Throwaway05
6mo ago
The 36 hour shifts are an exaggeration (well, more specifically in some specialties it happens in others it doesn't).
24s are the standard.
To briefly summarize residents are called residents because they lived in the hospital, back in the day when that made sense - the social technology existed to support it (everyone had supportive wives who would still be there after and bring them food) and the medical technology was limited (yeah you lived in the hospital but most overnight work was "shit hope he is still alive in the morning), also the inventor of residency was a massive coke head and we didn't figure that out until later.
Now it is a bit more complicated. Bad outcomes happen, see https://en.wikipedia.org/wiki/Libby_Zion_Law
But 24s are often more popular than the alternative. Often the alternative is something like working 16 hours a day 7 days a week. No or less days off. After a 24 you get home between 6am-12pm and get to sleep until the next day. Or run errands while fucked on sleep deprivation.
The problem is that you need 24/7 365 coverage and that's complicated to do and expensive, residents take the burden.
Importantly our regulatory entities have a bunch of research showing that working 24+ hours is better for patients than handing off to a new team. Things get missed. Your drunk (on lack of sleep) doctor is more reliable than a new doctor that doesn't know you.
Throwaway05
6mo ago
I mean preclinical years are an undergraduate class every 1-2 weeks. That pace cuts out a lot of traditional college activity. Once clinicals start you aren't on campus anymore and don't have time for fun. I'm sure this isn't the case in Europe but you can't change the work culture that easily (nor the geography which is a big piece of it).
Throwaway05
6mo ago
How would that work though? You "go back to college" instead of medical school - all the students are 18 instead of 22-26 and you do the curriculum designed with 18 year old maturity. I'm sure some people would still do it but that the amount would absolutely tank.
Throwaway05
6mo ago
Do you have any conception of the ratio of "excess regulatory burden" and "well shit this didn't work so we have to try again" is? (I don't really)
Throwaway05
6mo ago
The real problem is that the number of physicians hasn't grown- thanks AMA and limited residency spots.
This is incorrect and has no relationship to the problem at hand.
Also 50 years ago physicians did considerably less administrative work.
Throwaway05
6mo ago
Thank you for providing a good example, last pile on about this nobody gave me anything to work with. I'm assuming in this case that your plan is a high deductible one and once that runs out you no longer pay co-insurance right? (If not... I didn't think that was legal anymore?).
My mental model of the deductibles is that if anything remotely complicated happens you'll burn them instantly but it appears that isn't the expectation for most people. Probably because in hospital medicine if you so much as sniff a patient they've been charged an arm and a leg but our population on this board is mostly young people who aren't utilizing medicine too much with related expectations.
That said 25% your doctor is being lazy asshole for not trying to work with you, but 75% he's employed and not in charge which is pretty common these days. He can write his note however the hell he wants but the backend people are just going to do something else. He doesn't want to promise you anything because you'll take it at face value (because doctor!) but then somebody he never talks to in a building he's never been to changes some shit and you go form 0 to thousands of dollars.
Your story smells a little more lazy asshole doctor and I'm sorry that happened to you, during my training most of the attendings I worked with would try and save patients time and money, even when a little tiny bit fraud was involved to make that happen. I tried and remember that and encourage the people I train to remember that. I don't do any fraud though. Obviously.
Asking the doctor to know what somebody else is going to do (in this case, sometimes it's for knowledge he doesn't have) isn't super reasonable but that's a lot of this stuff at times.
The whole system is arranged around insurance plans where this kinda stuff never really applies but it hurts those in edge cases.
Also your plan sounds shitty.
Also also: shit. UC sucks. Follow the screening recs they give you. Seriously.
Throwaway05
6mo ago
Attending physician work life definitely lands more in the 40-60 range "on average." Surgical specalities can still end up in the 60-80 hour range as an adult.
As a resident 60-80 is more common with 80 being the "max" allowed but many places go over that. Neurosurgeons may end up working 100-120 hour weeks more often than not for like seven fucking years.
The devil is in the details though. Most medical jobs require someone to cover weekends, nights, and holidays. How that shakes out is pretty variable but you can be an attending with a relatively normal 60 hour work week.....but a few times a month you work 24s. Maybe you do trauma at a midsized trauma center. If it's Tuesday you actually sleep through the night. If it's Friday you are working 24 hours in a row. That is ass at age 27. At age 55 it is catastrophic.
pissed if I found out that a doctor who was seeing me...
Um.....about that.
If you go to a university hospital (you should if you have the choice) you WILL be cared for by a resident who hasn't slept in a day. If you get a surgery done the person operating on you might be on hour 28 and gotten 4 hours of sleep the night before that long ass shift.
Edit: these days theres a good number of women in medicine who decide to work part time for a pay cut. It is a thing but given how time consuming and expensive it is to train someone it's usually unwise.
Throwaway05
6mo ago
A good half of it is medical people being hysterical idiots about "right wing legislation." Dumb shit for sure.
The other half is people refusing to work in rural Mississippi or whatever because they are educated, selected to be blue tribe, and want to actually have fun when they finally have the money and ability to actually choose where they live.
Stop being woke AF and this will self correct to some extent.
Throwaway05
6mo ago
I've talked elsewhere about the whole residency and medical school slot thing. The residency length thing is a very complicated discussion.
I do want to point out there are some advantages to the U.S. system of 4+4 years. Yes lots of places do 4 or 6 years, but the ability to go through undergrad first gives you a few advantages:
-You actually have a college experience/fun. That's important!
-You are absolutely sure this is what you want. Really fucking important.
-Better balanced people - less medical school robots.
-Opens the door for career changers, who are some of the best doctors.
Throwaway05
6mo ago
Young breasts have a slightly different tissue composition (which is firmer) which changes with age resulting in an increase sag as you get older (beyond the size factor).
Should you have cause to feel a large number of breasts it is pretty noticeable lol.
Throwaway05
6mo ago
Wow.
First of all - thank you for writing this up, I imagine if I had asked for this in a work capacity it would have cost me, so I very much appreciate it (and I'm going to feel somewhat guilty about replying in a lot less words).
Second - I spend a ton of time here complaining about myths in medicine and so on so you bet your ass I'm paying close attention when a subject matter expert in something else is talking (again, thank you).
Third - Shit. I guess this means I have to drop this line of "here's the solution!!!"
To dig into some of the specifics you mentioned, those numbers don't surprise me. Supposedly (correct me if I'm wrong) damages in most cases are soft capped near the maximum the insurance will pay out because that's "easier" to get approved and would therefore result in lower numbers. Again this is all supposedly, but the numbers you tossed out line up with what I've seen a lot.
Ultimately physician decisions on this topic are absolutely vibe based - you see one colleague get nailed for something that wasn't even wrong and end up going through a five year trial and become a different, broken person... that changes what you do, even if it shouldn't. Or maybe we just say that's what we do and it's a meme? Hard to accurately study.
There are costs for settling though and we hate it even if it makes the most sense (or the hospital/our insurance forces us to). That's because it impacts all the hugely annoying paperwork we have to do for the rest of our career which sounds like a lame complaint but with the hoop jumping we have to do it adds up to a huge pain in the ass.
Fourth - Double shit. You are spot on, I was asking for arbitration - and I hate arbitration! I don't know if it is actually bad but my opinions on it are totally drive by the anti-arbitration memes.
I guess the next move would be to request the malpractice standards used in the VA and Prison, which are different. Not happy about that though because the care they give is awful typically.
Two sidebars:
-
Meddit has a running medmal blog poster. It's pretty instructive and you see a mix of "Jesus Christ fire that expert witness into the sun" and "fuck I hope I never make that mistake." Generally good discussion, if you develop any interest in this take a look!
-
OB malpractice can be absurd - as high as 150k a year (although that's the high end). On the low end Psych is like 5k. Darkly hilarious given that's the specialty with the most people who want to sue. That's an absolutely insane business expense though (for OB).
Throwaway05
6mo ago
Partially addressed with this user down thread.
Throwaway05
6mo ago
Same! When I see this online it's mostly people bitching about the U.S. being terrible but I'm sure that's not representative of how people actually feel.
Throwaway05
6mo ago
You do realize that people in healthcare deal with the frustration of the job because they want to help people and are therefore constantly doing quality improvement projects and establishing metrics and other ways of tracking and addressing bad outcomes right? It's one of the major drivers of cost.
Throwaway05
6mo ago
Ultimately the lack of price transparency is not something that should be relevant to patients, you functionally need insurance in the US and every having to do with payment outside of your insurance fees is a total nonsense dance between various entities. If your ultrasound costs 300 dollars or 350 dollars shouldn't be relevant if you are paying 0, 5, or 20 for the thing.
It's certainly annoying not to know stuff if you are a curious person, but I'm not really sure it is ever relevant.
Throwaway05
6mo ago
Iatrogenesis might become a leading cause of mortality
Is this a reference to the blatantly fallacious "medical errors" study?
Throwaway05
6mo ago
If you were working 24 hour shifts, weekends, and holidays - and then someone decided to cut your pay in half. Would you keep working period? Probably not. Would you entertain those hours? Zero chance.
Nurses typically work 3 12s or 4 10s and in some cases make six figures and we already have a nursing shortage problem because they don't like the schedule (because clinical work can suck and nights, weekends, and holidays also suck).
Throwaway05
6mo ago
I 100% believe they want to come here for South African (I actually had supervisor at one point who was South African, he was incredible). Australian, and NZ healthcare actually pays comparable to the U.S. to the point where we have people going there. I'm sure if you opened it up you'd get a mix in both directions. Canada is already pretty open to transfer with the U.S. is my understanding with some jobs making the same some making less, some making more.
Britain is the odd one. Granted redoing say IM/FM/Peds/EM residency here is only three years and be a huge life gain. They don't seem to sign up for it. Most of the time I see this online it's associated with a bunch of anti-Americanism.
Throwaway05
6mo ago
The official stance of the BMA per their website is:
"Doctors who are already on the UK specialist register may be able to apply for partial exemption from the residency programme requirement. To check if you are eligible, you should contact the relevant specialty board in the US."
My guess is that the answer is not yes or no but "it depends."
Throwaway05
6mo ago
Why don't they then?
I wasn't able to find a good single source of truth but medical students can do it (which Scott did(ish)) if they are interested. It's harder than it would be a for a U.S. grad but likely much much easier than an Indian medical school grad.
The BMA website implies that some "adult" (saying it this way because I can never remember the British terms) doctors may be able to come over without any specific retraining but does not provide details.
Training is probably somewhat worse in the UK but not enough that I'd have any complaints about anyone coming over (although this would obviously be bad for the UK).
Throwaway05
6mo ago
I do like the idea of restricting patents, but it is worth considering the potential downside. The U.S. Pharma industry kinda functions like the U.S. military does. Drug development is stupidly expensive and we do a massive chunk of it. Reign in costs and we lose a lot of drug development.
Maybe worth doing but also important to actually think about.
Throwaway05
6mo ago
I'm not sure I really follow what you want to do based off of this. Obviously the whole thing doesn't function as a market and shouldn't really given the reality of population irrational decision making and the amount of money involved.
I'm very much down to make the system get better and avoid weird stuff like your trucks example, but most of the suggestions I see don't really seem to be likely to do that?
Related to lifetime limits is the issue of pre-existing conditions. Some pre-existing conditions increase costs. Some pre-existing conditions patients will successfully or unsuccessfully lie about. Some pre-existing conditions are in in essence resolved but insurance companies would use them as excuses to deny things...
Throwaway05
6mo ago
I mean a 30% higher rate of random denials seems pretty assholish no?
There exists staff in the hospital who can tell you how much the "charge" (but not necessarily the "cost") is for a given thing but they don't interact with patients because our healthcare system is based around patients not paying for things themselves directly, these staff interact with the people who are paying (insurance companies).
Depending on the details of the specific complaint, your bag of saline costs a shit-ton of money because it was made and stored in a sterile setting with a restrictive expiration date and was handled by a large number of staff, all of which as per government regulations, or because the number is completely made up in a weird voodoo dance that exists to get insurance to pay for things.
Throwaway05
6mo ago
let’s import them (from native english-speaking countries with decent standards, like our peers in the anglosphere)
Do these people want to come? I'm not sure they do.
Other stuff.
Usually when this conversation comes up what happens is that I say something like "sure increase supply just don't compromise quality" and then someone says "being a doctor is easy, there aren't really quality differences or problems" I recall this argument from you in the past but if you don't endorse it now no problem, but ultimately most supply increasing options involve compromising quality in some way. Americans are mostly uninterested in decreasing quality, but if we decide that's on the table then we have a lot more tools available to solve some of these problems without touching supply at all.
Also, right now we seem to be in a situation where shortages are pronounced enough that the market can absorb a much higher number of physicians without bringing salaries down. In fact we likely need to increase salaries (specifically: one of the biggest problems right now is that people will refuse to work in red states or rural areas, these jobs already offer higher salaries, sometimes as much as twice as much, but in some cases that's not enough).
We already have some evidence that salaries are too low for some needs, taking salaries down further is liable to make those issues first (and again does little to decrease the overall healthcare costs).
Here's a source:
https://siepr.stanford.edu/news/just-how-much-do-physicians-earn-and-why
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