Throwaway05
3mo ago
The USMLE is necessary but not sufficient, other stuff is required to be a competent doctor (and NPs/PAs certainly become doctors without passing the USMLE, and while not actually good enough certainly make some people comfortable).
Preparation side of things gets weird, these days most applicants use uniformly the same few "best in class" test prep resources like Sketchy and First Aid, hypothetically someone could pass the USMLE without the structure and context of course work but it would be nearly impossible because of the sheer amount of crap you need to know.
As you know but the other poster likely doesn't, a lot of what is involved in being a good doctor involves practical experience doing shit in the hospital (sometimes physical skills and the like) with training wheels for awhile before you do it on your own.
You don't want your first time doing X to be doing it by yourself with no supervision, it's a terrifying thought.
Incidentally some states in the U.S. do allow lawyers to became barred without law school but I don't know the details of that.
Can't really do that in the same way for medicine.
Lastly it's entirely possible to pass USMLE and be ass as a physician for a variety of reasons including skills atrophying and laziness.
Throwaway05
3mo ago
Throwaway05
3mo ago
One of the things you learn in medical school realllllll fucking fast is that most people are shockingly honest with their doctors. Some topics are tough but many topics you think people would lie about (like drug use, or wanting to murder someone) are often whole heartedly endorsed.
It's more of a problem for families, and for often good reasons (I didn't want the kids to think smoking was cool!!).
Throwaway05
3mo ago
The existences of spots does not equal the existence of good spots.
Throwaway05
3mo ago
Some people smoke but don't want other people to know about it, a common sample motivation is because they know it's bad but don't want their kids/relatives to pick up the habit.
Throwaway05
3mo ago
I don't know that much about this because its obviously not relevant to my life but my understanding is that they mostly exist badly underserved areas (like Kentucky) and are vulnerable to legislators abruptly changing them and then you are trapped with no ability to work (or move out of state).
Viable for some but have caution.
Also Step is a lot of work, although it does cater toward foreign medical education in some ways (at least the earlier Steps, later not as much).
Throwaway05
3mo ago
It is certainly most common for lung cancer to be caused by smoking (at least in the U.S.). It does depend on the type of cancer though, one counter example you may know is mesothelioma - it's usually a lung cancer, and usually related to asbestos exposure.
I'd say in my clinical experience I've run into crypto-smokers more than people who got traditional lung cancer from other causes.
Keep in mind that the problem is more "pollution" than cigarette smoke. People with lives who brought in the in touch with all kinds of shitty carcinogenic bullshit can easily end up getting lung cancer without smoking, but that is less common in the U.S. Grew up next to a tire fire? Life history may present alternative examples.
Lastly, you do run into smoker-pulmonologists - they rightly point out that smoking is a genetic disease (even if it is a "two hit" situation). High genetic predisposition? Makes sense that lesser exposure would cause problem.
Throwaway05
3mo ago
Do keep in mind that even if you ass blast the shit out of Step you won't be 100% sure to get a PGY-1 position (especially with psychiatry which has gotten a lot more competitive).
Throwaway05
3mo ago
I don't think you or @Throwaway05 understand how shot trust in medicine is amongst the working class. It's kind of terrifying.
Be careful with this kind of thinking, I see a wider swathe of the working class than you do (because everybody shows up in the hospital eventually). You do see some doctor skepticism and such but most people are quite happy to follow most types of recommendations unless something basic gets in the way (we tell everyone to exercise, not everybody listens).
A small fraction are upset and anti-doctor in a vocal way, but most people shut up in the room for a variety of reasons (including things like not listening to the doctor suddenly becomes very costly if you are having a significant medical event).
The people who actually cause us problems are the woke more often. I acknowledge that this is likely due to my location but keep in mind that a lot of bitching is just bitching and is essentially a luxury belief that fades on actual contact with illness.
The best explanation for the gap between things like online sentiment and what I actually see in clinical practice is probably just people talking a big game, but the issue of a loud minority or hyper geographic concentration are other possible explanations.
I am worried about the young adults out there like me when I was a young adult, the undiagnosed schizophrenics (and the undiagnosed bipolars and major depressives) who would never give strangers power of deciding their fate
Good news and bad news here. Basically the people who are well and truly sick don't have a choice. Their friends, family, or the police drag them into interaction with healthcare if they really actually for real sick.
Throwaway05
3mo ago
MBTI has a bunch of different uses, one example is managers using it as a shortcut to determine what feedback style is most likely to work (at least initially) for the employee. Try and figure out what exactly they are doing with the data beyond sending people to various teams.
Throwaway05
3mo ago
The problem isn't necessarily your idea (although I'm sure some would take issue with it), the issue is the implementation. How do you decide? Some people with chronic medical illness look like a mental health patient, some mental health patients try repeatedly to get medical care and get ignored... when the issue is "live or die" you have to get things absolutely right.
Throwaway05
3mo ago
Everybody has a different response to medicine, and food. Some people metabolize certain medications well or poorly. Some people get a good response from Ozempic for all kinds of shit, some don't
Some people think Cilantro tastes like soap and we know exactly why.
Personally I am not offended at all by diet soda but I do know plenty of people who are. It does work for some people!
Throwaway05
3mo ago
The resources available to address vaccine hesitancy are in general very good, they have ones that lay the problems and considerations out in plain English with good details and citations to high quality research. I'd send you one but my desire to find the best one means I'd be going on a research rabbit hole I don't have to time for at this exact moment, but if you look you should find one (sorry I'm not a pediatrician, if I was I'd probably have one I like on hand).
The problem is the the left-wing political capture of the field and therefore the refusal to abandon any of the "teams" talking point which right now means over recommending the COVID vaccine.
"Hey we recognize that the COVID vaccine recommendations are unpopular but the evidence base is much stronger for everything else, here's how" would probably please a good chunk of the skeptics but broken woke brains can't do that, leaving frustrated people like me with a mess.
Which has been why I've been (loudly here and very very quietly in real life) been complaining about captured political expression in medicine since before Trump 1.
Throwaway05
3mo ago
Did you mean to reply to someone else? I am very deliberately not taking a stance on that side of things.
Throwaway05
3mo ago
Yeah I think you may have missed the "moment" and therefore would struggle to get into the headspace of some of the angry people. Probably ultimately good haha but people were pissssseedddd.
The people who still are still pissed are going to be hard to convince.
Throwaway05
3mo ago
If it makes you feel better you can usually have a healthy conversation about this in real life if you are sufficiently skilled, I've converted anti-vaxxers before, but it's nearly impossible to do online for all the reasons most things with any amount of heat are nearly impossible to do online.
Additionally most people have some things they are absolutely retired about, with many people feeling hopelessly abused by social justice and modern leftist politics they are likely going to be retarded about anything that touches that stuff at all.
I do wonder if some of your surprise comes from being in India during COVID - the way things felt in the UK or US vs India may make for some difference in experience or expectation?
Throwaway05
3mo ago
The impression I've gotten in my time here is that most people are pretty much just smart enough, with a side helping of tech-bro-ism.
Medicine seems easy/simple from the outside in a large part because most people here are young and healthy and don't interact with the complicated parts of the field. Most people here also don't exist in fields where a lit review is a thing (in a large part because most of the people who do that are far left at this point). A half assed opinion piece is considered an authority and their's no need to read primary source material or contra narrative information critically.
We (docs) also get used to hardcore digging in because of skin in the game. If I pick the wrong medicine my patient fucking dies. That means I'm naturally going to have much more "informed" commitment to my medical views (even when they turn out to be a wrong) than somebody arguing on the internet without significant consequence.
Add in the political climate - nothing I say when defending medicine is going to do anything to separate me seeming like one of "those" COVID people to skeptics.
All those types of things together and more and you get my downvotes and the vitriol.
You should use this as a Gell-Mann Amnesia moment however. As my media diet continues to improve I get access to more and more better primary source material and you see things like rampant factual inaccuracy here on other topics outside of medicine that I've just happened to have been informed about.
We are still pretty good here! But outside of a few reliable posters you'll see a lot of very confidently stated low information stuff being promulgated.
Ultimately most of the people still complaining about COVID are having a tantrum. I get why they are having a tantrum, I was not happy about some of the policy decisions - but it's still a throwing the baby out with the bathwater moment.
Throwaway05
3mo ago
I don't know one single person who had lasting adverse effects from the vaccine. This includes professionally. I do know many with acute effects (including myself).
I've also met a few people who have made claims of adverse effects but they've all been clearly mistaken (typically it involves active mental illness, or sometimes other clear medical causes of the problem which they attribute to COVID).
Throwaway05
3mo ago
It's not that simple. It's not always clear who is who. Some frequent flyers are coming back because they don't want to go to the shelter. Some are coming back because the ED keeps not treating them because they think the problem is mental illness and they never did a basic work up...
It may be helpful to model this similarly to however you feel about the legal system, letting guilty go free and so on.
Throwaway05
3mo ago
Context
Commented somewhere else but there are things to like about the VA, I suspect that part of the issue is that the part where it is weakest (inpatient care) is the part most patients know the least and where its hardest to tell when your care is ass.
Throwaway05
3mo ago
Much as I hate defending the VA I should say that the care can actually be very good at times. Inpatient medical care? Almost always awful. Outpatient care? Some of the clinics are actually excellent. PTSD treatment? Some of those programs are clearly best in the world in class.
Much of this had to do with the specific specialties and staff. Many people at the VA work at a slow pace because they want to be lazy and can get away with it, but some use that slow pace to do things like spending more time with patients which means satisfaction and care can sometimes be better.
Most of us train at the VA at some point though and the VA training experience is comically poor.
Throwaway05
3mo ago
If a patient comes into the emergency department the options are (loosely) you discharge or admit them.
People are allowed to go home even if doing so may result in death or bad outcomes. We typically calling this leaving AMA (against medical advice). Common reasons for this are illness disrupting decision making, denial, and needs (like drug use, or I have a flight to catch, or I gotta go to work).
If people in the hospital think a patients decision making is impaired (for instance: dementia, medical illness resulting in confusion so they can't make a decisions with full thought) they can do a capacity assessment. This usually involves calling psychiatry for help but you don't need to. If the patient understands the ramifications of their decision (oversimplification again) they get to go home and die or have their frostbitten fingers fall off or do too much heroin.
A sub category of this is psychiatric extremity.
If a patient comes to the ED and has a psychiatric history or has psychiatric symptoms then psychiatry needs to see them and say they are safe to go home. Some critical thought should be used to determine if psychiatry is actually needed but for various reasons (including the ED being overworked, midlevels, and liability concerns) no critical thought is used.
For instance "I'm sorry I said I wanted to die, but I had fallen off of a dump truck and could see all the bones in my legs going the wrong direction and it was very painful" "or I came here because I was looking for a therapist" now generate a need for an outpatient follow-up appointment. Also "I have no psychiatric problems but I was confused because I have early onset dementia" and "I came here because prison lore is that I don't have to go to jail if you guys say I have psychiatric problems" or "no I'm fine, that was some good heroin, let me out so I can go get more before they run out." None of these people necessarily need a psychiatrist, the ED psychiatrist's job is to determine if they do and if they are safe to go home.
Now they are required to see someone (supposedly, I don't know the legislative details), wasting everyone's time.
The other primary option is admission. If the patient is a threat to themselves, others, and in some states property (with a lot of at times hazy and at times specific clarification on what all of that means) then they can be involuntarily committed. You can also just ask the patient if they want to stay, which depending on resource availability may involve admitting someone who really doesn't need it. All kinds of complications fall out here, for instance some patient's say they want to be admitted but are admitted involuntarily any way.
In past times the U.S. was very free with involuntarily admitting people, very resistant to actually discharging people (from the ED and from the psychiatric hospital) and abused people in various ways, our current legal framework exists to protect against those abuses, some of which were very very serious (gang rape of patients at state hospital for example).
The downside of reforms was that homeless people who are too mentally ill to function or chronically treatment non-compliant are allowed to wander the street.
You may not care about those people, but we also used to accidentally catch people who really weren't mentally ill or were definitely safe to be at home. Not making this mistake is harder than you think because its very common for people with no mental illness, mild mental illness, and severe mental illness to all say the same things (especially when someone is taking the medication only because they are locked in a state hospital and will stop as soon as they leave and start murdering again).
Throwaway05
3mo ago
If you are asking this question you are likely not from the U.S., so some details:
The VA is the U.S.'s primary "socialized" medicine - health care for veterans.
It's been criticized for having amazingly poor care (what's the difference between a VA nurse and a bullet? A bullet can only kill one person), being more of a job program than a health system, at the same time some people love it (everyone involved understands the veteran experience).
It's a huge system with a ton of rot that is essentially a preview of what would happen with single payor in the U.S.
Throwaway05
3mo ago
This was a messy time. Ivermectin appeared to only work in the global south where people had a high parasite burden - when it worked it was saving lives by treatment of parasites which improved outcomes because less parasites.
The lab leak vs. natural is still hotly debated by knowledgeable and they actually gave good arguments on both sides that dont parse very well to laypeople.
Much of what you are complaining is also directionally incorrect, it's the media recruiting doctors, not the other way around.
They used to have less shit they could do so it was easy to have everything memorized aka we used to do jack shit, especially overnight (and reference textbooks are a thing!).
Also like 50 medications total lol.
Reminder that the treatment for a heart attack used to be ETOH and that was the better option than the alternative (bedrest).
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