Throwaway05
1mo ago
Pretty much everything you've said about the doctor side of things is wrong and much of it borders on malpractice. Frustratingly, I've corrected you on some of the clear matters of fact in the past and you've refused to update, so I guess this is more for the benefit of others who may be looking.
-Physician salaries are not responsible for high healthcare costs. They are a low percentage of healthcare costs. 8.6%. Half physician salaries (which nobody is suggesting and would collapse the system anyway) and you would barely make a dent in cost. Data: Stanford (SIEPR).
-Anesthesiologists do not make 700K a year. The average salary of a gas attending in the northeast is 380k. Data: MGMA survey (granted the one I have is a few years out of date).
--Can a gas attending make that much? Probably not in a desirable geographic area but if they want to work 2x full time or take a lot of weekend/holiday call they can get close. Maybe in L.A. if they do celebrity work, pain management or something like that? The ones I know who crack that level make the money off of owning something, patents, or something else of that nature, not working.
--On a more editorial note, why does gas make $$$? Gas is like being a pilot, most of the time it doesn't look like you are doing something outside of take off or landing but you get paid for the hopefully rare emergencies. Additionally procedural work reimburses well in the U.S. for historical reasons. Fix that problem if you want.
-The average physician salary is 350,000 in 2023. Not far off from Cim's range. Data: 2023 Mescape reports.
-Over half of doctors are in the "low paying" specialties where it's not uncommon for your salary to be under 200k (IM, FM, Peds, Psych). Depending on where you work and what you do you may be able to go over 500k but that's pretty much 95% percentile and involves shady cash only practice or working exclusively night shifts in Arkansas.
-No specialty makes over 800k without it being "fair." What do I mean by that? To make that much you are doing something like cash practice plastic surgery for wealthy people in LA, own and run a business (unrelated or related), have patents/high level consulting work, work 350 days a year (yeah people do do this), or are a neurosurgeon (egregiously long training, work hours, stress, and competency requirements).
-Doctors. Do. Not. Make. Millions. A. Year.
-The federal government is in charge of residency spots. However, state governments and private companies can and do make their own residency spots. We've had a bunch of recent scandals about this as the residents have been critically undereducated and frequently unhireable outside the system that trained them (specifically: HCA in Florida). Turns out medical education is complicated and you cannot just increase spots this is most true in surgical specialities which have small number of highly trained doctors, but also represent most of the specialties making the most money.
-The AMA is not a cartel. Most physicians hate the AMA and have for decades, as they've been lobbying for depressed physician salaries in the form of increased midlevel involvement (which is to the benefit of end career physicians at the expense of everyone else).
Their's a lot more to say here on things like "docs in Europe get paid less because their training is shorter and they don't have hundreds of thousands of dollars in debt" or "training quality if much higher outside the U.S., even in wealthy western countries" but this has gone on long enough.
Cim you have to reevaluate your level of knowledge on this topic because (among other things) you said "doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties" is very close to the system we already got.
Additionally doctor's wages in real terms have been decreasing for over 30 years while costs (including med school tuition) have been skyrocketing. It's driving a lot of people you want in medicine out of medicine. Just 68% of medical school graduates at Stanford went on to residency (with the majority of the rest going into tech or business instead). And that stat was in 2011, can't imagine how much worse it is now.
Throwaway05
1mo ago
Tylenol would not be approved as an over the counter drug if discovered today because of how easy it is to kill yourself accidentally (or intentionally) with it.
The average person has no idea how badly many drugs can interact with each other, recreational substances, and with medical comorbidities.
And that's ignoring other problems like the people who would give themselves antibiotics for viral infections etc.
Throwaway05
1mo ago
I can't possibly upvote this enough. :(
Throwaway05
1mo ago
Supposedly that specific black actress has some form of connection to SBI and that's why she has been in so many games lately. She's also in many of the games that had the "female attractiveness change."
Throwaway05
1mo ago
Malpractice is heavily dependent on state and specialty, can be as low as 5k-10k or as high as well into six figures (OB). Some states have caps on malpractice payouts, some everyone get sued constantly.
Loans are for 4 years undergrad + 4 years of medical school. After that you get paid while working 60-80+ hours a week (but the pay is 50-70) while in residency. Residency lasts like 3-7 years depending on the speciality, and to do some disciplines (like Cardiology) you have to do additional years of poor pay training on top of the residency.
Once an attending most jobs are 40-60 hours a week but some stay higher than that. Depending on the field you may also work weekends, nights, holidays, 24+ hour shifts, 2 weeks without a day off etc. even as a senior doctor.
Throwaway05
1mo ago
It's not unreasonable for a PCP to make 180-220 a year. That's a lot of money in comparison to most jobs, but when the surgical sub specialist is making 600-800.....people follow incentives.
Note: We have orders of magnitude more doctors in primary care than the sexy big number specialties.
Throwaway05
1mo ago
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.
Throwaway05
1mo ago
a large number have cluster B personality disorders
Identity instability is a literal symptom of borderline. Not surprising if these people (when unstable) have trans thought content. If you throw the long COVID equivalent into your research studies, it's going to give you a ton of junk data and hide whatever thing is really going on.
Throwaway05
1mo ago
I would guess a culture of "toughing it out" and "oh god we have tons of real health problems" limits the role for these softer diseases.
Also thank you for introducing me to "crore."
Throwaway05
1mo ago
It is my firm belief that people with severe psychiatric disorders that appear to be permanent should essentially try the kitchen sink of pharmacology and related lifestyle alterations.
You should probably separate out things like depression and anxiety from illness like bipolar and schizophrenia. Some (considered crackpot) physicians will try and manage bipolar with therapy or recreational drugs but schizophrenia is pretty much straight up well understood pathophysiology that 100% necessitates medication management.
The stuff that can be managed conservatively rarely catches a diagnosis in those cases which does admittedly complicate the issue.
Throwaway05
1mo ago
My suspicion is that this is a trans type situation. Yes there are real trans patients. Yes there are cultural contagion trans patients. Yes there are borderlines (and others) with identity instability manifesting as trans thought character.
Likewise with Long COVD et al you have a mix of those pathologies being rolled together and it really reduces clarity and makes it unclear to what extent it is a real thing. Some people likely do have mangled CNS/PNS as a result of viral illness, others are maybe looking for a more ego syntonic expression of their depressive symptoms.
I know less about fibromyalgia but my understanding is that some physicians are emphatic it's a real thing and more investigation will make real bio markers or whatever abundantly clear.
Not seeing any fibromyalgia in India is interesting but its possible that it's in some way culture-bound, or environment-bound - higher parasite burden, rougher lives may prevent the sensitization or whatever else is going on under the hood.
Throwaway05
1mo ago
You may find it fruitful to read some of the work done by non-woke Psychologists and Psychiatrists (ex: Life at the Bottom by Theodore Dalrymple), if for no other reason than to go "my god other people have noticed this!"
Everybody who deals with these people has experienced this stuff but having the tools to diagnose and label what these people do is helpful (and may at times give you some insight in how to work them for your needs).
Throwaway05
2mo ago
This happens a lot in our own fucking notes we used to share mission critical information with each other (called note bloat), pretty much zero reason to assume it will have the smallest usefulness for patient facing stuff (for the reasons you outline).
Throwaway05
2mo ago
Additionally the level of affirmative action in medicine is extremely intense, I haven't looked at the data in a few years so I don't know where it's at now, but it used to be absurd - something like 90% percent of black med students would not have ended up in medicine if put on a fair playing field.
Throwaway05
2mo ago
Not nearly as common as death by volume of paperwork, but an example of actual errors is when practice changes due to new information, and nobody updates the info sheets.
Throwaway05
2mo ago
So while I sympathise, I don't know what can be done. If doctors over-warn, that triggers panic, if they don't warn, there is risk of a very severe side-effect. And yeah, you'll have patients who don't listen anyway.
Yup. :/
Pharmacists do have a helpful role here though. Specialities like Psych and Oncology have medication that is complicated and generally have the time to pause and talk through some things, but an antibiotic for an infection? PCP gonna move on to the next patient - good time for the pharmacist to do med information while dispensing.
Throwaway05
2mo ago
Only allowing elective work to be done (especially risky or life altering stuff) after a longitudinal period sounds like a good step. Pretty common to do this for trans stuff but less so for things like a tummy tuck or the sterilization, which can also go wrong but we are happy to do.
I generally get the feeling the consent process exists to protect us from patients not the other way around, and longer/more clear communication may not help with that.
Written communication can be a problem sometimes though - you are going to have to write down that one of the risks is death, or other scary things and it's going to be worth it, and rare. But having that on a piece of paper that someone can stare at can be a bad thing.
Throwaway05
2mo ago
Barring that, I'd at least like doctors to make a good faith effort to communicate all major known risks, as well as known unknowns and unknown unknowns to the patient before they get them to sign the unreadable legalese that they likely have to do before a procedure.
On paper we do a good job of this (although realistically I know a lot of docs half ass the consent process). The issue is that people struggle with risk. 'If I had known I was going to have night vision problems I wouldn't have gotten the eye surgery." Well generally we can't predict that in advance, we can tell you the rate of problems and so on, but that's it. That doesn't stop patients from wanting us to have perfect knowledge and suing when we simply don't.
Throwaway05
2mo ago
Do you think physicians have a role in executions? Our stance is for the most part no (because do no harm), but I do think about the Solus principle - "had to be me, someone else might have gotten it wrong."
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
And then I face-palmed when the final quiz began asking questions about HIPAA, which is not a thing in India and not covered in the course itself, strongly suggesting the course had been designed by ripping off a US source, or perhaps the latter hadn't localized it particularly well.
Jesus fucking christ.
Anyway - thank you for in essence covering my thoughts better than I did.
I think what I struggle with is that people should be allowed to make mistakes, but they should not be allowed to be fooled (or at least we should try and be more proactive in preventing that) but we have this issue where so many big topics are misleading, or political (as the sterilization is) and therefore people may need more protection.
Throwaway05
2mo ago
It's pretty common to give print outs like medication information sheets, or something called an "after visit summary." Frequently what happens is that it gets comically enormous and useless as various stakeholders fill it with random bullshit.
Anything more personalized/off the cuff becomes extremely difficult, especially as corporate control of medicine pushes doctors to see more patients faster. Really hard to do when your visits are 15 minutes max and that's supposed to include your charting time.
Throwaway05
2mo ago
To what extent should we protect patients from themselves? Two things happened this week that had me considering this again.
One, some discussion on medical reddit popped up about how to handle people (chiefly young women) requesting sterilization at a young age especially prior to having children. This has obvious implications for regret and forcing people to be locked in to insufficiently considered choices.
Two I was talking to a friend who was complaining about a side effect of laser eye surgery and she said she was not told about the possibility. In talking to her she was very clearly told about the possibility of this side effect but simply didn't get it.
This is not uncommon. Either surgeons half ass the consent process, or patients just completely fail to understand and fully grok what we tell them. Generally both.
A different example - I've had the conversation "X problem is gone because of your medication, if you stop your medication X problem will come back" "okay doc I'm here to complain about X problem, I stopped my medication" a million times. Including with smart and highly educated people. People often don't understand what is told to them and that can include things like life altering surgery.
What do we do with this? Do we let people make mistakes? Where do we draw the line?
This topic comes up very frequently in medicine but the discussion quality is generally very poor "protect them from themselves unless they want such and such political topic in which case sterilize them at their request with no counseling etc etc." I think this community may have something more interesting to say.
I especially don't know how to handle this given the tendency to strongly protect autonomy in some areas but not others.
More general CW implications include the usual trans problem, but also "protecting people from themselves instead of the more specific patients.
Throwaway05
2mo ago
It's both a numbers game in terms of having your own personal random bad experience and in terms of meeting people who have zero insight into and understanding of their drinking, but if you expand that to a whole population you are going to catch some weirdness.
That attitude leads to things like the opioid crisis where the rest of society is left cleaning up the mess left behind by people making questionable decisions.
A huge chunk of healthcare costs these days are associated with lifestyle related problems. That's going to get worse if you have 100k people fuck up their kidneys and need dialysis.
Negative externalities are a thing.
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