Throwaway05
2mo ago
That approach can be fine for medical (as opposed to surgical specialties - in those you want someone who has some years of physical practice without being too far along in age), although the caution is that medical knowledge changes quickly. I remember within a couple years of starting residency (much less being an attending) some of what I was taught was outdated and it would have been very easy to not notice.
As to your other piece a lot of surgeons (and things like Oncologists) will have ancillary staff who can help generate counseling and additional information for patients in a way that is actually helpful.
Throwaway05
2mo ago
I think what make's the US rust belt different is that it's so large because the country is so damn huge (maybe kinda like Russia in that way?). Canada and Australia are also enormous but much more population focused.
I don't think other countries have something like Kensington in Philadelphia, although I've heard political winds have changed and theirs some thought the situation will be improved soon.
Throwaway05
2mo ago
That is hilarious and sad. Thank you for sharing.
Throwaway05
3mo ago
Given the general state of the U.K. I am entirely amenable to the idea that the exam is just absolutely fucking retarded, but I do want emphasize that it's probably just a tinge more likely that they are doing something on purpose, potentially with a heaping dose of "I don't like this."
Sometimes it's straight up "this seems like a stupid question but it seems to correlate with exam performance so..."
I don't know if this exercise is viable for India, but one exercise I have students do towards the tail end of clinical is look back at their first year exams, you'll see clinical correlate questions mixed in with basic sciences questions and at the time they are enormously frustrating "why the fuck did they ask about that" is a common refrain, but if you come back at the end of clinical you'll see that it's common, or a necessary concept to reinforce and so on.
The SJT for instance is stupid, but it's placed there with quite a degree of deliberation, just the two of us hate it.
Throwaway05
3mo ago
It may not be satisfying per se but some of the oddities of medical examinations come from a very well-defined place (well if it’s like the USMLE anyway).
-Specific pieces of data one specialty wants to convey to another. “No ortho you really do need to know this about the ‘beetus.”
-Making things harder in a way that assess actual knowledge and understanding instead of fact recall.
Those are two of the biggest. Also repeat questions are often stemming from the whole “experimental questions” aspect of the exam.
Making things vague, removing buzzwords. This means you have to actually UNDERSTAND the stuff instead of just memorize facts or guidelines. You need to know the why and what of currant jelly stool instead of just recognizing it in a stem and slamming down on the answer.
I swear to you with time and space you’ll find that some of the stuff is more reasonable than your experience of it felt like.
Except the SJT, fuck that toxic horseshit.
Put another away:
Ideally at some point you’ll be doing a boards question or some other assessment and you’ll have this experience of “I don’t know the answer to this question but my knowledge is sufficient to understand what the answer should be based off of other things I do know.” I’m not quite sure I made that come across the way I wanted to but hopefully you’ll have the ah-hah moment at some point.
Throwaway05
3mo ago
As usual the UK is different than the US so I don't know enough about what's going on here but some things likely hold true:
-Above average for a physician, on any type of assessment or metric.....is impressive as hell. These people are study psychopaths and you have your neurodivergence etc. Good. Fucking. Work.
-Have some caution with respect to specialty trends, these can turn on a dime and if you don't have a good source of intel you can miss out on wild swings in competitiveness (for instance in the US Psych went from not competitive at all to tough as hell to average, all in the span in 3-4 years. Advisors mostly missed this and left people high and dry). Sometimes it's better to swing the bat and not worry (shit, does that also work for Cricket?*).
-Ruralness. This one I can definitely comment on(ish). There are a handful of cities in the US most Residents want to be in, and approximately 10,000 places they don't want to be. Thanks giant ass continent. Normally when I'm advising students I'll tell them to rate location higher than they think. Not wanting to shoot yourself because you have fun things to do during your limited fun time is more important than higher salary or academic prestige. However higher than you think doesn't mean it's the whole list. Training is short, career is long, and the UK is small. As long as you have flexibility after you are done then you can live with wherever they put you and then leverage yourself into a better position later.
The reason I tell people to be in a big city is that you don't have too much time during training so you want to have access to easy fun. The flip side is that if you are in a shit location you don't have a lot of time to regret being in a shit location, and when you have vacation you can just travel where've you need to go (again, uk smol).
You might be concerned about training quality in a rural area and this is real, but psych isn't surgery. You don't need physical practice doing a Whipple, you can catch up on knowledge gaps through training and studying resources pretty easily. You also likely get to avoid the truly annoying patient populations (like malingering homeless) that a big city will be flush with, and rare shit like autoimmune encephalitis is still rare enough that you wouldn't see it in London or wherever. You will need to eventually learn how to deal with bread and butter homeless malingerers and decompensated psychosis but because they are common in a city setting you'll figure it out quick when you move to one.
At least I think, for all the above there. I don't know the UK well but I imagine some of the trends are similar to how it is here for that sort of stuff.
-I meant to reply to a post but didn't, so I'll ask here....how do you deal with all the hackers in Tarkov?
*apologies for blatant stereotyping.
Throwaway05
3mo ago
Yeah again saying I don't really agree with OP, but I do find it very plausible that American culture is significantly informed by immigrant communities that had a problematic relationship with addiction (ex: Irish, Borderers, Puritans (in the sense they hated that shit, would need evidence that such things were for cause)) and that generated and informed our toxic attitudes.
As an example, American pain and discomfort tolerance is overall pretty low with respect to seeking pharmacological intervention (notoriously noted in the opioid crisis but you can also see it with our OTC pain killer usage).
Throwaway05
3mo ago
Yeah not criticizing your approach or interests, I just have the suspicion that you might get confusingly aggressive pushback or skepticism (including on here) because of these events.
Throwaway05
4mo ago
I'm hammered so please forgive some element of nonsense here but keep in mind that earwax has several natural purposes that can be further impaired by irrigation, for instance if you have clogging but not full blockage it can be partially functional at most of its given tasks but failing at whats most superficially noticeable (that is: hearing).
If you are irrigating you are more likely to end up with shit like infections and physical trauma, which the wax is supposed to be assisting with.
Risk/reward benefit is tricky here.
As a side note lots of people end up with otitis because of things like rubbing the ear in response to irritation (which might be caused by something like eczema).
Try not to irritate it and that can make an honest to god huge difference.
Throwaway05
6mo ago
- Some mental disorders are more culturally bound than others, with Schizophrenia being something we see pretty much everywhere with similar patterns but different content being common.
- Severity of symptoms is variable, with some with most people experiencing a step-wise decline but with the extent of this being variable.
- Less severe or alarming symptoms means less presentation for help ex: hallucinations not being as distressing they can be not as bad, or fit better in the cultural milieu (think religious delusions back in the day), or if someone is more negative symptom predominant (think apathetic, reserved, anti-social).
- Religious delusions are common but tend to be unsurprisingly related to the culture at hand. Same for other delusions and hallucinations. Someone in rural Africa might think the chief of the next village over is out to get him, where an American might think it's Joe Biden etc.
- Manic episodes and full blown psychosis were historically deadly. If you were manic in a pub in London in 1630 you might get killed in a bar fight and nobody cares or you might end up summarily executed by the police for being a total idiot. It would not surprise me if the same phenomena happens today in certain places.
- Not sure if we'd have good quality of research on this though.
I should note that Western psychosis is more likely to be dangerous because of things like easy access to weapons, poor policing, good social safety net etc. Remove those things and they are likely to get killed, unable to arm people, exiled, whatever is my thought.
It's not like violence is Wester specific - read the wiki page on running amok for an interesting example.
Throwaway05
7mo ago
The short version is that it gives you a very bad brain infection and then you die (encephalomyelitis, if you like). What actually results in death is as usual more complicated than expected but that's the short version.
If you scroll to the "pathophysiology" section of the below article (accessible for me without a login) it should be pretty understandable even without specific training. It also mentions the whole hydrophobia thing.
Throwaway05
1yr ago
It depends on the region but the average is more 300-500.
And because you don't know anything about Anesthesia. To some extent this is fair, patients don't interact with gas much and medical TV shows are uniformly misinforming, but you haven't show any evidence for the idea that they don't do anything complicated or useful to be a reasoned and informed belief.
The pilot analogy is apt. Most people intuit that takeoff and landing are harder, and that emergencies sometimes happen. They don't know about ground prep and the other stuff pilots do. I'm not sure you are naturally making those connections here and "lol nah I'm not going to read that" does not help you become better informed.
To be maximally charitable to you it is reasonable to figure this guy is talking up what gas does (or more realistically is ignoring the difference between lazy docs and hard working ones) but that doesn't change the fact that their are multiple fundamental every shift job roles you aren't aware of.
Throwaway05
1yr ago
So we have a ton of top of the line decision support tools right now, (including things like auto-read for EKGs, suggestions to put in antibiotic if the computer thinks someone is septic, etc.) the problem is that they suck and are intrusive and annoying. This is important, not only do they need to be more right but they also need to be consistently right - people are trained just to ignore them and if you go from being helpful from 5% of the time to 30% of the time they'll still be functionally useless. If we get to a 70% range situation people will ignore them out of habit and ingrained mistrust.
That problem aside...why is this shit so hard?
It's not because medicine is complicated (it is, but that's not the problem*), LLM are perfect for digging through a bunch of data and such. It's because people are complicated. People come in with a severe illness and complain about something else, ignore a diagnostically critical symptom, report pain in the "wrong" quadrant for the pathology (happens all the damn time).
The decision support tool needs to handle this ambiguity gracefully, have some mechanism for sussing out the correct shit from the patient, and have graceful way of handling the editorializing of whoever is recording and entering the data (and ideally in a timely fashion as you mention).
And then you have super significant but more arcane layers to the problem. Okay my patient has a kidney issue and a heart issue. My decision support tool can help and send me the most updated guidelines. Well where are we pulling from? Cards or Neph? One is shouting Blue and the other is shouting Yellow and depending on which Ivory Tower Institution you pull from the shades of those colors are going to be wildly different.
Research in medicine is difficult and fraught and ethically complicated and we don't have enough high quality recommendations to load this stuff with.
In Europe they manage appendicitis mostly medically, in the U.S. we operate. You ask a surgeon here why the difference and they'll probably say it's because we are fatter. Is that right? Fuck if I know, but we can't agree on the most simple of management.
*I have no idea why the EKG reads are bad, that's pretty damn simple and doesn't bode well for getting anything more complicated done.
Throwaway05
1yr ago
My understanding is that the needing CPR twice was a miscommunication (likely because of something like "he was initially triaged in a resuscitation bay at the trauma center" which is a different kind resuscitation).
However even if he did have CPR twice that isn't evidence against commotio cordis, damage from "down time" (even with prompt high quality CPR) can lead to other problems like anoxic brain injury (likely avoided it seems), pulmonary damage (seems present), and issues with perfusion to other parts of the body that can lead to PT/OT needs. If your heart gets fucked up it fucks shit up. Not out of the woods after initial ROSC is obtained.
If you look at some of the initial medical social media discussion of this you'll see that some people were confused, commotio cordis is rare (and is more common in pediatric populations for physiology reasons) but that's what it looked like, pretty much slam dunk (ex: initial continued perfusion allowing to stand followed by sudden collapse). So we were wondering if it was an atypical presentation of something more "common" in this setting like hypertrophic cardiomyopathy.
I haven't seen a diagnosis released yet but cordis is most likely at this point and is pretty much a freak accident and has nothing to do with COVID.
Throwaway05
1yr ago
(and yes I know you asked for a general primer but the point is to build knowledge of the unexpected complexity).
Here's an example-
https://old.reddit.com/r/Residency/comments/104bwb4/why_was_damar_hamlin_in_the_sicu_after_his/
Why is Damar in a SICU (Surgical Intensive Care Unit) - some people are saying that's best practice, some people are saying that's best quality of care, some people are saying that's because of the resources specifically at UC and some people are saying it is because the case is high profile. And you can find someone saying the opposite for each of those. Everybody knows what they are talking about.
No way to know unless you work there and were involved and some combination of those answers is probably correct.
Stuff is very resource and facility dependent and a lot of things don't have strong consensus.
Throwaway05
1yr ago
You'd think so and it's a fair question which is why I gave example somewhere else in this soup of comments. Elective procedures, stuff done at an outpatient surgery center, cosmetic things. Low rate of complications, low rate of fuck ups, pretty simple with a lower range of prices. Sure. Places will do that.
Hard to do for symptoms for so many reasons (is that headache a migraine, a stress headache, or a brain bleed? You are complaining about 8 things and the real problem is heart failure etc etc, the pain is referred and it's actually a very different kind of thing).
Once you've figured out what's going on it's feasible for some things, but the American population is really unhealthy and the one person where you open them up, find out it's bowel cancer and not appendicitis costs hundreds of times more than the regular appy.
It's the equivalent of those housing developments where everyone shares water fees but someone has a pool that they keep emptying and refilling every day.
Throwaway05
1yr ago
I learned how to effectively grade scientific literature by looking for places where you'd see the hordes of "SOMEONE IS SAYING SOMETHING WRONG ON THE INTERNET" types and seeing what they said, and then after years of that picking up the skills myself.
Go to /r/medicine or other similar places, look for the hot button stuff, see what people say and complain about. At first you'll be missing context but you'll pick it up. Bonus points if you also go to the other places with different levels of training like /r/residency.
Be aware of the biases of the various areas though (anything remotely political is DOA on meddit, it's appropriate to hate midlevels but the residency subreddit takes it a little far).
Very common for industry adjacent people to do this, you'll see consultants, tech people, and lawyers pop in with their expertise because they are following or work or because of a partner.
Most of the mistakes people make are pretty basic- assuming it's simple and easy, or because they are falling for one of the agenda pushers (including us).
If you look closely you'll probably see one of those situations where three people with over 20 years of training and who very are on top of it are articulately arguing over if something like if "is a bandaid is actually a good idea or not" and you'll be like Jesus this is a nightmare.
Throwaway05
1yr ago
Is this for real? The person billing OP wasn't even a doctor, and no PA, NP, or doctor is getting paid that much for that type of work. Blame the admin and the billing people for the number, the PA has no control over it and is making 1/10 of that sticker price.
Again, as stated elsewhere doctors have been lobbying for their own competition for years, who proceed to do the same job for cheaper, with less training, and do a demonstrably worse job.
I'm always flabbergasted at how little people seem to know about this in relation to how enthusiastic their beliefs are.
Also the NHS is collapsing.
Throwaway05
1yr ago
-Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse. Insurance rules are complex, constantly changing, and do so with no notice, if a place says "it will be 500 dollars after insurance" they have no idea if that's accurate or enough, and that's when needs are static. And that's if you pretend cost of delivering care is static. It isn't. If a surgery costs on the median X a specific instance could be 0.8x (healthy thin young adult, 1.2x (obese 50 year old), or literally 100x (patient has a complication, crashes, ends up in the ICU). Is the hospital supposed to charge everyone 1.5x to cover for the one person who explodes? That's like involuntary insurance. Places will offer elective and simple procedures in a fixed price fashion but they are very very cautious with that.
-Healthcare in the U.S. is collapsing, many disciplines are moving out of public insurance (most OP specialties) or private insurance (psych, in a limited fashion). Hospitals and facilities are going under with enough frequency it is approaching a full blown crisis, but most of us live in big cities with a famous name brand academic hospital that just put up a 500 million dollar building and has a million billboards. Easy to miss the crisis.
-This process is not designed to extract money unnecessarily from patients, the insurance company is refusing to provide the paid for service and instead of refusing to pay the insurance company for sucking balls the patient is fucking a different victim who is also legally prohibited from retaliating. I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.
-As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.
Throwaway05
1yr ago
Surprise billing pops up in two major places- the ED and for consult/pop-in needs.
The later is rarer, less obvious to patients, and harder to fix without big sweeping reform (I NEED EXTRA HANDS IN THIS ROOM RIGHT NOW or "is anyone at work right now who can help answer this question?" are hard problems) attempts at fixing the ED stuff break this process to and discourages those resources from being available. Nobody wants to risk not getting paid so community hospitals have an increasing dearth of specialists and then whole death spiral (for the health system) and poor quality of care things happens.
The issue with the ED is that the structure of American healthcare discourages physician self employment and physician owned practices, so one of the major driving factors here is that private equity groups have bought all of the ED doctors who aren't hospital owned and then start some fuckery with the insurance companies and this is one of the things that shakes out.
Realistically it's still a problem in physician lead healthcare but right now it's those large and connected industries fucking with each other.
Some breakthrough protection would probably help a lot "in case of truly emergent care needs the professional fees need to be covered by insurance but at no more than 110% of the fee schedule for the mean costs of in network professional fees" or something would fix the problem.
I'm sure that would have issues but the point is that the insurance companies aren't interested in fixing the problem they are interested in lobbying so that they don't need to pay for things and someone else gets the blame.
Throwaway05
1yr ago
https://old.reddit.com/r/medicine/comments/da5ccm/in_california_a_surprise_billing_law_is/
In general you can dig around on meddit just search for surprise billing.
Superficially this looks more like a problem for docs than for patients (well fuck you guys just take a pay cut) but in general you want doctors to have more leverage and control because while they want money (just like anyone else) they came into the field despite the opportunity costs because they wanted to actually help people. The other interests are just trying to extract value for the least costs (insurance companies, private equity firms that buy physician groups and so on).
Physician power and influence (and self-employment) has been plummeting for awhile now and they essentially minimal influence over care and costs in a lot of settings which generates the stuff that pisses people off.
A doc can provide free care (and many did) if they aren't owned (by a hospital, practice management group etc).
Shorter version: monopolistic competition = bad.
Throwaway05
12d ago
I am sure that some people exist who feel this way, but all of the therapists I know (which is bounded by these people being mostly physicians, or PHD/PsyD psychologists), think that shit is nuts (and have much displeasure with the popular presentation of therapy, mental illness and so on).
Throwaway05
20d ago
Yeah don't date one, but you gotta keep in mind that if you are seeing them (at this phase in your training) it's either so bad they are on an inpatient psych unit or in the ED, or they are in the hospital for other reasons and they are such a pain in the ass that the diagnosis makes itself clear.
In training you'll get the skills to pick up more mild cases in the community, and presumably also see more mild cases in therapy clinic.
This also is true for things like depression and anxiety (early in training you'll only see total shit shows, but more mild cases exist they just don't need you).
This is also, also true for things like hypertensive emergency vs. generally outpatient family medicine seeing mostly controlled shit.
Throwaway05
20d ago
Borderline is better conceptualized as more like depression or anxiety than schizophrenia when it comes to severity. Many people with depression or depressive thought process never present for care, nor do they need it. Some of these people kill themselves.
The same is true with Borderline. At state hospitals in the U.S. you often see a mix of psychosis and severe borderlines who won't stop hurting themselves. It can be very bad. You also have borderlines where the symptoms are so rare or mild that you'd have to have a long relationship with a therapist to catch it.
Don't underestimate how "harmless" it can be.
When it comes to treatment it is treatable. Certain kinds of therapy work (chiefly DBT). Patients accumulate coping skills and calm down just by aging. Medications don't work great but can be helpful for symptomatic management.
Being an excellent PCP is possibly the most difficult and cognitively demanding job in medicine. On top of that pay is shit, prestige is shit, so great people don't go into it but great people are needed.
Corporate pressure and increasing health problems means they have less time with patients but more to do than ever before.
It's a mess and I understand why patients feel mistreated but they also have no idea whats going on.
As for the specifics in the U.S. IM or FM can be a PCP after completing a relevant residency, with (some?) states having a process for being a "GP" with more limited scope of practice after completing certain levels of residency.
The U.S. is weird because all docs can technically do anything in medicine (unrestricted practice) but getting permission to do that in a particular facility, malpractice insurance, and getting patient's insurance to cover what you do is all complicated. Certain kinds of ethically challenged people manage.
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