Throwaway05
1mo ago
it's food for thought nonetheless
Lol I mean I maintain shit ain't ready yet like I always have - it's very common for diseases to present atypically and even more common for patients to poorly explicate things. Neither of these is well captured in the literature and therefore the data set.
Throwaway05
1mo ago
That has long been the case. There are a number of medications which are approved in Europe but not in the US, for example.
While true this gets considerably confusing. Sometimes the more expensive drug is approved in the U.S. sometimes Europe. Sometimes the "more dangerous" drug gets approved here, sometimes there. Political considerations of all kinds pop up (like childhood vaccines). It gets weird.
Compounding matters is the fact that sometimes things are not approved for an FDA indication, unlikely to get approved by insurance, unlikely to get approved by your hospital/pharmacy, scheduled, totally legit but 100% sure to get you sued if anyone complains and so on...
My favorite example is Gabapentin, which has thirty seven million off label uses but only two official uses - and 9/10 competent physicians will get it wrong if you ask them.
Throwaway05
1mo ago
I am studiously silent on whether you could replace me entirely with one
I can't find the paper but I was linked recently to a study illustrating that generative AI performance on medical content drops precipitously when "not one of these" is added to the answer list and used.
We aren't dead yet.
Throwaway05
1mo ago
Unrelated but should still mention: not all specialities are sedentary/radiology, it's pretty common for proceduralists to actually do a decent amount (even if its just standing on your feet >16 hours a day) with Ortho at times being legitimately physically demanding (depending on what you do in Ortho).
My specific life course is highly identifiable which is one of the reasons why I've been vague about my specialty and background here but keep in mind that things like hobbies, pre or concurrent to medicine employment and family background can give people manual labor experience without the main career being one of those things.
To quote Heinlein - “A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.”
If you aren't moving your body on a regular basis in some productive way you are leaving behind a ton of physical and mental health gains.
Throwaway05
1mo ago
I absolutely hypothesize it's this. I'm getting older now and while I still go to the gym the numbers are much lower than they used to be, I hear my younger friends brag and I mourn the old days.
Ask me to actually do something and I smoke them.
Presumably because I have a bigger frame, more practice, and more experience actually using my muscles in manual labor.
Throwaway05
1mo ago
It's been a longtime since I've seen Candle Jack, maybe he did i
Throwaway05
1mo ago
...And for the lovely anecdote I mentioned, from Nancy McWilliams's Psychoanalytic Diagnosis:
I've been trying to get people here to read that for years! I appreciate the parallel advertising.
Throwaway05
1mo ago
It's both true and not true. If you give men an unlimited stipend and no consequences they'll go to strip clubs and buy hookers constantly. They probably know it's bad for them, but well people do shit that's bad for them all the damn time.
Dating apps are an equivalent for women, a constant parade of male attention and access to men they wouldn't have otherwise who in truth have no interest in them. A decent subset will abuse that, with intention or without. Eventually society and obligation will make them circle back (well for most).
Some may have insight into it or not.
"I want to fuck the prom king" isn't irrational when given permission to do so. It may be common but usually they grow out of it and it's a matter of when.
Throwaway05
1mo ago
Where is the evidence these people have fabricated studies in an attempt to slander the efficacy of opioids?
That's your claim right?
Otherwise you can find a minority population online saying whatever, but they need to have an impact on prescribing habits and the research you deny.
Throwaway05
1mo ago
There's also concern around organ donation. I've seen some reports online about adopting new guidelines around brain death so that (to put it crudely) they can start getting the organs as fresh as possible.
If you want to read more about this some discussion is here: https://old.reddit.com/r/medicine/comments/1mf2rv4/donor_organs_are_too_rare_we_need_a_new/
Throwaway05
1mo ago
Anecdotally I've had several significant injuries some of which have been managed with controlled substances and some of which have been managed with staggered dose ibuprofen and APAP, absent the "high" effect they are comparable (for me) when it comes to pain control. The research supports this - plenty of people manage without pain control or with more deliberate OTC medication usage.
Some amount of breakthrough pain or discomfort is normal and to an extent beneficial. Some research suggests that that the desire for total pain control and numbing is a somewhat American cultural specific desire and part of why we have addiction problems in this country.
Analgesia and addiction considerations aside, the medications have a number of problematic side effects that need to be considered. They do have their use though, and the people doing research in this area are aware of that.
Looking at a JAMA article and saying this clinical research is fabricated by non-clinician puritans is conspiratorial thinking, especially because the types of people have cultural sway for this kinda of thing at the moment are probably best categorized as dangerously pro-opioid - see: safe injection sites, methadone clinics, and pushing of Suboxone as the best solution to the problem.
Throwaway05
1mo ago
I don't know a single person in clinical medicine who wants to eliminate opioids and while I'm sure there might be some crack pots that's an extraordinary claim that requires some evidence to be taken credibly.
Reactive under-prescribing in some outpatient settings is certainly a problem but that's not really your claim.
Throwaway05
1mo ago
Sorry I don't really have a dog in this fight I just wanted to make that point specifically.
In truth I remain somewhat undetermined about how to handle this specific issue which is awkward given the possibility of it appearing in my clinical practice, however my plan is to just follow legal, regulatory, and hospital frameworks and stay out of the ethical side of this thing.
That said it is worth dialing in just how miserable certain classes of patients are. Again I'm not convinced we should assist them in dying but certain patients have a lived experience that is comparable or worse than the more typical examples (dying of chronic disease, intractably bad life experiences, significant chronic pain*).
For instance someone with severe borderline personality disorder may find themselves zigzagging from being too happy to wanting to kill themselves to burning down their relationships to getting fired to whatever on a regular basis. With associated involuntary suicidal ideation it can approach a point where the life experience is almost abhuman, miserable, and devoid of the traditional pleasures of existence.
That's a reasonably good case, especially since some people like this may struggle to successfully kill themselves because the system does a good job of preventing it and because the problem isn't pure depressive misery, therefore it becomes challenging to overcome the routine desire to live.
Again not necessarily advocating here just pointing out if you had chance to interact with one of these people you might go....oh yeah, I get it, holy shit (or might not).
*Although best we can tell this is somewhat linked to psychic distress.
Throwaway05
1mo ago
Okay, not a train. That's an asshole thing to do. If you're going to commit suicide, don't involve other people.
This is surprisingly hard to do. Someone needs to find the body and unless you plan carefully this can easily be a random bystander or group of random bystanders (and planning carefully is hard when you are suicidal).
Usually EMS and healthcare get involved and seeing someone who has committed suicide can be deeply harmful (especially if it's gruesome like a gunshot to the head). Often they'll have to run a code on the body even if it's clearly dead which is....awful.
Then you have to think about the family and friends of the deceased. Having a close contact or family commit suicide is a risk factor for suicide it hurts people around you in a way that just dying doesn't.
Throwaway05
1mo ago
Absolutely yes!
People have so much more variety in the way they view the world than you might imagine based on the fact that most people end up doing more or less the same things.
It gets super interesting in the case of legitimate pathology like personality disorders and speaks to some interesting things about the human condition (ex: true sociopaths with zero anxiety. They really aren't human, and it tells a bit about what anxiety is for).
As you note nearly everyone here is not normal at all and has features like super high ability to decouple, and a common fail state for people like us is to assume people with low ability to decouple aren't actually intelligent.
Another fun one is the way different cultures and native language speakers interact with the world can result in some foreignness. The results are generally mostly recognizable societies but a lot of Russians, Asians, Middle Easterners etc just experience the world in a way that is unexpectedly foreign.
Throwaway05
1mo ago
Not a lot, but google image search it and you'll see why.
Throwaway05
1mo ago
The guy who loads up on tight ends
I am in this post and I don't like it.
Throwaway05
1mo ago
Absolutely recommend Meteora.
Throwaway05
1mo ago
Yes, that's one reason the combinations are popular, but not the reason oxy with APAP (Percocet) is so favored over oxy with ASA (Percodan, no longer available) or oxy with ibuprofen (Combunox, no longer available). That's drug warrior pressure.
There is a bunch of research out there suggesting that OTC and milder agents are just as good as stronger agents for managing acute pain. Example:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786200
Lots of research. You might not find that research convincing but it is absolutely out there.
Additionally APAP is a safer choice than ASA or Ibu if taken as prescribed, which is easier to ensure in an acute course (less potential for severe side effects or interaction with chronic medical conditions).
Throwaway05
1mo ago
My APAP related disgust is reserved for drug warriors who ensure that oxycodone with APAP is the most available formulation of oxycodone, because they consider people trying to abuse it dying horribly to be a feature and not a bug.
I think these days they would argue that the reason is mostly because of synergistic analgesia (which is not incorrect) but yes I agree it's a questionable cost/benefit.
But ultimately society is organized around tradeoffs in your rights to enable you to have rights and the conveniences of civilization. Having to deal with mildly annoying blister packs or smaller bottles doesn't seem like a high price to pay for the amount of pain you can prevent.
Throwaway05
1mo ago
Tylenol is somewhat uniquely dangerous, it would possibly not have been approved as over the counter in the U.S. in today's regulatory environment.
This is for a couple of reasons.
-The therapeutic and toxic range are way too close (aka it's really easy to overdose accidentally, which does happen).
-It has significant interaction with some medical problems (aka liver metabolism). This is admittedly pretty minor in most situations.
And most importantly:
-Tylenol overdose is one of the worst possible ways to die. It is long, and slow, and for a while you think you are fine. This gives people lots of time to decline in misery knowing they made an irreversable choice. It's awful. Most other forms of overdose kill you quickly or rapidly alter your sensorium.
This creates agony on the part of the victim and their family, and also a significant amount of angst and distress in the healthcare team.
If you like you aren't paying for the minor inconvenience of harder to pull out of the packaging pills vs. fewer suicides, you are doing to reduce clinician burnout and doctors and nurses in the workforce longer.
It's also expensive to manage.
Throwaway05
1mo ago
Nobody does any teaching? Nobody has any Medical Students or Residents?
That doesn't seem right.
Could be regional though - Philadelphia (which is super dense) has nearly as many medical schools as the entire state of Florida, if you live in a place without trainees you aren't going to be teaching.
That said if you work for a hospital you should be doing something outside of your clinical duties (teaching, research, committee seats, extra jobs in the department like holding a medical director title). If you own your own practice you need to deal with the management side of this.
It'd be possible to work for someone to take on the least amount of responsibility (and the specialties you name are some of the ones it would be easier to do*) but you'd be leaving money on the table, not necessarily working any less (since teaching, research and administrative can eat up some FTE) and it is by no means typical.
*Family medicine in most practice environments is checking their in basket and finishing charts outside of business hours at least somewhat.
All of this is stay nothing of call responsibilities - someone is managing a phone line, going into the hospital PRN if needed, for most specialties. Ophthalmology is small and has rare but serious call responsibilities (going into the hospital) and has frequent enough need to phone triage. I'd be shocked if that person doesn't have some call. Radiology and Physiatry can dodge that. Neurology can be one of the busiest call specialties depending on practice environment, same with Family Medicine.
I would wager your friends do more than you think they just don't mention it or it doesn't come up.
Throwaway05
1mo ago
squints
nods
Em dash big? En dash small?
Small brain human use small dash?
Throwaway05
1mo ago
Think journalists, researchers (or their editor), pretentious literary types etc.
Yes! Destroy, the, grammatical, patriarchy.
I think it is probably worth thinking about how in the U.S. we are on the receiving end of a very successfully propaganda apparatus arguing that working hard and having pride in your job is stupid and pointless. Sure it's generally framed in something like "working for the man" or "capitalism sucks" but it is very successful, and past generations with similar views (ex: hippies) had quite a bit of pride in the endeavors they actually got up to which helped avoid this.
It's killing what makes America... America (and yes for the right excess immigration without cultural assimilation isn't helping).
I remember the days where you were more likely than not to find a helpful worker in a retail store. Those days are gone.
People have no pride in themselves or desire for excellence. It's sad.
In medicine it gets very gross because doctors still have that vibe but a lot of nurses do not and the ones who become NPs are often the worst. I've stayed late hundreds of times because I had the right skillset, I didn't want the night team to get swamped and so on. NPs just walk off.
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