Emergency physician, Charleston. Building Palmetto Medical Defense Consultants. Defense only. Also shipping RefAssess for referee coaches and mentors.
Charleston, SC, USA
Joined January 2009
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Heading to #HLTHUSA next week as an emergency physician.
My filter for every booth: what happens when this tool meets a packed ER night, and what does the chart show afterward?
Who should I find?
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An ER doc signs an AI-drafted summary. Now the doc's name is on every line.
Nothing shows which parts were checked against the source and which were accepted as written.
If you sign it, chart what you verified: meds, allergies, timeline.
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I'm still working full-time ER shifts while I build.
Not out of nostalgia. The shifts keep the problems honest.
Every messy handoff and every login that eats the first five minutes of a shift is a spec I didn't have to guess at.
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At #HLTHUSA as US Clinical Partner for @ElectronRx.
A 30-60 second phone camera scan reads breathing and heart rate at home, so clinicians can follow COPD and asthma patients between visits.
ER doc in Charleston. Building PMDC and RefAssess on the side. Say hi.
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"Doctors want to keep you sick."
Spend a night in a trauma bay after a rollover. The whole team is working to get one person home, and none of it is a business model.
The system has bad incentives. The people at the bedside aren't one of them.
The idea doctors want to keep you sick because it's somehow good for us is totally absurd
Do you think trauma surgeons want to see more people horribly maimed by car accidents so they get more work?
Listen to yourselves
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What the chart has to show at shift change: 3 things.
Who owns the patient now, what's still pending, and what would worry the next doc.
A handoff that lives only in conversation leaves no record of who knew what.
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I built RefAssess between ER shifts. No CS degree, no team. 10 assessors are testing it now.
Why it exists: feedback written days after a match is feedback written from memory.
Same as a chart. The best note gets written while the shift is still in front of you.
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An AI tool gets it wrong in the ER and a patient is harmed. Who should answer for it first?
67%The doctor who signed
33%The hospital
0%The vendor
0%Depends on the tool
6 votes • Final results 2
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The ER Version of prior auth: there isn't any for the emergency itself.
Coverage is supposed to follow the symptoms, not the final diagnosis. Crushing chest pain still earned the workup, even if it turned out to be reflux.
So chart the symptom in the patient's words.
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COPD flare-ups despite maintenance therapy are some of the most common ER visits I see. Every one starts the same way: "I'm using my inhalers, I just can't breathe."
New therapies like tozorakimab only help if we find the right patients. That means testing, not guessing.
That's why I'm proud to be US Clinical Partner for ElectronRx. We're talking about exactly this at #HLTH2026. ElectronRX.com
Who should be getting tested earlier?
COPD can be associated with exacerbations despite maintenance therapy. Two phase 2 trials tested add-on tozorakimab, a monoclonal antibody that inhibits interleukin-33 activity. Research findings from the phase 3 OBERON and TITANIA trials are summarized in a new Quick Take video. nej.md/47Edhqp
ALT A visual representation of the OBERON and TITANIA trials, which assessed tozorakimab, a monoclonal antibody that inhibits interleukin-33, to reduce COPD exacerbations.
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A board complaint never asks what kind of doctor you are.
It asks what you did, why, and whether the note shows it.
In the ER, I write every note assuming someone outside medicine will read it with no context.
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Physician by night, founder by day.
The honest part: something always gives. Tonight it's sleep. It can never be the patient.
Doctors building on the side: what's the one thing you refuse to let slip?
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RefAssess update: last week I asked for 5 referee assessors to test it. The X post got 0 replies.
It has 10 testers now. None came from X.
Lesson: the people I'm building for aren't scrolling here. The next ask goes where they already are.
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When an ER chart gets reviewed in a lawsuit, what's hardest to reconstruct?
100%What we knew, when
0%Why we waited
0%What the patient said
2 votes • Final results 63
The ER Version of scope of practice: the debate is about who can see the patient.
The chart asks something else. A co-signature is one click at the end of a shift. In a deposition, it reads as supervision.
For the defense, who actually saw the patient is the first question.
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Busy Monday yesterday. Morning: on set with @WCBD talking about a question I get every shift: ER or urgent care?
Quick version from the ER side: Chest pain, trouble breathing, stroke signs, a bad head injury, or "worst I've ever felt"? Come to the ER.
Sprain, cut, sore throat, UTI symptoms? Urgent care is usually faster and cheaper. When in doubt, come see us.
Evening: back to building…
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From the ER side of building: I made RefAssess myself between shifts, no CS degree, no team. Big AI made the code cheap. It didn't make knowing the workflow cheap. A tool nobody opens mid-shift is worth zero. Is domain the last moat?
I keep saying this but if you understand basic economics the only one winning here is Big AI and Big Tech
It's a race to the bottom for anyone else in software
So try become a co-owner of big AI and Big Tech stock and survive off their dividends and/or stock appreciation
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An $84M chest pain verdict, and most of the takes blame the PA.
From the ER side, I'd look at the schedule first. 20+ patients a day, two visits, and chest pain in a 53-year-old man. The system set that clinician up to miss it.
Defense lawyers, how often does the schedule get as much scrutiny as the clinician?
Ughhhh they had a clinic PA seeing over 20 patients a day and this led to provider missing ACS (acute coronary syndrome) in a 53 year old male patient (who happened to be an exec at Ernst & Young). Patient was evaluated twice for chest pain … and both times the PA appears to have misdiagnosed him with something benign.
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