentence at least once while talking to a normal person
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You would be surprised at how often we see CTs for this finding.
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I often think about how multiple choice testing is far and away the most highly rewarded skill at all levels of academics, from grade school testing through medical board certification, and how little relationship this has to the actual skillset required to practice medicine
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@mattyglesias
If I was a shareholder of any of these companies I would certainly have a lot of questions about how it is possible to effectively manage three multibillion dollar corporations while also not seeming very busy most of the time
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Diagnostic radiology, just saying 🤷♂️
my dream is to have a job where i can go to work and do my job and get paid and nobody is mean to me and then i go home and never have to think about it
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I am a:
⚪️ boy
⚪️ girl
🔘 radiologist
Seeking a:
⚪️ boy
⚪️ girl
🔘 useful clinical history and top differential considerations
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Please think hard before you follow up renal cysts with an MRI in a patient over 90 years old.
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@kjdelay1
The ER nurse has put in more Foleys than if Frederic Foley himself was still alive and placing them
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This is an extremely controversial opinion, you've been warned, but: I like being a doctor and I think it's a good career choice
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Saw somebody comment in a private doctor group that "medicine used to be a ticket to the middle class but no more", which is just the most doctor bubble-brained thing you can think as a member of the highest paid profession in the entire world
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I did my intern year cardiology rotation with another intern who was a practicing cardiologist in his home country. Very convenient for us on the rotation but what a dreadful waste of his time and talents 🤷♂️
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@DougJBalloon
The Progressive Case for Andrew Cuomo, Who I Do Not Support | By Glen Greenwald
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Funny, but the chronic misconception of radiology as a banker's hours 9 to 5 subspecialty really amuses those of us who are putting in the hours on call to provide patient care 24/7/365
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@atrupar
It always seemed a little on the nose that there was a facility for the purpose of remitting large bribes to the President located just down the street from the White House
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@DougJBalloon
This parody Twitter account to real life NYT opinion reverse feedback loop is just the gift that keeps on giving
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Doctors offering the option to quickly respond to and manage your health needs from the convenience of your own home, at a significantly lower cost than an office visit? What absolutely unhinged thing will they think up next?
Hopkins announcing that they’ll be billing for MyChart messages is truly a new low lol
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Every incidental subcentimeter cystic pancreatic lesion you choose not to see is $10,000-$25,000 of nearly zero yield follow-up imaging over a decade your patient doesn't have to have; thank you for coming to my TED Talk
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Radiologist opening the 8-year follow-up MRI for a 0.7 cm pancreatic cystic lesion
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@DougJBalloon
Tell us how you literally enter the pop culture psyche of a 70 year old woman to write these brilliant bad puns
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Remember! As a radiologist, the style of your reports has to please a wide variety of readers, including patients, primary care physicians and APPs, subspecialists, and coders/billers, but MOST IMPORTANTLY, other radiologists on Twitter
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I don't know who needs to hear this but it is completely okay to not even mention benign incidental findings like cysts in your reports. You are sparing patients anxiety, referring docs phone calls/chart messages about incidentals, and unnecessary, expensive follow-up imaging.
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@DGlaucomflecken
Whoever sat down and really figured out that commercializing journal publication, creating expensive monopoly pricing on institutional subscriptions, and then co-opting an army of free labor could be an extremely profitable business model was an evil genius
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Counterpoint: staging is not medically emergent, ERs and radiologists are insanely busy on call, and it is a disservice to the patient to have the staging exam read by an on-call radiologist when it could be done by a specialized body or chest imager on the next business day.
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Physicians are bad... because a pharmacist recognized classic, boards question symptoms of type 1 diabetes in a child? I don't really follow the argument implied here 🤷♂️
Physicians: *complaining about not getting paid for MyChart messages*
Pharmacists:
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Patient: "how do I know that you are a competent and safe radiologist?"
Me: "Don't worry, I answered about 50 online multiple choice questions for Maintenance of Certification last year"
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Stop making fun of older kids who still believe in Santa Claus. There are still radiologists who believe that incidental pancreatic cysts need to be followed by MRI for 10 years.
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It is very interesting that, completely by coincidence and unrelated to my personal biases, all radiologists who read faster than me are missing too many findings and all radiologists who read slower than me are not working efficiently enough.
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@shycollie
@tafolabi_MD
@RIDICULO_pathy
Fair warning, pointing out that doctors make lots of money later in their career and have extremely high lifetime earning potential is not popular around these parts
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@BTiff
@AshleyGWinter
Radiology has literally nothing to do with the clinical management of this problem but I nonetheless feel comfortable offering our endorsement as well
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The huge income disparity between procedural specialists and primary care is a much bigger problem in American healthcare than medical school student loan debt
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@2Davez
Similar story: as a student worked on a surgery rotation day and night with a surgeon including 20 hour days taking calls for organ donors. Asked for LOR on last day of rotation and emailed my CV. He pulls out his phone and goes "who the hell is this guy who just sent me a CV?"
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There are interesting things about being a radiologist semicolon for example comma you live in constant fear of accidentally dictating punctuation while talking on the phone and sounding like an insane person period next line
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As it just so happens, the way I personally prefer to dictate radiology reports is objectively correct. Therefore, in this thread I will carefully explain to you all the important musts and must nots when writing reports. The first topic is the use of "There is" 🧵 1/482
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STAT inpatient MRI abdomen for renal cyst characterization, discharge pending, you say
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@kenklippenstein
Probably just a coincidence that the party fueled by racism, anti-semitism, disinformation and conspiracy theories dominates the count of people banned from social media platforms for spreading racism, anti-semitism, disinformation and conspiracy theories
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My number one piece of advice to any radiology resident or fellow: get as much exposure to general radiology as possible, preferably in an on-call or moonlighting environment. It's the most important career skill set for the majority of practicing radiologists.
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Seems really weird that densely populated countries with strong social norms of wearing masks in public during respiratory pandemics fared much better with COVID, doesn't it? Maybe "masks aren't helpful" was just a bunch of intellectual backfill for our deadly shortage of PPE?
German medical association advises everyone to wear a makeshift mask at all times👇What of the widespread ‘expert’ advice we’ve heard for weeks that makeshift masks are pointless + masks bought at pharmacies were for those with infection to wear to protect others???
#coronavirus
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Really disagree with this - as with every form of resume gatekeeping for medical school entry, creating a language proficiency *requirement* will advantage people whose parents can afford fancy language tutors.
The ability to speak Spanish should be a REQUIREMENT for entering medical school in communities where 1/4 of patients of the population are Latino. That means that every medical school in some states like California would require medical students to know the language before…
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oh you like bad boys? well sometimes I don't report subcentimeter cystic lesions of the pancreas and don't recommend 10 years of incredibly low yield MRI follow-up
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As with all language, the way radiologists phrase their reports is heavily influenced by whatever their attendings preferred while they were in training, and yet every radiologist seems to have some kind of comically elaborate lore that explains why their way is the One True Path
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Radiologist reading the ACR whitepaper guidelines that say a small incidental pancreatic cyst needs to be followed by MR for 10 years
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A lot of radiologists discovering during this contrast shortage that 1/2 or 1/3 the typical dose is almost always sufficient for basically any exam. There's literally no exam that requires 150 mL of Omnipaque!
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Radiologist spending 10 minutes talking about a CT in multidisciplinary conference with 15 cases on the list
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Sincere question: if you are going to order a PE study on a patient even if the D-dimer comes back negative, why are you ordering the D-dimer?
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@Sludge
@ParkerMolloy
@FidelityChrtbl
What is really happening is that individuals are donating to individual DAFs and directing Fidelity's DAF admin to make donations to hate groups (which are organized as charities) and Fidelity simply does it. Then in tax filings, the donor is listed as Fidelity.
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@tiredmedstuden1
Part of being in medicine, unfortunately, is being around a lot of people who are in relatively blind bubbles of privilege whether it be flying around all over the world all the time or my personal favorite, complaining about student loan payments while making $300-500k a year
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"It turns out that seasonal epidemic influenza is completely optional" is an extremely underrated story, isn't it?
We carried out a great big experiment in public health last year. It worked. Let's do it every year now!
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Good morning to everyone except radiologists who recommend thyroid ultrasound to evaluate an incidental heterogeneous thyroid in an elderly patient with metastatic cancer 🌞🌞🌞
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@KurteL10
Every sharp, every procedure. Anything less is careless and irresponsible towards the safety of your staff.
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@mkraju
Wow I am just shocked that this guy was anything but an absolute paragon of medical professionalism. Who could have ever seen this coming
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Today is Friday; "STAT read needed, Dr's office closes at 2:00 p.m. today" is now my absolute all time favorite STAT indication
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CT PE *plus* CT abdomen pelvis from the ER 🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩🚩
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Potentially hot take: side gigs and other various forms of hustle culture for physicians are mostly a waste of time relative to maximizing your professional income, and very few of them actually improve work-life balance
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@DGlaucomflecken
Yes exactly. The reason that this crazy arrangement works, for which there is no analogue anywhere else outside of literal charity, is that academics are required to write papers for free in order to get jobs, promotions, and raises.
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Another quintessential textbook for any radiology resident, I don't sit down to the workstation without a copy of this handy:
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My very controversial opinion is that pharmacists are not trained to diagnose and treat illness, and should therefore not be reimbursed for these services. I guess I am part of this problem 🤷♂️
@thats_bone
It’s about being accessible, creating less barriers & doing your job yet receiving no reimbursement & being told your job isn’t clinical & being told you don’t deserve reimbursement for clinical services. The fact that you don’t get it means you’re part of the problem.
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@PoleDoctress
Lol imagine looking at that list of ingredients and being like, "as a normal human this is what I should eat for breakfast everyday"
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@mattyglesias
Say whatever else you want about Donald Trump and his extended family, but you can't deny that their criticisms of Hillary Clinton and her emails were made in good faith and they took government information security rules seriously at all times during the Trump administration
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@mattyglesias
But you have to admit it is very funny to watch the crypto ecosystem recapitulate the history of banking regulation by stumbling across all the reasons why various things are in fact regulated, for example wrong way risk in margin lending
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The volume of material one must learn to reach the minimum standard of knowledge and competency as a radiologist in clinical practice seems very daunting, but with a modest time commitment to studying during your residency, say merely one textbook per week, it can be achieved
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Please, please do not do this in the ordering comments of an *X ray*. I promise you I will report on the presence of "bone pathology" and both "old" and "new/acute" fractures even if not specifically instructed.
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Please do not waste anybody's time with facial bone x-rays if you have any actual clinical concern for a facial bone or orbital fracture, please and thank you
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@bemooremd
@NColemanMD
But don't forget: you love pie, you've dreamed about eating pie since you were a kid, and the only thing you can imagine yourself doing with your life is eating pie! 😂
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When the ED orders a CT head neck angiogram, PE study CT chest, CT abdomen pelvis with and without contrast, and a lower extremity runoff
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Look, I'm just saying, if you're in academic medicine and there's a Vice Chair of this or an Associate Dean of that in your department doing little or no clinical work: someone is paying their salary and it's probably you!
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I maintain that it is in fact possible to afford a place to live, own a car, go on vacation, and raise your children with a mere $200,000 a year income
@thats_bone
@TimDHWoo
Seriously? Are you thinking about those who chose to go down the ROAD - rad onc, optho, Ortho, anesthesia, derm? Cause a PCP/peds/gerontologist bring in 200 K. Try to buy mid range house, mid range car, go on mid range vacation with that salary, 200 k of debt and 2 kids.
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@gretchemaben
@dancindoc1022
@Hilton
My response to this would be that housing you for the duration of your locums contract is still their problem to deal with, whether it is in their budget or not in their budget. Hope you get this sorted quickly. What a pain in the ass in the middle of a work week.
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@ali_oats
I think you have no real choice but to offer this candidate an in person interview at this point
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It's like my work day hasn't even started until I have a CT for pulmonary nodules in front of me where on the prior one year ago I dictated "no further follow-up is indicated for these definitively benign nodules"
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This is a definitively benign finding that does not require CT work up. I have seen this queried as a pulmonary nodule several times in my career. What is this and what is it called? Answer below.
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ED triage nurse notes: "unwitnessed fall, found down in burial chamber, not responsive to stimuli, last seen normal 600 BC, CT head, cervical spine, facial bones, chest abdomen pelvis, spinal reformats"
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@DrLongissimus
The fact that attendings often work harder and longer than residents and fellows is an extremely rude awakening for a lot of people
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Looking at the most recent match statistics, we should be in panic mode as a profession attempting to increase compensation for primary care and make it much easier for qualified international doctors who want to work in primary care to immigrate to the US
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@TirathPatelMD
23 (!!!) APPs lol, just goes to show you that nobody puts up with bullshit like captive resident labor. PS if you are a surgical NP or PA willing to work at UNM I bet you can negotiate very good terms right now 😅
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The logic of "Report what u see. Period." falls apart under very trivial scrutiny to anybody with experience in interpreting radiology. For example, abdominal pain CT: Do I measure every normal organ and lymph node? Describe DDD level by level? Report normal ovarian follicles?
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Good morning. I don't know who needs to hear this, but 👏 Don't 👏 Order 👏 STAT 👏 CTs 👏 For 👏 Pulmonary 👏 Nodule 👏 Follow-up! 👏
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Just thinking about how many RVUs first year radiology associates read -and what a scandalous racket it is to pay radiology fellows $70,000 a year while saddling them with a bunch of unwanted chores like reading stacks of plain films on off hours
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@DougJBalloon
We Wanted to Understand the Situation with Amherst College's Dining Halls, So We Talked to Six Unvaccinated Trump Supporters at an IHOP in Florida | NYT Opinion
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Good morning to everyone except sonographers who send 6000+ cine images to PACS on an ultrasound 🌞
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Thank you to the x ray tech for clarifying in the exam notes that the toddler getting a chest x ray is in fact a non-smoker
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I've already ignored a clinically unimportant thyroid nodule and subcentimeter pancreatic cyst, avoiding thousands of dollars of unnecessary, low yield workup and surveillance, so basically today is already a success 😊😊😊
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@dfreedman7
AntiAPP docs: the thing that separates APPs from physicians is our thousands of hours studying evidence based medicine
Also antiAPP docs: NP/PA residency programs that provide thousands of hours of supervised training are bad
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There's a serious global shortage of iodinated contrast. So naturally one of the first cases I read today was a contrast enhanced chest CT for indication of interstitial lung disease.
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