Throwaway05
1hr 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
1hr 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
2hr 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
2hr 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
2hr 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.
Throwaway05
21hr ago
I know this is a meme but it is one I've never encountered in real life (although I've heard about it often). Hard to tell if that is due to geography or era (these days most of the male doctors I know are terrified of being on the wrong end of woke crimes and are careful at work for that reason).
Throwaway05
22hr ago
clear delineation between work and rest
While this can be true for some practice environments and specialties, I would hazard it is untrue more often than not.
Most doctors have some combination of research, teaching, administrative, and managerial duties all of which bleed outside of traditional work hours in the usual ways. Additionally many specialties (ex: family medicine) will involve significant time outside of work catching up on documentation and managing your in basket and so on.
It's not impossible - gas usually does little outside of work, same for things like radiology, inpatient psychiatry and so on. Especially in a hospital employed community setting. But as soon as you take on any additional responsibilities, go academic, or hang your own shingle...that goes away most of the time.
My suspicion is that doctors seem to cope well in comparison to lawyers because the sheer depth of abuse, abstruse requirements and zero flexibility in the medical student and residency days makes anything that comes after seem reasonable.*
Although by the numbers substance abuse, divorce rates, suicide are all high for doctors (but maybe not as bad as lawyers).
*"My 24s aren't that bad" is a common attending refrain. It is also insane.
Throwaway05
1d ago
He was poor, but what he had going for him was that he was likable and not dysfunctionally insane and his crime didn't fit neatly into reprehensible crimes like murder or assault with a deadly weapon
I think people miss how foul tempered the vast majority of "real" criminals are. Half the patients I treated in prison felt entitled to call everyone a faggot then demand thirty different types of controlled substances. If you make at any attempt at all not to be a huge asshole than the system is extremely more likely than not to go extremely soft on you.
Sure - it isn't guaranteed too, but I met guys who committed incredibly heinous murders and because they were nice they were treated like they committed a white collar crime.
Throwaway05
1d ago
I think you could have a more charitable take where the government isn't sending a lot of resources and doesn't have a lot of leadership buy-in (because the crimes are ironically not very sexy, ultimately pretty small, and it is somewhat sketchy that it is federal at all) and the person they are prosecuting is throwing every last financial resource at it because he doesn't want 20 years in jail.
This can easily result in the prosecution being tired, busy, buried in paperwork with minimal resources and therefore forgetting things that now seem brain dead obvious.
Throwaway05
2d ago
I suspect if you know a PsyD or other actual psychotherapist they might have more helpful advice but my quick lit review didn't turn up anything useful.
I do generally suggest that everyone in medicine read Nancy McWilliams Psychoanalytic Diagnosis for an understanding of personality structure since it has broad application to life and general medicine still needs to know how to deal with personality dysfunction.
Some of the chapters are still fun to read with zero background (ex: Anti-Social).
It won't answer your specific question directly but will provide a lot of context and peck at it a bit.
Throwaway05
2d ago
Usually I unhelpfully reply "do a lit review!!!" to these sorts of questions but after a quick look myself I don't think it would be that easy - "become an expert in therapy" is probably more accurate but is as about as unhelpful as it is predictable.
The challenging bit is that therapy (especially CBT) is "indicated" for about everything but that doesn't tell you which types of patients will benefit most from which types.
I'm not an expert in this by any means.
It is worth noting that "real" therapy (or many types of popular therapy) is often less ooey-gooey emotional exploration and more resembles socratic questioning or an outright class (in the case of CBT which is driven by "homework").
I do have a family member who is not in psychology or psychiatry (or medicine) who listens to psychiatric podcasts and a few of them dig into this explicitly, you could probably do that if you really wanted to develop a knowledge base.
Some modalities are more specific however, DBT is for Borderline Personality Disorder and people struggling with cluster-b coping mechanisms as part of their pathology. It can work quite well for this.
Classically (especially for any U.S. medical students reading!) the answer to any board question at the Shelf or Step 1-3 level that includes CBT is going to be CBT unless it's DBT for Borderline.
Throwaway05
2d ago
- Therapy is better than you think.
I don't really want to write an entire novel on research and stuff but the short version is that medical research is hard and research on anything that involves people and society is also hard. This results in seemingly low effect sizes for therapy but that shit really does work. It's not necessarily going to work for every patient, situation, (and critically) or therapist.
Part of the problem is that we have a large number of low skill therapists, incorrect patient therapist/modality matches, incorrect indications, and the whole therapy culture thing.
CBT and DBT have excellent evidence bases for instance and are meant to be highly structured with clear end points. We also have a pretty good understanding of what patients and situations should use each of those therapy modalities.
PTSD treatment is done through therapy and can be quite effective.
For many common conditions you very much need both medication and therapy (and only using medication leading to poor efficacy is the other side of the psychiatric complaint coin).
However most presentations of therapy you see on the internet are people getting matched to a random low skill therapist they don't vibe with and indefinitely engaged in a process that is never explained to them which therefore feels like just venting.
That's not the real thing, in the same way paying your friend who is a college athlete to help you isn't the same as getting actual PT.
However low skill therapy is probably better to have around for society than nothing and high skill therapy can be extremely expensive so we are stuck with this.
- AI therapy is ASS (well, so is much of real therapy too).
The preliminary research seems pretty good but a lot of psychiatrists are essentially betting their careers that some of the usual business is happening: motivated research looking for the "right" conclusion, poor measures of improvement (patients may feel subjectively supported but don't have an improvement in functional status), and so on. Every time The New Thing comes out it looks great initially and then is found to be ass or a bit more sketchy.
The lack of existential fulfillment provided by AI, overly glazing behavior, and a surplus of Cluster-B users and the psychotic receiving delusion validation will lead to problems including likely a good number of patients who may end up actually dangerous and violent.
If the tools don't improve drastically quickly (which they probably will be) I'd expect a major terror event then STRONG guard rails.
You see some reports on social media of doctors finding their patients encouraged to do some really bad shit by a misfiring chatbot.
Throwaway05
7d ago
At this point, I'm beginning to wonder if the medical definition of 'sanity' even exists anymore,
Well keep in mind that various lesser versions of psychiatric illness (depression, anxiety, cluster-b coping mechanisms) are expected in the community and healthy as long as they are not excessive.
On top of that you have various cultural problems like the whole anxiety thing, The Last Psychiatrist's idea of generational narcissism and so on.
One of the big things that happens now is that certain mental illness adjacent or maladaptive problems are supported by society (like anxiety and cluster-b behavioral patterns). The underlying sanity is there but the maturation and cultural PUSH isn't.
In any case the old school psychotherapists thought fucking the girl would clear out the BPD if you stuck with it soooooooo.
Also keep in mind "neurosis" and how it has been evicted from the DSM but is still behaviorally present. That is 90% of "bitches be crazy" alone.
Throwaway05
8d ago
Health systems do sometimes try and figure this stuff out and help patients but its complicated because insurance companies make a full time job out of causing issues here - one of the classic is the way that COPD/Asthma inhalers change every year because insurance companies change what they will pay all the time.
The insurance company has no desire to clear things up with their staff for the obvious reasons.
With respect to diseases like this you will absolutely get the best possible care in the U.S. because no socialized system will spend the money involved. It will just cost you an arm and a leg in the process.
Throwaway05
8d ago
Bribing a prison guard doesn't take that much money. In my state, quite a few are caught every year smuggling drugs into facilities for paltry amounts of money, and certainly paltry amounts when compared to the pension/benefits they're losing for the rest of their life.
The thing with guards getting bribed is that they are convinced they aren't going to get caught, which is one of the reasons they are cheap. Getting involved with something like Epstein is a 100% bad idea and even idiots guards would know it.
Throwaway05
8d ago
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Congrats that it seems to be helping.
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I am on vacation and absolutely obliterated right now but I'll respond because I don't want to forget about this.
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U.S. system is bonkers, it has its advantages but it is still bonkers. Lots of wealthy companies invest in not paying or making things as confusing as possible.
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For the most part doctors are employed cogs who have no control, authority, or influence (these days). Usually your contract gives up your right to be in charge of coding and shit. We have enough to do unfortunately and limited ability to help so we don't know and can't do much. Understanding billing is a full time job.
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I support attempts to fix or simplify things as long as you don't throw the baby out with the bath water but 90% the first step is cut doctor salaries and I'm out.
Throwaway05
8d ago
Medicine has usual replication and research issues but the issue is more that anytime something abuts anything political you run into difficulties. Anything to do with race, social topics, and trans stuff is absolute trash. COVID related is more a mixed bag, etc.
Throwaway05
8d ago
You've got alternative possible explanations for Epstein - legitimately it seems like he would commit suicide, he might have bribed others to allow it, this guy bragged about being a spy which isn't really something most spies do and so on.
I don't know enough about Hoffa but I doubt we have other significant ideas.
Throwaway05
8d ago
Right most people know "open secrets" in their community or profession. Sometimes they get picked up by the public, sometimes they don't, but conspiracy theories that actually come out are almost always in this category.
Throwaway05
8d ago
I'm not going to listen to a six hour long podcast, if their is any evidence that isn't circumstantial and isn't just "that sounds weird" feel free to send it along.
But my point is that it isn't reasonable to think some of that kinda business was going down, it's that it's also perfect reasonable to be unconvinced.
Almost every conspiracy theory that turns out to be true was also widely known in the relevant communities just underreported (ex: Weinstein being a sex pest).
This matches more to conspiracy theories that turn out to be untrue.
Throwaway05
8d ago
but it's mostly isolated to the "usual suspect" departments: anthropology, sociology, literature, and The Studies.
Medicine is a much "harder" field than the social sciences but is pretty much just as woke captured, with all the bells and whistles you see along with that and extremely problematic results such as lots of people on this forum not believing that COVID actually happened.
You'd have to completely redo a million things to get anything resembling more politically balanced medicine and with the way our licenses can be attacked nobody has any interest in stepping up without a ton of protection.
Throwaway05
8d ago
Epstein was an Israeli intelligence asset. This should be as obvious as saying that the four legged furry animal that barks at the mailman, chase tennis balls, that lives in my house, and had two parents who were both dogs, is, in fact, a dog.
Do you have any evidence to support this? All I've really seen is a bunch of sus shit that could easily be alternatively explained as "person with a lot of connections has a lot of connections" and sensible counter arguments like "the first rule of spy club is don't tell random people you are a spy..."
I don't think it is as clear as you think it is or alternatively - it is very scissorish.
Throwaway05
10d ago
I've heard some people in gaming think meta refers to "most effective tactics available." Maybe that?
Throwaway05
10d ago
OK, horse riding codes rural in America more than upper class.
Definitely depends on the location, but it makes sense to me that Texas would see it as more rural than wealthy in comparison with say, the North East.
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.
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