Throwaway05
4d ago
It's both true and not true. If you give men an unlimited stipend and no consequences they'll go to strip clubs and buy hookers constantly. They probably know it's bad for them, but well people do shit that's bad for them all the damn time.
Dating apps are an equivalent for women, a constant parade of male attention and access to men they wouldn't have otherwise who in truth have no interest in them. A decent subset will abuse that, with intention or without. Eventually society and obligation will make them circle back (well for most).
Some may have insight into it or not.
"I want to fuck the prom king" isn't irrational when given permission to do so. It may be common but usually they grow out of it and it's a matter of when.
Throwaway05
6d ago
Where is the evidence these people have fabricated studies in an attempt to slander the efficacy of opioids?
That's your claim right?
Otherwise you can find a minority population online saying whatever, but they need to have an impact on prescribing habits and the research you deny.
Throwaway05
6d ago
There's also concern around organ donation. I've seen some reports online about adopting new guidelines around brain death so that (to put it crudely) they can start getting the organs as fresh as possible.
If you want to read more about this some discussion is here: https://old.reddit.com/r/medicine/comments/1mf2rv4/donor_organs_are_too_rare_we_need_a_new/
Throwaway05
6d ago
Anecdotally I've had several significant injuries some of which have been managed with controlled substances and some of which have been managed with staggered dose ibuprofen and APAP, absent the "high" effect they are comparable (for me) when it comes to pain control. The research supports this - plenty of people manage without pain control or with more deliberate OTC medication usage.
Some amount of breakthrough pain or discomfort is normal and to an extent beneficial. Some research suggests that that the desire for total pain control and numbing is a somewhat American cultural specific desire and part of why we have addiction problems in this country.
Analgesia and addiction considerations aside, the medications have a number of problematic side effects that need to be considered. They do have their use though, and the people doing research in this area are aware of that.
Looking at a JAMA article and saying this clinical research is fabricated by non-clinician puritans is conspiratorial thinking, especially because the types of people have cultural sway for this kinda of thing at the moment are probably best categorized as dangerously pro-opioid - see: safe injection sites, methadone clinics, and pushing of Suboxone as the best solution to the problem.
Throwaway05
6d ago
I don't know a single person in clinical medicine who wants to eliminate opioids and while I'm sure there might be some crack pots that's an extraordinary claim that requires some evidence to be taken credibly.
Reactive under-prescribing in some outpatient settings is certainly a problem but that's not really your claim.
Throwaway05
6d ago
Sorry I don't really have a dog in this fight I just wanted to make that point specifically.
In truth I remain somewhat undetermined about how to handle this specific issue which is awkward given the possibility of it appearing in my clinical practice, however my plan is to just follow legal, regulatory, and hospital frameworks and stay out of the ethical side of this thing.
That said it is worth dialing in just how miserable certain classes of patients are. Again I'm not convinced we should assist them in dying but certain patients have a lived experience that is comparable or worse than the more typical examples (dying of chronic disease, intractably bad life experiences, significant chronic pain*).
For instance someone with severe borderline personality disorder may find themselves zigzagging from being too happy to wanting to kill themselves to burning down their relationships to getting fired to whatever on a regular basis. With associated involuntary suicidal ideation it can approach a point where the life experience is almost abhuman, miserable, and devoid of the traditional pleasures of existence.
That's a reasonably good case, especially since some people like this may struggle to successfully kill themselves because the system does a good job of preventing it and because the problem isn't pure depressive misery, therefore it becomes challenging to overcome the routine desire to live.
Again not necessarily advocating here just pointing out if you had chance to interact with one of these people you might go....oh yeah, I get it, holy shit (or might not).
*Although best we can tell this is somewhat linked to psychic distress.
Throwaway05
6d ago
Okay, not a train. That's an asshole thing to do. If you're going to commit suicide, don't involve other people.
This is surprisingly hard to do. Someone needs to find the body and unless you plan carefully this can easily be a random bystander or group of random bystanders (and planning carefully is hard when you are suicidal).
Usually EMS and healthcare get involved and seeing someone who has committed suicide can be deeply harmful (especially if it's gruesome like a gunshot to the head). Often they'll have to run a code on the body even if it's clearly dead which is....awful.
Then you have to think about the family and friends of the deceased. Having a close contact or family commit suicide is a risk factor for suicide it hurts people around you in a way that just dying doesn't.
Throwaway05
6d ago
Absolutely yes!
People have so much more variety in the way they view the world than you might imagine based on the fact that most people end up doing more or less the same things.
It gets super interesting in the case of legitimate pathology like personality disorders and speaks to some interesting things about the human condition (ex: true sociopaths with zero anxiety. They really aren't human, and it tells a bit about what anxiety is for).
As you note nearly everyone here is not normal at all and has features like super high ability to decouple, and a common fail state for people like us is to assume people with low ability to decouple aren't actually intelligent.
Another fun one is the way different cultures and native language speakers interact with the world can result in some foreignness. The results are generally mostly recognizable societies but a lot of Russians, Asians, Middle Easterners etc just experience the world in a way that is unexpectedly foreign.
Throwaway05
7d ago
Not a lot, but google image search it and you'll see why.
Throwaway05
7d ago
The guy who loads up on tight ends
I am in this post and I don't like it.
Throwaway05
7d ago
Absolutely recommend Meteora.
Throwaway05
7d ago
Yes, that's one reason the combinations are popular, but not the reason oxy with APAP (Percocet) is so favored over oxy with ASA (Percodan, no longer available) or oxy with ibuprofen (Combunox, no longer available). That's drug warrior pressure.
There is a bunch of research out there suggesting that OTC and milder agents are just as good as stronger agents for managing acute pain. Example:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786200
Lots of research. You might not find that research convincing but it is absolutely out there.
Additionally APAP is a safer choice than ASA or Ibu if taken as prescribed, which is easier to ensure in an acute course (less potential for severe side effects or interaction with chronic medical conditions).
Throwaway05
7d ago
My APAP related disgust is reserved for drug warriors who ensure that oxycodone with APAP is the most available formulation of oxycodone, because they consider people trying to abuse it dying horribly to be a feature and not a bug.
I think these days they would argue that the reason is mostly because of synergistic analgesia (which is not incorrect) but yes I agree it's a questionable cost/benefit.
But ultimately society is organized around tradeoffs in your rights to enable you to have rights and the conveniences of civilization. Having to deal with mildly annoying blister packs or smaller bottles doesn't seem like a high price to pay for the amount of pain you can prevent.
Throwaway05
7d ago
Tylenol is somewhat uniquely dangerous, it would possibly not have been approved as over the counter in the U.S. in today's regulatory environment.
This is for a couple of reasons.
-The therapeutic and toxic range are way too close (aka it's really easy to overdose accidentally, which does happen).
-It has significant interaction with some medical problems (aka liver metabolism). This is admittedly pretty minor in most situations.
And most importantly:
-Tylenol overdose is one of the worst possible ways to die. It is long, and slow, and for a while you think you are fine. This gives people lots of time to decline in misery knowing they made an irreversable choice. It's awful. Most other forms of overdose kill you quickly or rapidly alter your sensorium.
This creates agony on the part of the victim and their family, and also a significant amount of angst and distress in the healthcare team.
If you like you aren't paying for the minor inconvenience of harder to pull out of the packaging pills vs. fewer suicides, you are doing to reduce clinician burnout and doctors and nurses in the workforce longer.
It's also expensive to manage.
Throwaway05
7d ago
Nobody does any teaching? Nobody has any Medical Students or Residents?
That doesn't seem right.
Could be regional though - Philadelphia (which is super dense) has nearly as many medical schools as the entire state of Florida, if you live in a place without trainees you aren't going to be teaching.
That said if you work for a hospital you should be doing something outside of your clinical duties (teaching, research, committee seats, extra jobs in the department like holding a medical director title). If you own your own practice you need to deal with the management side of this.
It'd be possible to work for someone to take on the least amount of responsibility (and the specialties you name are some of the ones it would be easier to do*) but you'd be leaving money on the table, not necessarily working any less (since teaching, research and administrative can eat up some FTE) and it is by no means typical.
*Family medicine in most practice environments is checking their in basket and finishing charts outside of business hours at least somewhat.
All of this is stay nothing of call responsibilities - someone is managing a phone line, going into the hospital PRN if needed, for most specialties. Ophthalmology is small and has rare but serious call responsibilities (going into the hospital) and has frequent enough need to phone triage. I'd be shocked if that person doesn't have some call. Radiology and Physiatry can dodge that. Neurology can be one of the busiest call specialties depending on practice environment, same with Family Medicine.
I would wager your friends do more than you think they just don't mention it or it doesn't come up.
Throwaway05
7d ago
squints
nods
Em dash big? En dash small?
Small brain human use small dash?
Throwaway05
7d ago
Think journalists, researchers (or their editor), pretentious literary types etc.
Yes! Destroy, the, grammatical, patriarchy.
Throwaway05
7d ago
Lol, well "no actually it is quite a bit more complicated than that and the popular presentation and imagining is grossly inadequate" is like the central lesson of The Motte. Internalizing that and putting it to use is YOUR credit.
For the issue at hand - it's worth noting that most Americans can be signed up for Medicare or Medicaid and hospitals will do that in an attempt to deal with some of the cost of mandatory care.
Illegals become more problematic and can easily end up sucking up hospital level resources for a year and a half while waiting for a charity care dialysis placement or something like that.
Incidentally I write with - transitions all the time. Is that materially different than that em-dash thing all the kids are complaining about? Do I look like an AI??????
Throwaway05
7d ago
To be clear I am specifically talking about the evidence based way in which increased access to firearms increases suicides. I do not support restricting gun rights in the general population on this grounds, but it is still a real problem.
You can acknowledge that guns have an impact on suicides and say this is not a reason to restrict rights.
Throwaway05
7d ago
In many European countries it is common to see police armed with rifles at every public transit station (at least it was last time I was abroad).
Britain is the exception.
Throwaway05
7d ago
Imagine you hate your life. Every day you go home from your job, stare off into space, and drink a ton of alcohol. You aren't particularly suicidal, but you have fleeting thoughts at times, you still function...with the drink anyway.
One day the thoughts are a little less fleeting...you think to yourself but shit, I don't live on a busy road and getting hit by a car sounds like a lot. How would I even hang myself? Stabbing myself? Seems hard.
The thoughts pass, as they always do.
But if there was a gun? "Well fuck it." Lights out.
I've seen a shocking number of patients who managed to shoot themselves in the head and think it was an oopsy.
So yes limiting access to lethal means is an important part of standard of care and improves outcomes.
Throwaway05
7d ago
Yeah, OP has bit (and I cannot blame him given the amount of poor reporting and understanding out there) on a lot of the popular misconceptions about U.S. healthcare.
Your mention of EMTALA and how the ED works is super instructive. Supposedly during the recent strikes in South Korea hospitals would just post up guards outside the ED and not let people in and they would wander off to another hospital, get better on their own, or just die on the street. Not an option here and EMTALA violations are one of the few ways a physician can get truly screwed.
But yes the U.S. isn't really a private system, it's not really for-profit (or non-profit - it's a mix of both in surprising ways). It is super complicated but is part of where the confusion comes from a lot of time.
Things in the U.S. are more expensive than the rest of the world but part of that is cost of living part of that is poor health of the population part of that is the fact that the U.S. can actually afford it and subsidizes everyone else...
Usually expensive cancer treatments in the U.S. end up discounted, or insurance will cover them (but not fast enough), and they might not be available at all in other countries or it takes too long to get an appointment to get delivered them.
Throwaway05
7d ago
Yeah the environment couldn't be more different - stress is going to be the same (not even long hours depending on the country) but the way US physicians have hundreds of thousands of dollars of debt, can be compensated very well (depending on speciality), have to deal with the nonsense of the U.S. health system, wearing of multiple hats and so make them functionally a different class of job.
Throwaway05
7d ago
Yeah I've heard Pilots and Flight Attendants are basically fuck city. In truth I've never heard an IRL doctor make any kinds of claims about rampant sleeping around or cheating in the departments. I've heard patients who work in aviation tell me about their and their coworkers exploits totally unprompted.
I've been trying to get people here to read that for years! I appreciate the parallel advertising.
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