Throwaway05
4hr ago
Hypnosis is actually not fake, it just doesn't work the way people think it does. It's used in modern (Western) medicine it just doesn't really work well and the real version isn't mega useful so you don't hear about it a lot.
Throwaway05
7d ago
I mentioned this before, but I again recommend you read "Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process" by Nancy McWilliams.
Easy to grab a copy on the high seas, you'll find it will expand your view of human behavior outside just the DSM (see: neurosis) and it's written in basic enough English that anyone clinical will get a lot out of it. Hell, I've tossed it at some of my big business family members to help them understand toxic behaviors in finance.
Previously I would have hit you with "no you'll have these patients in every field and it is going to help." Now I am very pleased to hit you with "bruh it's your field, get a bit ahead of it."
Throwaway05
7d ago
Dr. House doesn't really exist, the equivalent in real life is something like a specialty tumor board at a premier research institution, which is a group of knowledgeable specialists "discussing" the specific approach to a known problem (and rarely trying to figure out what the problem is or arguing over what it is).
Your situation is different in that you know what the problem is, and it's a basic diagnosis, but you can't seem to get it treated. It's not unreasonable to be like "okay what's up we need more options, more heroic measures."
However, my suspicion is that you need to go back to basics.
Basically - you need therapy. Medication may not help in the way you want it to help.
This doesn't mean you should give up on medications, you can always try more/different SSRIs etc. to find something that hits for you, but at a basic level you have to keep in mind that some things are more responsive to medication than others and this includes in psychiatry.
The classic example non-psychiatric example is insomnia (well some consider this psych). We have meds. We have a lot of meds. We have really expensive meds. We have really dangerous meds you should never use but people demand anyway and have really bad outcomes. What works for insomnia? Behavioral modification and therapy. Works (maybe an exaggeration, maybe not, I'd have to review the data) orders of magnitude better than meds.
In psych - for people with certain types of depression (terminal cancer? live in an active war zone and your family all got blown up?) medications aren't going to work for a lot of people. Therapy is generally going to do more.
Back to anxiety.
Anxiety often requires higher doses of medications (sometimes to the point where the side effects outweigh the value), but best practice is essentially to have medications lighten the load enough for therapy to be useful and helpful.
You don't need a genius psychiatrist, you need an excellent therapist (can be a psychiatrist), which is not the same thing and is something you can absolutely pay for if you wish in most metro areas (and a cheap, serviceable therapist may do). It is possible that a slightly more clever psychiatrist would throw something on that would solve the problem but that should be a secondary goal.
Now I don't know what your relationship with therapy is but you might be skeptical about it and might be asking why that would suddenly be a thing you would need now later in life after medication worked for so long. Additionally, if you are posting here you are probably intelligent, high resource, and rational - and thinking because of all that therapy shouldn't be needed. Unfortunately that's not how this work.
For example: a lot of anxiety related behaviors and experiences are basically just good old Pavlov fucking with your nervous system. Don't matter if you are mucho smart, if the bell goes off you'll salivate.
I wonder if a process like that happened here - you went off the med and expected something to happen or something happened, you felt like the safety net was gone, you had experiences, they rapidly reinforced themselves now you are in an anxiety spiral..... one you'll be able to get out of with time and space maybe, but faster and more effectively with some skills training, CBT, whatever - all with medication as a supportive factor. The meds are often a crutch, and therapy skills can be more definitive treatment (one of the reasons why you may want to avoid meds for anxiety).
Keep in mind that other conditions often work very differently.
It may also be reasonable to see your PCP to rule out any medical problems (not that they are likely) and assuage any health anxiety.
Throwaway05
16d ago
Fuck. I need to get a drivers license already.
Yes.
Also do keep in mind that the USMLE is a total horror show, my suspicion is that the switch to pass/fail for Step 1 probably puts "not entirely committed" people in a bind because it's harder to tell if they are excelling at the level they will need for still scored Step 2/Step 3.
Throwaway05
16d ago
Hell yeah man. As we say in the states: P=MD.
You can always catch up on whatever you feels is lacking once you have freedom to move, the hardest part is getting to the spot you just got to.
Scotland seems beautiful anyway.
Throwaway05
25d ago
Assuming not a joke - relativistic kill vehicles.
Throwaway05
26d ago
Unfortunately, as someone pointed out downthread, "monetizing their skills" these days increasingly means going into tech or pharma, rather than actually, y'know, treating patients.
This is a really important point in my mind, you can argue that doctors aren't the smartest people in the world but by the time you get into late training you've demonstrated that you are among the hardest working (24-36 hour shifts, 80+ hour weeks for some specialties) and best at stupid box checking.
Throwaway05
26d ago
People fuck this up constantly. Educated people. Smart people. People believe in antibiotic stewardship until they have a cold and demand antibiotics "just in case." People take medications and are told "no really tell me if you start supplements or something really bad could happen" and then something really bad happens. People are told "don't eat before your expensive, time sensitive, maybe life saving surgery" and then they eat. Sometimes they die because they eat and we can't do surgery.
See front page of meddit today for a discussion on colonoscopies.
People can't be trusted to do a good job of this, and that includes health care professionals (including doctors). Thus the waves of verification.
Throwaway05
26d ago
That's all stuff which is much amenable to discussion and debate (even if we disagree) but these are unrelated to my problem with your post which was the gross factual inaccuracies.
It's several orders of magnitude more common for a doctor to start making 250K a year at age 32 with a half million dollars in debt than it is for a doctor to be making over 750k a year, which nearly zero are doing through clinical duties alone.
Your comment, much as I loathe to use this term, is misinformation.
"What is the right amount of money for a doctor to make" is a reasonable question but it's functionally entirely unrelated to healthcare costs in America.
Throwaway05
26d ago
Do keep in mind that the UK does its own thing and doesn't map well to the process in the U.S. (or other western countries).
At an extreme example if you want to be an electrophysiologist in the U.S. you'll be doing a minimum of 16-18 years of training after high school, with many looking at 22 years. During 8 of those years you will be working 60-80 hours a week with some programs closer to 100 hours a week. Even if the years are the same you are doing twice* as much work during each year (is that sane? No. But it is).
All the while you are dealing with an average student loan debt of around 250k, with that number not counting interest or all the rich kids (who are admittedly a fair chunk) with zero debt.
If you want anybody in the U.S. at all to do that you need to offer them a pretty big carrot. And you do want them to do that - we've seen the outcome disparity between U.S. MDs and other populations (most notably of late, midlevels).
AND.
Lower quality doctors (or doctor replacement) increase overall healthcare cost due to increased unnecessary testing. Very well documented at this point.
You need to change the regulatory and malpractice environment first if you want any of this to work, which nobody seems to be interested in doing, and if you did things would cost less without coming for MD salaries at all.
*these days 1.5 times the work is much more common and realistic but that's still a fuck huge disparity.
Throwaway05
26d ago
Most European countries have 6 years of combined med school and undergrad (see: Germany) vs. 4 years of undergrad + 4 years of med school in the U.S. these days 1-2 gap years is also common, with 3-5 being uncommon but not rare (for things like PHD, MPH, MBA).
The amount of debt is important because it is relevant to the level of pushback you get for changes, and the fact that if you cut salaries by half and allow limitless importing of doctors then you will have pretty much zero people applying to med school in the U.S. overnight (and that would be the rational response). People still interested will do PA/NP school instead.
Do also keep in mind the quality difference which is real but is frequently not acknowledged.
Throwaway05
26d ago
That attitude leads to things like the opioid crisis where the rest of society is left cleaning up the mess left behind by people making questionable decisions.
A huge chunk of healthcare costs these days are associated with lifestyle related problems. That's going to get worse if you have 100k people fuck up their kidneys and need dialysis.
Negative externalities are a thing.
Throwaway05
26d ago
Pretty much everything you've said about the doctor side of things is wrong and much of it borders on malpractice. Frustratingly, I've corrected you on some of the clear matters of fact in the past and you've refused to update, so I guess this is more for the benefit of others who may be looking.
-Physician salaries are not responsible for high healthcare costs. They are a low percentage of healthcare costs. 8.6%. Half physician salaries (which nobody is suggesting and would collapse the system anyway) and you would barely make a dent in cost. Data: Stanford (SIEPR).
-Anesthesiologists do not make 700K a year. The average salary of a gas attending in the northeast is 380k. Data: MGMA survey (granted the one I have is a few years out of date).
--Can a gas attending make that much? Probably not in a desirable geographic area but if they want to work 2x full time or take a lot of weekend/holiday call they can get close. Maybe in L.A. if they do celebrity work, pain management or something like that? The ones I know who crack that level make the money off of owning something, patents, or something else of that nature, not working.
--On a more editorial note, why does gas make $$$? Gas is like being a pilot, most of the time it doesn't look like you are doing something outside of take off or landing but you get paid for the hopefully rare emergencies. Additionally procedural work reimburses well in the U.S. for historical reasons. Fix that problem if you want.
-The average physician salary is 350,000 in 2023. Not far off from Cim's range. Data: 2023 Mescape reports.
-Over half of doctors are in the "low paying" specialties where it's not uncommon for your salary to be under 200k (IM, FM, Peds, Psych). Depending on where you work and what you do you may be able to go over 500k but that's pretty much 95% percentile and involves shady cash only practice or working exclusively night shifts in Arkansas.
-No specialty makes over 800k without it being "fair." What do I mean by that? To make that much you are doing something like cash practice plastic surgery for wealthy people in LA, own and run a business (unrelated or related), have patents/high level consulting work, work 350 days a year (yeah people do do this), or are a neurosurgeon (egregiously long training, work hours, stress, and competency requirements).
-Doctors. Do. Not. Make. Millions. A. Year.
-The federal government is in charge of residency spots. However, state governments and private companies can and do make their own residency spots. We've had a bunch of recent scandals about this as the residents have been critically undereducated and frequently unhireable outside the system that trained them (specifically: HCA in Florida). Turns out medical education is complicated and you cannot just increase spots this is most true in surgical specialities which have small number of highly trained doctors, but also represent most of the specialties making the most money.
-The AMA is not a cartel. Most physicians hate the AMA and have for decades, as they've been lobbying for depressed physician salaries in the form of increased midlevel involvement (which is to the benefit of end career physicians at the expense of everyone else).
Their's a lot more to say here on things like "docs in Europe get paid less because their training is shorter and they don't have hundreds of thousands of dollars in debt" or "training quality if much higher outside the U.S., even in wealthy western countries" but this has gone on long enough.
Cim you have to reevaluate your level of knowledge on this topic because (among other things) you said "doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties" is very close to the system we already got.
Additionally doctor's wages in real terms have been decreasing for over 30 years while costs (including med school tuition) have been skyrocketing. It's driving a lot of people you want in medicine out of medicine. Just 68% of medical school graduates at Stanford went on to residency (with the majority of the rest going into tech or business instead). And that stat was in 2011, can't imagine how much worse it is now.
Throwaway05
26d ago
Tylenol would not be approved as an over the counter drug if discovered today because of how easy it is to kill yourself accidentally (or intentionally) with it.
The average person has no idea how badly many drugs can interact with each other, recreational substances, and with medical comorbidities.
And that's ignoring other problems like the people who would give themselves antibiotics for viral infections etc.
Throwaway05
1mo ago
I can't possibly upvote this enough. :(
Throwaway05
1mo ago
Supposedly that specific black actress has some form of connection to SBI and that's why she has been in so many games lately. She's also in many of the games that had the "female attractiveness change."
Throwaway05
1mo ago
Malpractice is heavily dependent on state and specialty, can be as low as 5k-10k or as high as well into six figures (OB). Some states have caps on malpractice payouts, some everyone get sued constantly.
Loans are for 4 years undergrad + 4 years of medical school. After that you get paid while working 60-80+ hours a week (but the pay is 50-70) while in residency. Residency lasts like 3-7 years depending on the speciality, and to do some disciplines (like Cardiology) you have to do additional years of poor pay training on top of the residency.
Once an attending most jobs are 40-60 hours a week but some stay higher than that. Depending on the field you may also work weekends, nights, holidays, 24+ hour shifts, 2 weeks without a day off etc. even as a senior doctor.
Throwaway05
1mo ago
It's not unreasonable for a PCP to make 180-220 a year. That's a lot of money in comparison to most jobs, but when the surgical sub specialist is making 600-800.....people follow incentives.
Note: We have orders of magnitude more doctors in primary care than the sexy big number specialties.
Throwaway05
1mo ago
Being an excellent PCP is possibly the most difficult and cognitively demanding job in medicine. On top of that pay is shit, prestige is shit, so great people don't go into it but great people are needed.
Corporate pressure and increasing health problems means they have less time with patients but more to do than ever before.
It's a mess and I understand why patients feel mistreated but they also have no idea whats going on.
As for the specifics in the U.S. IM or FM can be a PCP after completing a relevant residency, with (some?) states having a process for being a "GP" with more limited scope of practice after completing certain levels of residency.
The U.S. is weird because all docs can technically do anything in medicine (unrestricted practice) but getting permission to do that in a particular facility, malpractice insurance, and getting patient's insurance to cover what you do is all complicated. Certain kinds of ethically challenged people manage.
Throwaway05
1mo ago
a large number have cluster B personality disorders
Identity instability is a literal symptom of borderline. Not surprising if these people (when unstable) have trans thought content. If you throw the long COVID equivalent into your research studies, it's going to give you a ton of junk data and hide whatever thing is really going on.
Throwaway05
1mo ago
I would guess a culture of "toughing it out" and "oh god we have tons of real health problems" limits the role for these softer diseases.
Also thank you for introducing me to "crore."
Throwaway05
1mo ago
It is my firm belief that people with severe psychiatric disorders that appear to be permanent should essentially try the kitchen sink of pharmacology and related lifestyle alterations.
You should probably separate out things like depression and anxiety from illness like bipolar and schizophrenia. Some (considered crackpot) physicians will try and manage bipolar with therapy or recreational drugs but schizophrenia is pretty much straight up well understood pathophysiology that 100% necessitates medication management.
The stuff that can be managed conservatively rarely catches a diagnosis in those cases which does admittedly complicate the issue.
Throwaway05
1mo ago
My suspicion is that this is a trans type situation. Yes there are real trans patients. Yes there are cultural contagion trans patients. Yes there are borderlines (and others) with identity instability manifesting as trans thought character.
Likewise with Long COVD et al you have a mix of those pathologies being rolled together and it really reduces clarity and makes it unclear to what extent it is a real thing. Some people likely do have mangled CNS/PNS as a result of viral illness, others are maybe looking for a more ego syntonic expression of their depressive symptoms.
I know less about fibromyalgia but my understanding is that some physicians are emphatic it's a real thing and more investigation will make real bio markers or whatever abundantly clear.
Not seeing any fibromyalgia in India is interesting but its possible that it's in some way culture-bound, or environment-bound - higher parasite burden, rougher lives may prevent the sensitization or whatever else is going on under the hood.
Throwaway05
1mo ago
You may find it fruitful to read some of the work done by non-woke Psychologists and Psychiatrists (ex: Life at the Bottom by Theodore Dalrymple), if for no other reason than to go "my god other people have noticed this!"
Everybody who deals with these people has experienced this stuff but having the tools to diagnose and label what these people do is helpful (and may at times give you some insight in how to work them for your needs).
Some of that was deleted (or I otherwise can't see). Missed the previous discussion in the weird psychopathology thread line.
I invite you to read the wikipedia page, which links to some actually studies on the matter (ex: https://onlinelibrary.wiley.com/doi/10.1111/apt.13706)
Basically the most evidence based approach to hypnosis concludes that it seems to function similar to mindfulness meditation, biofeedback, and other similar modalities where someone hacks their cognitive state and level of arousal, which is often easier to do with assistance from an external resource then by a person on their own.
Obviously this implies a limited level of clinical utility but it can help with psychosomatic adjacent pathology and any time "mind over matter" is more directly relevant.
I was fortunate enough to experience some training in this during my medical education and while I personally was not hypnotized I witnessed some of my colleagues experiencing it....and it was ultimately very unexciting and contrary to media portrayal (which is as this usually goes).
It seems most reputable people who do this emphasize the limitations and the fact that it can't really make you do stuff you don't want to do already.
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