Throwaway05
8d ago
You get shit on so much in medical education that I find most people forget what the exams are for and minimize their value. A good chunk of preclinical learning is laying the ground work for later knowledge growth (Step 1, the relevant exam, included). We also need something that isn't pure pedigree or totally luck of the draw and subjective evaluations to provide candidate discrimination. It also needs to happen early enough for people to filter themselves to specialties that will be actually realistic for them.
Basically Step 1 + Clinical Evaluations (but not preclinical grades) and the usual Letters of Rec/Research/EC.....that shit worked great.
However Step 1 was enormously stressful and got harder to write questions for due to exam prep resource inflation. Someone uncharitable may also note that minorities tended to underperform. So they made it pass/fail.
This killed student motivation in preclinicals (which is again, supposed to be foundational knowledge) and was a huge win for premier med schools (and loss for lower tier ones).
If I had to change one thing I'd increase the weight behind Letters of Rec - they are unpopular these days and admittedly make things harder for those without a medical family (and I was one of those) but done responsibly they can do a lot to recognize good and well trained candidates.
Returning to Step 1 - people get upset because a big chunk of the exam is "low yield" but that's because everyone successfully learns the basic stuff. And they need to. And the old exam format forced them to. The low yield stuff is also things that doctors should be vaguely aware of because you'll see individual rare cases all the time, just not a specific rare case.
Throwaway05
8d ago
My grumpy self has to say good, because that's more knowledge than I normally see, or perhaps Ive been ranting about this here for enough years.
We have an excess supply of med students (mostly provided by the Caribbean and outside the U.S., and therefore of much lower quality but still an excess).
However it's not as simple to increase the number of residency slots as you may think. You probably know that most residency funding comes from the federal government (and good luck getting them to fund more) but some states fund slots, as do some private hospitals (most notoriously HCA), as residents are a revenue positive thing (although hospitals will claim otherwise).
In the case of HCA the residents from those programs have been notoriously underprepared and unemployable outside the HCA ecosystem, not because the candidates are bad but because the education is bad. Robust medical education is very hard and expensive and complicated and in some cases like surgery you can't create more of it no matter how much money you spend (due to case requirements).
So increasing spots varies from "eh it's doable" in some specialties to very hard to impossible in others.
A related problematic trend is that people find primary care (biggest specialty shortage) and working outside big cities undesirable. Nobody wants to increase doctor salaries so it's incredibly hard to motivate people to go into primary care (it pays half as much and has more un-fun burdens like excess charting requirements) and nobody is ever going to convince a large number of people who had to skip their 20s to move to rural Iowa as soon as they have freedom without a massive pay bump.
But yes the problem is mostly allocation as opposed to shortage.
Throwaway05
8d ago
Not sure what they are talking about specifically (the linked data was for clinical "shelf" exams and the course length change is preclinical) but a number of higher tier schools started to condense the traditionally two year preclinical curriculum into a year and a half or so (the spared time was used elsewhere).
This transition predates making Step-1 P/F, COVID, and recent social justice advances, but not every school is picking it up at the same time. They may also start to roll it back because it can be very rough on students.
A number of massive changes have hit medical education all at once, some of which are quality suppressing some are not.
Throwaway05
8d ago
If you meant for educational quality:
We've already introduced "lower education" doctors in the U.S. for awhile now, they are called PAs and NPs. It's been researched. Tellingly, their best case (presented by the nursing lobby) is research that shows that NPs results in equal outcome with U.S. MDs without controlling for case complexity (basically the doctors got the complicated cases, the NPs get the easy cases, and they still ended up with similar outcomes).
More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).
Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy
If you meant for the bottle neck:
I'm asking you, as I generally find that posters with an opinion on this don't actually know where the bottleneck is.
Throwaway05
8d ago
It does, it's very common for patients to ask for things they don't need or for things that may be bad for them (classic examples are controlled substances and antibiotics). People don't like being told things like "just wait out the infection, it is viral" or "well I know you are in pain, but actually the narcotics are bad for you." People who just prescribe like crazy get better reviews.
Inpatient things can be a bit more different, but those encounters don't generally result in reviews.
And that's not counting things like psychiatry where a good psychiatrist is always going to get angry reviews from certain classes of patients.
Throwaway05
8d ago
A friend of mine recently went to a specialty conference, she described a lecture she saw that was talking about the difficulty in giving feedback to students these days, a student at the end asked "wait is that why all of my friends and I are told we are doing great the whole rotation and then get a 3/5 on our evaluation at the end?" Everyone just nodded.
Good teaching requires being able to safely give feedback and that just isn't possible anymore. The problem isn't limited to minority students.
Okay fine this a bit of an exaggeration but still.
Throwaway05
8d ago
This has been huge, students used to spend 2+ years studying to get the highest possible score on an exam they get to take one time so you had to be sure. Now they just try to pass. Now a lot of that exam was stuff that "doesn't really matter" (ex: biochem pathways) but the incentive shift was absolutely massive.
Throwaway05
8d ago
I encourage this attitude, it's extremely hard to know if your doctor is good or not because the things that are available for a patient to know are generally customer service things that are often extremely uncoupled from actual medical knowledge and practice ability. Very common for people with good customer service skills to be bad doctors.
Throwaway05
8d ago
You'd be surprised how much academic pedigree "matters," plenty of people don't care but you'll find soccer moms, educated people, the neurotic and all kinds of others very insistent on a "good doctor from a good school with good reviews on google," despite how often many of those disconnect from reality. For us it can matter because certain of jobs (like being a program director) may be essentially closed off to you without training at a "good" institution. Now, again this isn't necessarily reality based but it matters to a lot of people.
What you might find more interesting is that programs don't really work like undergrad or other fields. The preclinical half of med school is essentially the same country wide, in a large part because students have settled on a half dozen ultra high quality learning resources and ignore whatever the hell their school is trying to do. Pass rates for the exams (which can be using standardized exams but don't need to be) and boards (standardized) are higher at higher tier schools because the students are better. Therefore fail rates jumping is a huge huge black mark.
The other half of medical school is clinicals which uses standardized exams and evaluations from preceptors to determine your grade. The evaluations can get more program dependent and may actually have deflation, but this is also where variation in educational quality comes in since most schools pre-clinicals are basically the same* these days.
This is a gross simplification but for the purposes of this discussion should do.
Throwaway05
8d ago
What's your epistemic certainty on this? Where is the bottle neck? What level of selection is necessary? Do you know the data on under trained providers vs traditionally trained ones? We have it.
What does a doctor actually do? I don't think you actually know, in all likelihood your primary interaction with medicine has been outpatient or maybe some emergency, where most of the work is in inpatient (and for academics, research) and necessarily invisible to patients since they aren't following us around. Most patients don't have any actual need to see the hard work but it's very much their and being done and intensely concentrated on things like the elderly, chronically ill, and people who randomly role through with a one time episode of something.
For instance proper antibiotic selection can be tremendously complicated, and we can see this by looking at things like stewardship rates between NPs -> Urgent Care -> Procedural -> Primary Care -> IM -> ID.
Doctors almost always insist that their friends and family see actual doctors instead of NPs and PAs for a reason, and that's because the job is complicated and the training is doing something useful.
Throwaway05
8d ago
Every field has bad apples, the way medical education is structured it is very hard to get through without a certain floor level of competence.
When I think about "bad" doctors the ones I run into are generally lazy/burnt out types, or outright malicious/unethical types. Traditional incompetence is rare, because those people get kicked out of medical school or residency....unless they are a favored minority group.
In my career I've run into a handful of white/Asian doctors who are truly incompetent, while I've run into plenty of great URM (underrepresented in medicine) doctors, a noticeable percentage of URMs should never have been advanced through training. It's not a lot, but it's way way way more than the near zero for other demographics, and all of the absolutely catastrophic idiots have been URMs.
From asking it around it seems like the attitude is that it's easier for a programs reputation to advance an incompetent URM student than deal with the flack from trying to put the person through remediation and/or termination (in part because medical education now includes a lot of mandatory education in toolkits these students can use to complain).
Throwaway05
8d ago
I once saw an interview with a bunch of (young) Japanese women where said women expressed they wouldn't mind if a partner went to a brothel but they'd get very upset if the partner went to a Hostess Club.
Who knows.
Throwaway05
9d ago
The primary treatment for ADHD is stimulants (and Concerta is one). Most people get some form of benefit from stimulants, if this wasn't the case Coffee wouldn't be as popular (or uhhh Meth, which is what Adderall basically is).
It is however, very common for people to think they have ADHD (and even get diagnosed with it) when that is not the case. Other things can cause problems with attention, focus, and so on - depression, anxiety, medical illness, personality disorders. Most notably perhaps is simple modernity. Sitting in an office focusing on boring shit all day is not what our bodies and brains are designed to do.
If you don't have ADHD, taking a stimulant will likely give some form of performance boost but how helpful it is, is going to be deeply variable and may pass diminishing returns very quickly.
People with "real" ADHD are going to have a very different experience with stimulants most of the time.
That's not to say the above is 100% guaranteed, but it's good short hand. Plenty of people will pop a Vyvanse while studying for a tough exam and get some benefit out of it, but the way the medication is meant to address ADHD symptoms does not apply to people with "normal" brains, which may not be intuitive.
Throwaway05
9d ago
“You have to realistic about these things.”
Throwaway05
9d ago
“Once you've got a task to do, it's better to do it than live with the fear of it.” ― Joe Abercrombie, The Blade Itself
Throwaway05
12d ago
I see a much bigger rise in prevalence in women and assume the usual causes, for instance I've had a number of female friends and family members asked me if they should get a tattoo, if they'll be judged for it, will men hate it etc. I say nothing. Which is the same approach I assume most people use. The judgement for tattoos is still there, but saying anything that can be interpreted as critical to a woman is such a bad idea that people say nothing and the gap in preferences goes unchallenged.
Throwaway05
12d ago
Why shouldn't an owner be able to buy a failing restaurant, sell the real estate, and then let the restaurant fail?
Sounds fine, until your area loses its hospital because PE came in and did something similar (it's a growing problem in healthcare). Lots of organizations you wouldn't want to lose are sitting on valuable real estate and operating with razor thin margins or other similar sins.
Throwaway05
14d ago
Hey man, like what about justice man?
I do mean this seriously however. Don't underestimate how many people on both sides are incensed due to their understanding of the facts on the ground and feel like the situation is untenable. In the case of the pro-Israel side you'll find people from all over the word who interpret events as "I have no particular interest in or affection for jews, but I see Hamas as terrorists and terrorism can't be allowed to flourish, out of either a sense of justice, or out of fear for what may later happen to me and mine if people find this valid."
Throwaway05
14d ago
It's worth noting that while some of the impetus for anorexia may come from social and cultural expectations and so on, it is very, very much a mental illness and has dysmorphic components. You can't easily reason your way out of it especially if people "feel" fat (while objectively being thin, it's somewhat of a psychotic process). "Yeah yeah if I was really skinny you might be right but I just have to shed these last few pounds to be normal" is a bizarre sounding but reasonable in their own mind response.
Throwaway05
14d ago
I wouldn't call it "don't allow." VBAC's can be very dangerous, they can also be safe, the relevant care team will likely try to assess the risks and summarize for the patient. OB is pretty notorious for being a bit more heavy handed with consent than some specialties, but that's ultimately not that unreasonable when many women are interested in fucking off and having a "natural" birth at home even when it's high risk to the baby and mom (and notoriously, will see the doctor even when it's a consequence of their own shitty decision).
This over focus on outcomes and liability potential is also why you shouldn't trust those stories from mothers. Yes it probably happens at times, and certainly used to be more common back in the days when OB was >85% male instead of >85% female, but OBs are way too worried about getting sued and making sure the baby is okay to do that for the most part.*
And hospitals are very likely to have a dedicated laborist these days anyway.
*"Force" mom to have a C-Section and something goes wrong because you wanted to go play golf? That's a multi-million dollar liability judgement. Everyone knows that isn't worth it.
Throwaway05
26d 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
27d ago
To conclude, is therapy helpful when administered by someone who knows what the fuck they're doing? Yes.
This point is the whole thing. I notice here that a lot of people seem to have complaints about "endless therapy" and "never getting better," but reputable, well trained therapy involves a constant progression towards "being done" (well typically anyway).
I suspect this is equal parts misunderstanding and a surplus of shitty therapists, which makes sense since it's far harder to regulate, train, and assess than "traditional" medicine.
Small amounts of therapy that anyone with diligence and training can do (like motivational interviewing) can radical improve care for any specialty.
Shit is good when done well. And even more fluffy and "less evidence based" therapy modalities like psychodynamic therapy work great when done by someone who cares and knows what they are doing (and are shocking similar to CBT anyway).
Throwaway05
1mo ago
It's also worth keeping mind that mental illness almost always impairs insight - your ability to understand and read your mental state may be hampered (not that the average person is truly good at this, but it can be more important in someone who struggles).
Many borderline patients hear the diagnosis and its description and go "thank god, that's me! it all makes sense now." Many go "no that's bullshit I AM TOTALLY FINE LALLAALAL................."
Throwaway05
1mo ago
Mild symptoms complicate both diagnosis and treatment - much of what DBT is designed to help is for moderate functioning people (can be great) and low functioning people (where it isn't likely to).
Your diagnosis could be wrong, but I'd guess what's happening is that you are well enough, and the underlying biological reality of a borderline brain gets in the way sometimes.
However also possible you are what you are and don't meet criteria for anything.
This one is a myth, example citation: https://www.mcgill.ca/oss/article/critical-thinking-health/medical-error-not-third-leading-cause-death
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