Throwaway05
3mo ago
chicken pox party like they
Please don't. Shingles.
Edit: In case you weren't aware Chicken Pox is a type of herpes and therefore once you get it, it never leaves.
Throwaway05
3mo ago
Yeah sorry lemme rephrase as "please please please follow the *U.S. vaccination schedule."
Not accusing you of not going for MMR but just using it as an example of downstream effects.
Something to keep in mind is that the U.S. schedule is optimized for "we are the wealthiest country in the in world" others may have more resource limitation focused choices.
COVID you can skip.
Using your other post as a reference point (and please forgive me Peds is not my area so I my professional level knowledge of this is distant).
Also several of these can impact getting jobs or housing at university (ex: the Heps, Meningitis), and skipping them will put you in the naughty bucket in your pediatrician's mind which isn't necessarily appropriate but is the reality.
Hep A - prob rare in Denmark? Hep B - prob rare in Denmark? Chicken Pox - no idea why they aren't doing this. Per PLOS Glob Public Health. 2023 Apr 5;3(4):e0001743. doi: 10.1371/journal.pgph.0001743 eople are advocating it? Rotavirus - this one is super complex and can't really be summarized here. Covid - skip if you want. Flu - don't skip please. Tetanus (from age 12) again probably low yield. Meningitis (from age 12) - don't skip please, looks like they have it but don't give to kids? Maybe it's pre college matriculation? IDK seems strange.
Keep in mind that incidence of disease varies country to country and the sheer variety and amount of immigrants in the U.S. (as well as poor health) put people at higher risks of somethings. This impacts the schedule.
Throwaway05
3mo ago
Please please please follow the vaccination schedule.
Pediatricians take a 6 figure pay cut because of how much they care about protecting kids, everything on there is for a reason - COVID nonsense aside.
If you have something specific other than COVID you have concerns about you should dig into that separately.
Keep in mind we've already started to have things like Measles outbreaks because of people become vaccine hesitant. Many of these disease are very deadly.
You also may introduce logistical problems down the line as your kid can't go to certain schools or get certain jobs (like healthcare) without jumping through extra hoops.
Also considering almost every kids gets this stuff we'd know about problems for the older stuff at this point.
Throwaway05
4mo ago
It turns out that at least in outpatient settings, the rule is that controlled substances need a hand-written prescription. Which strikes me as odd given that in all my inpatient work, I just had to tick a few boxes and sign a physical copy when it came to those classes of drugs.
Hmm probably helps prevent fraud and such.
meds
....Priapism from the Atomoxetine? Meds you would not expect can cause that.
research
It does sound like you did do some research but you should be looking things up, reading /r/psychiatry and /r/medicine - always be learning! (especially if you feel like you aren't getting enough at work). Be curious! Just the other day I was looking up the pharmacology of a med I use all the time (ODT Zofran) because I realized I had forgotten some details. Chasing stuff like that will make you a better doctor.
Scott
Scott is smart and is a good writer but he has a very idiosyncratic bent to his medical views that often doesn't match other clinicians. Beware. The Last Psychiatrist on the other hand is fucking incredible (and importantly - equally entertaining). I make everyone in every specialty I see who has deep questions about pharmacology of any kind read his receptor article.
Trazodone
In the U.S. Family Medicine, Sleep Medicine, Neurology, and Psychiatry all have different views on Trazodone (and everything else). For a long time lots of these were like "the evidence says it does jack shit" but some recent literature has some weird noodly explanation about why that's all wrong. It's hard to evaluate. Many docs go off anecdotes.
In the U.S. we do use Remeron but are often cautious because we have enough weight to go around... for the right patient it is great though.
Officially the answer is sleep hygiene and other lifestyle mods/therapy (and especially CBT-I first and foremost and all the time before using meds).
Vyvanse
I mean if it works who cares, but if you end up needing something else going forward keep that in mind.
Throwaway05
4mo ago
or because he's the old-fashioned type.
Low-key I prefer it most of the time because if the pharmacy is out of whatever the patient can just roll to the next one. Clearly I am positively geriatric.
actual content
Okay soooooo
Puts on attending hat.
This is eventually going to become part of your bread and butter - you should feel very certain that amphetamines of all kinds are better than methylphenidate (or not!) and eventually be familiar with the considerations for use of one or the other (especially since it impacts your own personal life).
You should also stop reading Scott for these things, he writes for lay people and in a very entertaining way, but you have the toolset to actually do a lit review and deal with the less engaging/more scientific writing.
This is going to be important for a few reasons, one is that Scott often elides some of the practical concerns that we need to know about (like actual availability, as you ran into) and he cues into very specific old evidence bases at times which is fine for what/who he writes about but misses new innovation (lets see.....psych example....how about the conversation about Trazodone as a sleep aid?) and importantly isn't necessarily the standard of care - your attendings, billing processes, and potentially malpractice attorneys (yes yes UK) are going to look at you funny if you take him seriously.
He also has a tendency to miss or underemphasize some of the research errors (some spotted in this article! What they are is left to the learner lol).
IIRC Vyvanse is now generic in the U.S. but in short supply (as is basically everything else for ADHD), I don't know what it is like in the UK but for my money it is almost always the better choice if the patient can get it and afford it. Being a prodrug presents a ton of advantages and I'm mildly irked at the way Scott is minimizing it.
Very much my choice for "if my family member asked me what to get for ADHD I'd say try this first..."
Caveat: like all doctors I have my things I am very insistent and convinced about, others may not agree.
Throwaway05
4mo ago
Y'all don't have eprescribing in the GB?
Also why no Addy (or better yet - Vyvanse).
Throwaway05
4mo ago
One of the worsts parts of the extremism of wokeism (and #MeToo is the best example of this) is the way it enables people with mental health problems (especially Borderline Personality Disorder) to engage in the worst parts of their mental illness totally unopposed.
It's not good for them, it's not good for their victims, and it's not good for society.
Throwaway05
4mo ago
Sir. On no day is neuroanatomy slide flashbacks on my dance card.
Easily the worst part of the entire run of medical education, I'll even take a surgical 36 over that shit.
Throwaway05
4mo ago
Thank you for dragging me back to med school.
Throwaway05
4mo ago
KG House: Keeping a gaming house.
VG House: Visiting a gaming house.
Hah!
This gives me mental images of some twitch streamer getting raided.
Throwaway05
4mo ago
If you've ever tried to manage people in a large and complicated setting like a concert, a mass causality event and so on you know it's extremely hard to triage these sorts of things and get them to the right people. Even something as self-contained as running a single patient trauma or a two pilot aircraft can result in poor communication and distribution of information.
Consider how easy it would be to mentally write this off as "oh yeah that's one of the police sniper teams."
Now if you have one organization that should have a plan for how to handle "tips" like this and not fuck up like this it should be the secret service - but that's incompetence not malice.
Throwaway05
4mo ago
There's actually a practical use here. Certain populations (two big examples in the use: inner city black men (see: "down-low" culture), and the prison population) will have sex with men and never ever say they are homosexual. In the case of the convict side of things they'll often never have sex with men outside of prison.
Awareness and use of this information ends up being relevant for certain kinds of health screening.
Throwaway05
4mo ago
I think their is some truth to this but I also saw a lot of people saying things that amounted to "well if I can't provide abortions than I'll just leave the state and leave their mothers/babies to die" which suggests their is some mean spirited and political aspects to the whole thing.
Although, in support of your point (incoming vagueness because OPSEC) I was talking to a prominent medical ethicist a few months ago and he was telling a story about how he was doing something in two different states with mutually incompatible laws, and reached out to the state AGs for both to ask which situation took precedence (ex: when the patient calls the doctor from one place but the doctor is in a different state). Shocking both of them said "our rules!"
Nobody knows what would actually happen unless you run afoul of something and it actually goes to court, but actually following the rules is at times inadvisable and awkwardly at times outright impossible.
Throwaway05
4mo ago
And in the case of the doctors and anti-abortion laws, it really feels like you're doing the thing so many people do where they assume they live in the "most convenient world" for their worldview. Like, how convenient that anti-abortion laws would never lead to any negative outcomes ever, if not for malicious compliance on the part of doctors.
Am doctor. Spend a lot of time here defending doctors.
The level of overreaction and fear mongering from the relevant physicians on social media was profoundly immense, these people are grossly ideologically captured, and I could absolutely see them letting someone die because of it.
Throwaway05
4mo ago
Everyone points fingers at a variety of things but physician salaries are under ten percent of spending. A massive drop in doctor salary only gets you 3-4 percent less expensive healthcare.
The AMA historically was engaged in what you are talking about but then spent multiple decades lobbying for increased role for midlevel providers which is a de facto supply increase. It's finally moving away from that in the last few years but has yet to find a new passion lol.
Historically the limiting factor on doctor production has been residency spots which are mostly funded by the government, however plenty of states and private corporations will fund those spots because the labor is dirt cheap and they actually make a ton of money.
Additionally ability to increase spots in the higher paying/lower number specialties is limited because you need enough work to adequately train and all kinds of things have caused problems with that (ex: a reduction in surgical frequency secondary to an increase in medical technology meaning not enough cases). Lower paying specialties like FM and Peds have more room to grow but nobody wants to do them because of the poor (relatively speaking) pay.
Throwaway05
4mo ago
A big piece of it is admin bloat, just as in academia the number of middle managers and other folks like that (assistant infection control nurse - whose job is to make sure we don't order any labs that may show signs of infection!). Also more general middlemen/industries of various kinds.
Examples: PBMs, billing staff, EMRs.
If you look at a surgery a small fraction of the cost is the surgeons professional fee - yes lots of labor costs but thats because their are literally scores of people involved. Supplies, instruments, equipment....all places where someone could be greedy (see: ortho vendors).
Executives in healthcare are increasingly MBAs or nursing and often have authority over the doctors that can lead to both increased cost and decreased quality (see: travel nursing).
Doctor supply issues may be a problem but they are pretty orthogonal to the overall cost disease problems.
Throwaway05
4mo ago
- Healthcare:
Destroy the AMA’s supply-limiting bullshit, dramatically increase the number of doctors, dramatically decrease cost of healthcare.
Reminder that physician salaries are a low percentage of healthcare expenses, that the AMA has nothing to with supply restriction, spots can be expanded by local governments and hospitals (and have been!), and that the AMA has been lobbying for a supply expansion for decades.
Throwaway05
4mo ago
but a danger to her career by way of voluntary association
This sounds similar to that one scene at the beginning of Cryptonomicon (granted it's been a few years since I read it).
I think even at the time people knew what was up if they wanted to.
Throwaway05
5mo ago
Yeah you made do with what you had which was wise, but next time you are in a country where you can get a real one do so!
Cold cuts have a surprisingly high quality ceiling, and cheese is something that can taste incredibly different depending on what you got.
Throwaway05
5mo ago
There's a few layers of problems here.
First:
Yes I need to acknowledge that a lot of medicine is guess work and throwing up our hands and going "this makes sense" or "anecdotally this works." This is because proper research is extremely expensive, difficult, and is often unethical to do correctly (a lot of research in Peds is just not performed because nobody wants to test shit on kids). We do have things that we have really good quality research for, or know with a good deal of certainty. Medicine has some of the strongest validated research evidence and some of the weakest. It is totally a shit show and it's important to acknowledge that.
Second:
Again most medical care is centered around reducing mortality and morbidity. Optimization is considered less important and rewarding but it is what most people want since most people aren't actively dying at any given time.
Third:
Optimization is orders of magnitude more complicated. Individual genetics, lifestyle, life history, gut microbiome and so on radically impact the effect of these types of interventions. You'll see vegan or paleo diet advocates, touting the general wisdom of something that may have worked for that specific person. We don't have the research base and money for too much personalized medicine at this point which is a weakness of ours but any of this type of evangelism is fundamentally worse since people are bad at nuance and anyone involved in fad diets or whatever has a tendency to be extremely bad at "try it for a little bit and see if it works for you" type preaching instead of "behold, this is magic."
Fourth:
As alluded to above some people are capable of responsibly using this type of information, but by the numbers most people (or just enough) who get into "alternative medicine" (or however you want to label it) decide to abandon traditional medicine, and that includes the wealthy, intelligent, and educated. A common path is starting on a "fad" intervention and then just refusing mainstream medicine leading to future poor outcomes which can be extremely disturbing for the patient and care providers. This also makes most of us reflexively hate this shit which isn't productive but is the reality. Most people who are suffering are very willing to engage in black and white thinking and assume that mainstream medicine doesn't have much to offer them if this other plan helps with relief.
Vaccine refusal is a parallel - there's some nuanced discussion to be had on the COVID vaccines but any doctor who has seen a kid avoidably die from measles is going to want to put an anti vaxxer into a woodchipper because in their head it's the same crowd that is letting kids die.
Fifth:
One of the reasons for the difficulty in good research for this stuff is subjectivity vs objectivity. "I don't feel right" is a lot harder to chase, scale, and improve than "my blood pressure/sugar is elevated." This also means that the placebo effect and psychiatric impacts are extremely important and in all honestly might predominate.
People don't like to be told "this only works because you think it does" or "no there's nothing physically wrong with you it is a complicated psychiatric problem" but the reality is that many things are like this.
Unfortunately POTS is a good example, as is CFS/EDS/Long-COVID. People do appear to really have these diseases but the vast majority of people who say they have them, don't. This is magnified because of the importance of patient reviews and lack of time to actually speak to patients. Your doctor might be sitting in the back room going "yeah no way does this chick have POTS, but I don't have time for this fight so whatever I'll go along with it" and of course the fact that the physical and psychiatric side of things are tightly linked together doesn't help anything.
Ultimately almost all symptoms of these kinds of things (examples: tiredness, weakness, sleep problems, concentration problems) are equally or better explained by just depression/anxiety and are known to be symptoms of such. Treat the depression adequately and they go away, but identifying the issue as medical is more ego-syntonic and often impairs recovery.
You also see patients identifying as having ADHD because they can't concentrate and its really depression, bipolar, or personality and they refuse to acknowledge it but ADHD seems like a "better" disease to have and importantly has a clear treatment.
For a wildly different example: aging men demanding testosterone because they are feeling symptoms of aging or unhappy with their life course. It's not wise, but people refuse to not pursue it.
Fundamentally PEOPLE (all people) aren't really psychologically equipped to navigate these sorts of things in the modern world and it adds an enormous layer of complexity to the proceedings.
Sixth:
Assuming the previous point didn't turn you off the next layer is the assumptions of the math brain type person. If you've seen me post here before or on my previous account on Reddit you'll have seen me going at it with a bunch of hard science/math/finance people about how hard medicine is. People used to working in fields with way less ambiguity struggle to understand the realities of health and medicine (and research on the same). Your code runs or does not, the $$$ goes up or down. Why can't you turn medicine into an algorithm just like in our fields?
Medicine is an art as much of a science, translating what patients are actually saying, interacting with patients, figuring out how to interpret p-hacked and clearly biased research, navigating legal environments and regulatory burden all make the field way more complicated and subjective than you'd expect from something that seems to so firmly abut hard science.
Epistemic certainty on the vaguer things is going to therefore be shitty as hell.
Seventh:
Okay so what does all of that boil down to?
I have no idea if what you are doing is working because you think it's working, because it's turning some corner psychologically, or because it is doing something biochemically useful for you. I have no idea how likely it is that it would work for you specifically and you just got lucky.
Nor do I really care, and perhaps you shouldn't either. If it makes you feel better than power to you!
You just have to be careful and have some insight. Still get regular medical care. Don't overdo it. Don't do it if your medical status changes in some way that makes it unsafe.
B-vitamins are pretty benign but lots of people end up overdosing on some supplements.
Is your improvement really for the reason you think it is? Probably not...but maybe? However because actually verifying that is nearly impossible it isn't something we can reasonably roll out as population level advice.
I'll leave you with one final example - one of the common ways to hack research studies for novel psychiatric drugs is to take advantage of improvement in an inpatient setting. Turns out that being checked in on and cared for every day, being surrounded by peers and social opportunities, and getting regular therapy makes people feel a lot better. Do these things and dump a new psych drug on them and they'll get better! But uh, not clear it really is the medicine doing it.
Throwaway05
5mo ago
...you know that anecdote makes me wonder if another interpretation of the reality distortion is just nerds being shocked to interact with someone with actual charisma.
If you've ever met with someone high level (especially while young and impressionable) it can be quite stark, your ego gets totally consumed and you just go along with it (and for some people it's not even temporary).
Throwaway05
5mo ago
Sure thing. Quick tl;dr about chiropractors is that I had one and just found another one that was around $40 for an adjustment, so to go from moving gingerly because back pain to just a little soreness and full range of motion when I need it is worth that and then some for me when I need it.
Just keep em away from your neck lol.
Jobs
Hmmm you make a good case.
I think the counter argument would be going all map vs. territory invalidation and then pointing out that their didn't seem to be much functional impairment, but that's to some extent luck given the way Apple went and the obvious retort is "avoidable cancer."
I guess he does pattern match to "tortured genius artist" types, and outside of obvious bipolars that's gotta be cluster-b.
Throwaway05
5mo ago
RE: Chiropractors.
They can do some useful and real stuff but from everything I've seen everything they can do that is "real" is encompassed within the scope of practice of PTs and DOs doing OMM. And with much lower risk of random BS or ya know, sudden death.
RE: Jobs.
It's interesting you bring him up in that context, I was just thinking the other day about Trump and how he seems to exhibit a level of resiliency that is inconsistent with the way NPD seems to manifest itself. Obviously you could label him with some of the traits but everyone can get that accusation at times. So back to Jobs, the level of functional impairment in those two means they probably don't meet formal criteria...and then that makes me have a think about what kind of things pull people out of a formal disorder. In Jobs case maybe he that BPD brain but is absent the life history that manifests it in a clinically significant way? Or just that the visionary thought patterns and reality distortion stuff are correlated in some way?
This whole line of thinking isn't fully fleshed out but if you've got some thoughts, please share.
Throwaway05
5mo ago
You did a great job!
You can google some "official rules" but given your location that has no culture for this I have two thoughts.
-
A big chunk of this is aesthetics. If it photographs well you did your job (and personally I think yours does, but it is subjective!). Nerdy optimizers aside most people are just going to take a photo, share it on social media, and then devour the thing.
-
Use what's available. Don't use low quality salami because that's all you have. It's pretty common to use some fruit and a jam or something. But you aren't going to have access to Harry and David pears so don't try.
In America most of the time we use more of a variety of cheese and crackers but again use what you got. I have no idea if you can find an Italian specialty store in India that has some real cured meats but if you can that is the way.
Ultimately you don't know what you don't know - see the chickenpox party bit.
Also, the COVID vaccine is uniquely politically compromised but is a. not insanity, b. has an incentive we understand for the handwringing on both sides - political bullshit.
Vaccines in general have little incentive (as many are mature at this point it's not a money thing) to over push them or hide flaws. If you do the research on say the polio vaccine you can see exactly what went wrong in the past and why and the rationale behind the U.S. (and Danish) schedules. This stuff is out in the open and risks and benefits are known and the people who decide them are extremely competent and knowledgeable.
And the risks of the vaccines are minuscule (again with little incentive to lie or minimize them) and the benefits are immense, if rarely applicable for some things like Hepatitis A in the U.S..
Not following the schedule is essentially gambling with your child's life with the justification being "eh, the risk of this bad outcome is low but I won't take very easy steps to avoid it anyway because I'm mad about COVID."
You are welcome to be obstinate about the public health response to COVID but if you are putting other people at risk, especially your own children you should really look inside yourself and think about what you are doing.
That's putting aside the whole sentencing your child to a bunch of extremely avoidable paperwork and administrative headache in the future and the risk of things like ending up with a lower quality pediatrician because you refused to follow the vaccine schedule.
Importantly, if you are going to decide not to listen to medical advice and potentially put your child's life at risk you need to actually research what you are doing. Do not just jam it into an AI which you already admitted misled you or go "well shit this can't be right because COVID." Raising a child is one of the most important things someone should do and if you decide you will not listen to the medical consensus then you must actually put in time or effort or a reasonable person may judge you a poor parent.
Generally I don't get too heated with the questionable medical content that appears here because people aren't doing anything more than promulgating misinformation (which I'm committed to allow as a free speech person) and harming themselves - and people here do come up with novel things sometimes.
Putting a kid at risk and under baking your thought process is not that however.
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