Throwaway05
6mo ago
The benefits are all theoretical.
I don't really care about DST but it is worth noting that there's supposedly an association between time zone changes and medical and psychiatric health issues. Healthy people can change their sleep easily but medically ill people get more heart attacks, people with bipolar are more likely to have an episode etc.
I say supposedly because doing a lit review right now the evidence base isn't aggressive, but it is often passed around as medical fact.
Throwaway05
6mo ago
Hahaha I guess that counts as fitting though?
Throwaway05
6mo ago
______>
Throwaway05
6mo ago
I don't think I disagree with any individual thing you said there - downvotes aren't representative and shouldn't be over analyzed, the job and pay are worth it (but less so than the past), people are meaner and angrier in person (to say nothing of online) these days, and so on.
That said - the excess of disagreeableness and decline of respect for institutions and expertise is real (everywhere and sometimes deserved). It's extremely noticeable in our jobs though, because most of life and health takes place outside of the hospital so we can easily see when people don't listen (and come back or die) or make a mess during their stay/visit.
Our oldest can tell us how different it was in Ye Olden Days, or if we work in settings with radically different populations we can see the gap (Vets).
These days we see more and more patients doing things like walking away from treatable cancer to ending up terminal on homeopathic arsenic from someone who is legit licensed in Oregon because that's a thing they do. While I'm not immune to slinging mud at times...people yelling at me on the internet scratches the fundamental same itch writ small.
What bothers me a little more is when people don't realize the decline, especially when it is the respectable types, because of course that hurts more.
Yes I want to be respected (who doesn't?) but it's so intrinsic to the job for us. Yeah its kinda funny when I whinge about it being harder to pick up women as a doctor, but patients shooting their doctors (real but rare), people demanding things that are dangerous to themselves and others like antibiotics for a virus (common as all hell and a problem but individually small potatoes) to the expansion of midlevels because people don't realize how much worse they are (metastasizing everywhere and I'm tired of seeing my patients and friends end up with bad outcomes from it)...these things are real and bringing my end of things closer to collapse.
Like much of everyone's current ills I don't know what the solution is, but I will get on the soapbox and mumble a bit.
And on traditional and all together saltier note, since I was a young intern on call at one point in the distant past: yes nurses get it worse from patients but they totally deserve it.
Throwaway05
6mo ago
The complicating factor is that many presentations of illness look very similar - does your young person with chest pain have heartburn, an honest to god heart attack b/c of something like genetic disease, anxiety, costochondritis, or something else?
The triage process tries to prioritize people and then once questions are answered (okay the EKG is reassuring, anxious Karen can wait for six hours) readjust how to prioritize people. If you send someone back out to the waiting room and they die because you missed something or had an atypical presentation.....massive lawsuit.
How you get prioritized and triaged usually happens in the background without you knowing about it (for the obvious reasons).
One approach that a lot of places uses kinda zigs a bit from your idea. EDs will have a "fast track" area (will likely have a euphemistic name to make it harder for patients to know) for simpler chief complaints. Work that is expected to be more brainless and less acute (what constitutes this is not necessarily obvious, someone with a diverticulitis flare up or a broken arm is in crippling pain and need some specific intervention but it doesn't require a lot of cognitive resources to figure out the plan) and it's staffed with generally less experienced or competent staff. They can then churn through the simpler cases while people spend an extended period of time in the main idea waiting on labs, images, consults, a hospital bed, someone to figure what the fuck is going on).
You might note the name is kind of the opposite of what you are saying - fast track, so it doesn't disincentivize the over utilization behavior, but ultimately getting people out of beds or the waiting room takes priority, and a lot of regulatory/bonus/compliance structure involves reducing wait times anyway.
Throwaway05
6mo ago
There's a good discussion on EMTALA today on Meddit:
https://old.reddit.com/r/medicine/comments/1hdpuq6/seeking_advice_on_emtala_violation_allegation/
Throwaway05
6mo ago
Doctors (and myself) certainly exaggerate sometimes but the amount of good (and bad) shit that happens and sounds fake is nuts.
I'm assuming quite a few of the downvoters on my latest posting spree are assuming that the 24 hour shifts aren't real or are a gross exaggeration.
Nope.
Throwaway05
6mo ago
My primary care dr told me he gets way more time with patients at the VA then when he was at the local privaye clinic. Unfortunately he left to do research. Now I have a Nurse Practitioner whom I haven't seen yet.
Thank you for sharing.
Yeah slow pace does have some benefits - you carry less patients you spend more time with patients, which is mostly what we want. It has the costs though.
I'm not going to say the VA is a guaranteed death sentence and depending on what you need the quality of care can be higher (I'd say that psych is probably better in the VA because you see people with more time and specialized knowledge and time and that helps a lot in psych), but the VA is usually the butt of the joke in general medicine.
Throwaway05
6mo ago
Gas is a lot like being a pilot and flight attendant in that you receive a lot of training for things that aren't often happening and that the average person doesn't see or notice. Job looks easy when things are going smooth. Every time you do something you do a lot of preparation and planning that seems to happen automagically to outsiders.
Unlike aviation, the plane tries to crash repeatedly and active actual plane crashes happen a few times a week. Fundamentally you are fighting to keep the patient alive while the surgeon tries to kill the patient. Think about things like open heart surgery. Even something as simple as an open gallbladder involves radically changing the patient's physiology. Bad outcomes get blamed on you and are your fault.
Surgery isn't everything gas does though.
Imagine you are working a 24 hour shift overnight, it's 4am and you are sitting in a break room watching jeopardy reruns and eating shitty chips from a bag, your pager goes off. You have 90 seconds to get to the trauma bay, where you find a patient has got hit in the face with a sledgehammer. His anatomy looks a cheeseburger put in a food processor and pulsed. You have to keep the guy alive long enough to put a tube down this throat, get fluids and blood running, and get the guy to the OR where another doc and the surgical team repairs the guy's face in an 16 hour surgery.
Ten minutes later you are back to eating chips and watching jeopardy.
OB, psych, and gas have serious tempo issues which more resemble the military and police and are not for everyone.
Throwaway05
6mo ago
and they have incredible status to boot
I don't think this is true anymore. Anti-doctor viewpoints are super common right now. The left and the right hate us. Corporate media blames us for cost overruns. We aren't independent anymore. Patients murder us and it doesn't make the news. We get threatened all the time at work and the police and the hospital both shrug, even in places where there are specific laws against that.
Look at the tone here. Sure I'm not a perfect communicator but every time I try and refute lies about the AMA I get buried in downvotes, the "doctor bad" and "doctor is the problem" memes are rampant, and that extends to general society.
Not saying it isn't true, just saying that people absolutely feel that way.
For a practical example - you used to be able to get laid or find a partner b/c you were a doctor. Doesn't really work any more.
Throwaway05
6mo ago
That's the high end of the range, here's what google AI bullshit says on the matter:
"Obstetric malpractice rates are high, with OB/GYNs having one of the highest malpractice rates of any medical profession: Malpractice claims: More than 62% of OB/GYNs are sued during their career. Malpractice insurance: OB/GYNs have some of the highest malpractice insurance rates. Costly claims: Obstetric malpractice claims are among the most expensive medical malpractice claims. Birth injuries: Birth injury claims are the most expensive obstetric malpractice claims."
And from an article: "As a result, an OB in Chicago typically pays about $140,000 a year for med mal insurance, while the median premium for other specialties is $30,000 to $40,000."
Some key bits - OB gets sued a lot, OB patients are pretty much by definition healthier than most patients so that means bad outcomes are more expensive (compare 75 year old with kidney failure with 30 year old mother of two with no past medical history). If you injure a kid literally while they are being born you are like on the hook for everything that ever happens to them...
I think it's probably more of a practice environment issue than mistake issue, on average they get sued (62%) and there are states that are known to be hell holes for this (example: NJ).
Don't know for sure though.
Throwaway05
6mo ago
We've been trying to figure this out at work and we have a few theories.
Sidebar: social media presence rarely paints an accurate picture of a person for a variety of reasons. This is also a huge part of why social media is so damaging for young people.
None of this is a diagnosis. I know fuck all about actually clinical relevant information for this guy, media sucks and speculation is rampant. Mostly writing this as a thought experiment to see if I can come up with any good questions for you to ask if you get another chance.
In no particular order.
-
Mostly depression/pain and he decided to make a political statement instead of just toping himself. Sample evidence for: back pain problems? has caused murder before in others. The supposed withdrawal from family. What could you ask your friend: probably not a lot given the timeline. Usual "depressed y/n" questions would work if someone saw him more recently. Caveat: more to depression than just the stereotype most people know. Against: Doesn't really look the type in the photos and such we have now, but that's shitty quality data.
-
Pure politics/radicalization (I'm including drug/psychedelic induced scrambled brain in here). For: superficially that looks to be what happened, easily fits the data we have now. Drugs. Ask: need someone close enough to him to know how he actually thinks about things (we are all familiar with hiding our power levels), behavioral and thought patterns suggestive of tendency towards radical politics. Looks like you spotted some of those. How'd he feel about Trump, COVID? How evangelic and aggressive was he about those? Did have radical political swings in response to popular stuff? Think about the stuff you see that predicts someone becoming a "woke crazy" type. Same underlying thought patterns and behaviors can cause radicalization in all kinds of different directions, even in the rational and intelligent. May not even be "wrong" see: US founding fathers. If your friend is intelligent, thoughtful, and aware of this stuff you can just ask him if he looks like someone who could easily be radicalized with the right setup. Against: some of the other explanations work better with the limited information we have right now.
-
Personality disorder. (What is this? Think antisocial personality disorder, narcissism. The latter is hypothetically where most school shooting type events come from, which is a surprise to some). For: makes it easy to decide to kill people. Is normally what causes similar events. Ask: Check out the DSM criteria for ASPD and NPD. The former is easier to ask about "does he like, not fucking care about other people's rights at all?" The latter is going to be hard to elicit from a layman if it's not obvious unfortunately. Many people pick up the vibe on these people though so your friend might go "oh yeah." These are essentially life long so would have been present when your friend interacted with the guy. Against: Doesn't smell right (ASPD especially) and doesn't really match with the online profile so far in my opinion. If he ends up being more incel seeming with more data NPD could end up being a good explanation though.
Probably the most interesting:
- Prodrome. (What is this? The guy is catching schizophrenia or something else and is starting to go weird but it is still early). For: Guy is organized, intelligent and had a good plan but it went off the rails in a strange way that doesn't match the rest of the story. Substance use. Manifesto stuff. Some things are off. Withdrawal from family. People with good intellect, education, and resources hold it together, often for some time and then it starts to fall apart but not usually in this rough of a fashion. Ask: Any family history of mental illness, especially serious mental illness (your friend probably doesn't know but this would be huge). Did his behavior change in any way while your friend knew him? Weird beliefs, social withdrawal, "looking like" a different person (seems like the interaction wasn't longitudinal to likely catch this)? Was he weird? some weird people have a predisposition towards mental illness of this kind and develop it (or don't). You'll notice the person is off. Poor social skills. Not as emotive. Strange beliefs. Doesn't seem to move through social situations as well. Oddly confrontational about strange things. Limited functioning in some ways (if they have partners the partners are more like them). Can't emotionally connect with others. I'm sure an expert in first episode psychosis would have a better way of conveying this but there's a vibe most people are able to notice once it has been pointed out to them. I know you said your friend stated the guy is weird but we are looking for a specific weird here. Against: Little old for this to be common (usually starts more like late teens early 20s, but his resources may have impacted course). Doesn't seem overly psychotic right now (but again this is more prodrome than full blown illness)
Throwaway05
6mo ago
The Canadian system absolutely has problems with insufficient resources, long wait times, and rationing, however that kind of wait time in the ED specifically can happen in the US pretty easily.
I imagine this exact case would have gone differently but it is pretty common to sit in the ED for a very, very extended time with nothing visibly happening to you. Here the primary driver is over utilization (people refusing to go their PCP instead or not having a PCP).
A bit different but the most alarming example is behavioral health, especially for kids (although this bit is shortage related). It's not uncommon for an ER to have one kid who has been boarded in the ED for weeks to a month waiting for a bed at a psychiatric facility. For adults it's often days to weeks.
Throwaway05
6mo ago
Fair point, my only personal VA experience is with hospital and residential programs.
A common problem whenever healthcare discussions come up is that patients view the outpatient experience as the majority of healthcare but for us it's the opposite. Most of the training, complexity, fun stuff, whatever is all hospital based. Ideally as a patient you do that the absolute fucking minimum and mostly interact outpatient.
The more general problem with the VA is that standards are very different from the rest of American healthcare except for things like Prison/Indian Health Services.
Malpractice standards, rationing, staff competence and speed and quality of care, documentation standards. VA staff work less hard and get to skip some very frustrating types of administrative work (like having a lower documentation burden), VA patients are some of the most fun to treat because they are often pleasant and friendly. This leads to happier staff and therefore pretty high patient satisfaction.
Unless you fall afoul of some rationing or speed based need I doubt it makes a huge difference in an outpatient setting, but I get very, very nervous every time one of my relatives or friends ends up in a VA hospital.
All the horror stories (mostly undiagnosed conditions) I've heard were in the private systems.
I'd love to hear more about this. Outside some scummy for-profit systems like HCA this is totally alien to me.
Throwaway05
6mo ago
Yeah I don't think there really is a way to make this change. A common suggestion medical people have is to reduce the cost of medical school tuition to international norms which would then decrease the laser focus on higher paying specialties.
I don't think that really matters because of my thesis - MD salaries aren't the problem. Fixing supply, reorienting where people are going, etc. All distractors.
Throwaway05
6mo ago
Let me first reiterate that I don't think this is super rational.
Keep in mind that like 55-60 of percent of grads are women, and ultra woke ones at that. A good chunk of the guys are gay. 45% are non-white (mostly Asian and Indian).
The politics these days are super far left (downstream of admission requirements and other factors).
That alone makes these people disproportionately want to live in the biggest most blue areas or "one of the good ones" in a red state.
If my mom was here she would tell me to shut the fuck up about making this too much about politics so I'll point out other things like - you didn't do anything at all for fun (exaggeration but gets the point across) in your 20s or early 30s. You want to live in a place where you can go and make up for that, and not feel 30 years older than everyone else. That means SF, LA, NYC, Chicago, etc.
A college town has amenities but most of the people using them are younger and don't look soul crushed and it makes you feel worse.
This got rambley.
Atlanta/Houston/DFW are fine at attracting people but where the need is a two drive away from each of them. That's fine for a weekend trip but when you are trying to make up for lost time it isn't viable, you want to be able to catch a show after work, go to a hip new bar or restaurant.
An alternative way to think about this is that a lot of people graduate from college, spend a few years downtown somewhere partying and having fun, then calm down and move to a suburb or further out than that. Physicians are 10-15 years behind their peers on that process.
And then kids get involved and you want a good education because it is pretty much impossible to get through training without valuing education and unsurprisingly that extents to your kids. Not finding that in most rural areas or most places in general.
Throwaway05
6mo ago
What I REALLY want to see is the percentage of drugs that make it to FDA testing and THEN fail.
Really good thought.
If you don't already know about it you should read up on the story of what happened with Aduhelm (summary not provided in order to avoid being biased).
Throwaway05
6mo ago
I don't see how they're not part fo the problem. If they increased the supply of doctors, they'd be cheaper and healthcare costs would go down.
A realistic salary cut brings down healthcare spending by 2%. That's barely anything. Bring administrative spending down to 1980 levels and you probably save something like 25%.
Throwaway05
6mo ago
The classic example is that pretty much everyone who rotates through there has arrived in the morning to see a patient and found someone dead and cold but who was charted as alive by the nurses. The follow-up is "what's the difference between a VA nurse and a bullet?" "you can fire a bullet" "a bullet can only kill one person" "a bullet can draw blood."
The care quality is pretty bad. However the VA is actually pretty popular with veterans.
If you mean "why is it abysmal."
Well it is government run is probably most of the answer. However it is also a jobs program for vets instead of a health system so that may be a big chunk as well.
Throwaway05
6mo ago
locked in to a particular set of postsecondary education(often sharply limited) by their mid-teens at the latest
Yes also my understanding which is why I'm concerned about killing career changers.
Throwaway05
6mo ago
Previously I've advocated for tort reform as a way to reduce defensive medicine and cost of care, but elsewhere in one of these threads it was pointed out to me the complexity of addressing that (fixing things is hard, who knew haha).
There should be a way to reduce administrative burden - capping profits more diligently and reducing overhead /forcing institutions to be lean should be feasible. Health insurance companies and healthcare admin are both hideously bloated and didn't use to be that way, and I'm sure well intentioned regulation is what caused the problem.
In my mind it is fundamentally the same question as "lets make college cheaper again" similarly hard to fix but what works for one will probably work for the other.
Throwaway05
6mo ago
No, running theory is that the people in the pipeline currently are simply too culturally blue and want to avail themselves of big city resources when they finally have the ability to do so.
Given how many people leave residency single there is also the reality of finding a partner, and since most people want a class/wealth/intelligence equal and being a doctor isn't really a draw anymore, they go where the other young professionals are (and stay).
Throwaway05
6mo ago
Great! Abolish the match. All the trainees are down. I'm down. I'm not sure it's a good idea but I'm down.
That's also not the problem (the problem is that programs with unmatched slots would rather have nobody than the available candidates in SOAP/candidates available in SOAP would rather take a year off than go to those programs). Also all kinds of slots exist in a gray area outside the match.
But by all means abolish the match. Institutional memory for why it exists is low enough that people are willing to give it a shot.
Throwaway05
6mo ago
And the bulk of these cases were debt collection claims filed by credit card companies against people who didn't pay their bills. In other words, the numbers were skewered by claims that were vastly different than what one thinks of in terms of "consumer claims", and that would have had the same result in a regular court.
Goddamn that's a huge confounding variable.
Hilarious story
This is overall great teaching, you explain the issue and then tie it into a humorous and relatable anecdote that gives it context.
I appreciate you sharing and have updated my thoughts on arbitration.
I'm not sure it is possible in the sense that I believe the USMLE scores become invalid after a certain period of time (somewhere in the 5-10 year range?). Would need to investigate that and potentially move quickly.
I don't know if you can take them again if they've expired but it would be extremely hard most likely (on just the studying level if nothing else).
If they are still valid though - NYC almost always has a bunch of unmatched FM and IM spots. That's probably the best place to look. EM has been off and on grossly uncompetitive in the last five years but it hasn't been consistent. Psych used to be a place people looked but it doesn't really work anymore. Peds may have more spots open now.
HCA and other for-profit places have started offering program slots and they aren't popular with US grads but could be a good spot for FMG/IMGs
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