Throwaway05
1yr ago
Do you believe health systems should be forced to provide care for someone who has no willingness and/or ability to pay? (They are - if you walk into an emergency room and say I will not pay for any care you provide me they are legally required to give you the same shit as anyone else).
If your response is "you know what I don't want any medical care" then my complaint is withdrawn, but otherwise it sounds like you want to "steal" because you don't like how the process works and don't have a lot of information about healthcare economics.*
*From your other post it sounds like you've been on the receiving end of a practice called surprise billing, which is controversial and legislated against in some jurisdictions but exists for a complicated and justifiable reason but is still annoying, as is usual the problem is health insurance companies being pretty much straight up evil and then blaming everyone else.
As for your frustration with medical debt, if people refuse to pay their medical bills all the hospitals go under and nobody gets medical care. I can understand you're frustrated but these things exist for a reason.
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
9d ago
Hypnosis is actually not fake, it just doesn't work the way people think it does. It's used in modern (Western) medicine it just doesn't really work well and the real version isn't mega useful so you don't hear about it a lot.
Throwaway05
1yr ago
If you have your car repaired and drive off without paying you are going to get reported, and you certainly don't get to come back and demand the next issue be fixed. It's absurd. Even in outpatient land you can't fire a patient (even with just cause like total refusal to pay or blatantly abusive behavior) without jumping through a ton of hoops.
Rural hospitals and suburban/urban hospitals with poor payor mix (in a lot of areas/for a lot of types of care medicare and medicaid pay less than cost) are going under left and right, and other places are closing their EDs in an attempt to stem the bleeding associated with most of the people least likely to pay. It's not getting a terribly large amount of attention outside the field because it's mostly poor whites and the media/left feels awkward about leaving healthcare out to hang after so much superficial support during the pandemic.
This specific practice (this explanation is abbreviated)* is driven by insurance companies refusing to negotiate with physician groups and just say lol I'm going to underpay you, fuck you. When providers try and negotiate the insurance companies label this "surprise billing" and lobby jurisdictions to ban, knowing that the result is professionals have to just not get paid or accept the lowball offer. It's a negotiating tactic. In the last few years providers and low resource health symptoms have seen total crashes in economic health while high resource systems and insurance companies are doing fantastic, but they don't replace the resources that are closing and retiring.
About half of the psychiatrists in the country are able to retire and they are just fucking right off instead of staying and during a time of sky rocketing mental health crisis. We have limited ability to train replacements if we even wanted to (for a number of reasons) and the stopgap (Psych NPs) are uniformly terrible and create more work for the leftover physicians (psychopharmacology is a lot more complicated than most management, as in diagnosis).
*Their are other explanations, you have stroke and the one neurologist on call doesn't take your insurance. Either they let you die, or work for free/try and bill your insurance anyway.
Throwaway05
9d ago
Some of that was deleted (or I otherwise can't see). Missed the previous discussion in the weird psychopathology thread line.
I invite you to read the wikipedia page, which links to some actually studies on the matter (ex: https://onlinelibrary.wiley.com/doi/10.1111/apt.13706)
Basically the most evidence based approach to hypnosis concludes that it seems to function similar to mindfulness meditation, biofeedback, and other similar modalities where someone hacks their cognitive state and level of arousal, which is often easier to do with assistance from an external resource then by a person on their own.
Obviously this implies a limited level of clinical utility but it can help with psychosomatic adjacent pathology and any time "mind over matter" is more directly relevant.
I was fortunate enough to experience some training in this during my medical education and while I personally was not hypnotized I witnessed some of my colleagues experiencing it....and it was ultimately very unexciting and contrary to media portrayal (which is as this usually goes).
It seems most reputable people who do this emphasize the limitations and the fact that it can't really make you do stuff you don't want to do already.
I'm going to be a bit fiery here because this comment is top to bottom incorrect. It will never cease to amaze me how strong opinions on healthcare are with no experience, knowledge, or accuracy.
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The minimum amount (with room for a lot a lot more) of training for a physician to practice independently in the U.S. is 11 years (4+4+3), there are some exceptions but they are very rare.
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The person caring for OP who they are complaining about is a provider (a PA), not a doctor, and has a minimum (and essentially maximum) amount of training of 7 (4+3) years.
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Physician lobbying groups have spent the last 15-20 years heavily lobbying for people outside their "club" to able to provide healthcare (providers), because they could charge for it in a supervisory capacity. Now it's biting them in the ass because those providers are lobbying for independent care, providing inferior and infuriating care (often while identifying themselves as doctors) and increasing costs (PA/NP care costs more but it's in stuff that the hospital/ownership group gets to take a bite out of instead of professional fees, for example unnecessary lab testing).
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Fixing a nosebleed is harder than you think it is. A lot harder. A school nurse or a person at home can shove a tissue up your nose but that doesn't mean they are thinking about coagulopathy, and considering the risk of TSS, other infection, necrosis, know when to call ENT or to do a further work up and so on. Nasal packing for epistaxis is something requires a surprising amount of considering and critical thought, but you don't know that, the nurse doesn't know that, the PA probably doesn't know it, and an annoyingly large number of EM doctors don't know it. Ask a pediatrician.
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Physician professional fees are a small portion of the cost of healthcare.
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
7d ago
I mean it's entirely possible it's more potent than described by medical literature. It's also entirely possible that people who buy into it are more likely to have out of character or excessive manifestations.
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
1yr ago
Healthcare provision outside the U.S. is structurally different in a number of ways that fundamentally change the feasibility of what you describe like:
-Rates of nonpayment being orders of magnitude lower (a huge chunk of ED care is just not paid for by anybody, in most countries some combination of less recalcitrant insurance and single payor takes care of this).
-Our population is sicker and requires more care and more complicated care and more variable care (the number of patients with BMI over 70 in most countries is close to zero and that kind of stuff is more expensive to deal with and more variable than diseases of poverty).
-Other countries can ration and not engage in heroic care
-Related to that most countries don't have the legal environment. Malpractice related stuff is a huge driver of U.S. costs and complexity.
-You don't know what's going on under the hood with your bill, does the health system automatically write off most of the encounter for tourist patients because it's easier than trying to send a bill to another country? Is that care funded by something specific?
-The type of care where this likely to be relevant is stuff I'm doubting you are getting (how are you getting operated on in multiple countries????).
-Where are you getting this impression of U.S. healthcare? Costs are skyrocketing and health is plummeting but that's not a sign of health. Physician salaries have been decreasing relative to inflation for decades, not sure where you think higher salaries are coming from.
-Shockingly people are not willing to work at places which underpay or have a risk of not getting paid at all, this is doubly a problem because it's incredibly hard to get physicians and to a lesser extent midlevels to work outside of a major metropolitan area. Increase the risk of you not getting paid and nobody wants to work there. A hospital can't exist without providers. This is one of the causes of the death spirals leading to hospital closures recently.
-So is your claim that wanting to get paid for doing work "unnecessary?" That kind of attitude is why people are leaving medicine in droves. Not just doctors, nurses too.
-The villain is the health insurance company for not providing the agreed upon service, but if you say "no I'm just going to steal from someone else and demand the right to continue stealing" than the villain includes you. Again we aren't talking about a heart attack here, we are talking about care that shouldn't be initially triaged by an ED.
Throwaway05
7d ago
Lots of weird shit causes orgasms, and IIRC people have used hypnosis as a replacement for anesthesia. Dissociation is powerful.
If you are saying hypnosis can make your boobs grow then I'm going to call you a crank unless you have some damn good evidence.
Throwaway05
8d ago
This is a common side effect of that class of medications, you should discuss this with your primary care doctor and psychiatrist, they may recommend medication changes, dietary counseling, ancillary medications like statins etc.
Throwaway05
3mo ago
I'm not a dentist but I am in healthcare.
Most medical research is crap because people are complicated, research is hard, and the number of questionable incentives is immense. Dentistry might be worse because of the peculiarities of how healthcare is arranged in the U.S., but maybe not. I don't know.
I lean on two things when I'm trying to investigate stuff like this.
- Is anyone making money off of this?
- What do knowledgable clinicians actually do for their personal care?
As an example - ophthalmologists almost always wear glasses and almost never get laser eye surgery.
Flossing is cheap and I got to imagine almost every dentist does it (maybe not some of the ones with great genetics).
In my personal experience flossing reduced the amount of nagging I got from my dentist, and a water pick had not. Notably, flossing only did so after I got proficient at it. I don't know how true this is but I remember seeing on reddit "flossing doesn't work" type posts and the response being "digging into the research it seems like most people suck and that what leads to that data, just do a good job."
I don't know if the literature supports this however.
Throwaway05
1yr ago
And yes, the idea that you need over a decade of training to do the majority of what people are paying for in the healthcare industry is absurd and broken.
Just so so wrong. Even in other countries with faster tracking the thing that gets cut down is undergrad (which is fair but hard to do in America, has its own significant problems, and is logistically unfeasible without completely uprooting our system in a way that isn't happening, and only shaves off two years anyway). We have some good evidence for this in the highly limited care given by providers - the NP lobbying groups best data says that NPs outcomes in simple cases is about equal with physicians outcomes in complicated cases (of course they jazz it up but that's what their data says, never mind the MD studies). Keep in mind that doctors are also the only ones getting that much training, everyone else is considerably less....and it shows. Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.
As for your other point, flow chart care just doesn't work, no matter how much the MBA types may want it to. Decision support tools are miles off, for some godforsaken reason you can replace artists with an "AI" but the EKG autoread (which is one of the most computationally simple tasks imaginable) would get people killed if put in charge.
In addition to the always underestimated medical complexity, you have the human element - patient entitlement these days is sky high (as exhibited in this thread), people are always demanding things that are not indicated or are outright bad for them (ex: antibiotics for viruses) and your flowchart clinic would be immediately going off the chart or burned down.
That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.
If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.
Throwaway05
1mo ago
Most European countries have 6 years of combined med school and undergrad (see: Germany) vs. 4 years of undergrad + 4 years of med school in the U.S. these days 1-2 gap years is also common, with 3-5 being uncommon but not rare (for things like PHD, MPH, MBA).
The amount of debt is important because it is relevant to the level of pushback you get for changes, and the fact that if you cut salaries by half and allow limitless importing of doctors then you will have pretty much zero people applying to med school in the U.S. overnight (and that would be the rational response). People still interested will do PA/NP school instead.
Do also keep in mind the quality difference which is real but is frequently not acknowledged.
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
1yr ago
Nurses are leaving bedside nursing in droves and while some specialties are keeping up with retirement rates we are slipping behind our overall healthcare needs.
My problem is not that OP has a moral requirement to pay a bill no matter how stupid it is, it's that he doesn't know if it's stupid or not in this case, he (and everyone else) is blaming the wrong parties (the PA has no idea what's being charged and has no control over it, blame the insurance company or the hospital/practice management group that owns the PA). He also went to an inappropriate level of care and was surprised that costs were excessive. If you get admitted and demand to be in the ICU instead of on the floor it'll be your fault when the bill is an order of magnitude higher.
Throwaway05
7d ago
Since you are asking this question I'm sure there is a paper from 50 years ago with terrible research methods that suggests this is a thing, but that doesn't make it not absolute nonsense.
To more directly answer your question, I predict the literature that is the body of scientific knowledge suggests that this is not a thing and does not take it credibly. The existence of crank papers to the contrary does not mitigate this.
Especially since it is now known that many strange papers at the time represented intelligence work.
Throwaway05
8d ago
If you are willing to explore changing medications (may not be safe depending on your situation) some of the medications in that class are more weight neutral than others.
Additionally depending on the pathology an alternate medication class might be available, especially if you haven't really revisited it in the years since you started (some things will require that type of med though).
Medicaid may cover a dietician which is better than nothing.
Your primary care may have some routine health suggestions (again a statin, some preventative care etc) or maybe even something like Ozempic.
Throwaway05
2mo ago
Manual restraint by people untrained in medicine is inherently risky for people with compromised cardiopulmonary health
It is not possible to safely restrain a patient. Their are more and less safe ways to do so, and it is tightly regulated - however these regulations essentially exist not to maximize safety, but instead to introduce liability to some poor individual staff member or the facility (for example: making a sleep deprived resident run to the opposite end of the hospital to lay eyes on granny for 2 seconds to make sure she's alive before running back to the other end of the hospital to deal with the emergency surgery they were supposed to be performing. Now if they fucked up and granny's arm was pinched they are liable...).
Places deal with this problem in various ways, with the worst being for-profit psychiatric hospitals, often they elect to "ban" restraints, meaning that they did some math and having staff and other patient's attacked is better for the system than the risk of a poorly managed physical restraint. Often they just sub dangerous amounts of chemical restraints (medications) instead, which is much better at causing invisible morbidity in the long term.
It's extremely easy to have a decompensated patient in the ED who refuses to stop trying to murder the staff, get placed in a restraint bed for 10 days, scream constantly the entire time (and give themselves Rabdo in the process), and manage to choke themselves on a combination of their clothing and spittle and expire when the 1:1 steps out of the room for two minutes because of another fight elsewhere in the ED (for legal reasons this is not a true story).
Physical holds (as the police do) are safer since they are necessarily actively maintained, but aren't great either, especially when their insufficient number disparity and a notable size disparity (as was the case with Floyd I believe).
You can end up with someone like a group of 5 or 6 hundred pound nurses trying to restrain a lineman sized agitated patient and have someone accidentally collapse his trachea in the scuffle, or have a guy tear his scrotum because agitated patients often don't wear clothes and skin can easily caught on stuff during a scuffle.
No restraint is safe.
Restraints are however necessary.
Police have much better training (and practice), significantly higher levels of physical ability and size (which is critical) and more options (including stuff like tasers) and flexibility (generally speaking beating up an agitated but not-sick person a little bit is the best option to facilitate a safer restraint, not an option in healthcare though). It's generally safer (assuming no malfeasance, not making an argument that was present or not present in the Chauvin case).
As another random example - patients who are restrained rarely have vitals monitoring (since most patients by volume are substance, psych, or ED boarded on a stretcher in front of the nursing station to keep a close eye on them).
Throwaway05
2mo ago
Like Dean, I have also followed this topic over the years and had intense disagreement with you and felt extremely frustrated with your response patterns.
Unlike him I'm not convinced you are lying exactly, but with respect to this specific topic (and maybe also the "unequal treatment of BLM protesters vs. Jan 6 people) you behave in a way that is out of sync with the rest of your presentation and temperament, and is not unlike Darwin (as a point of comparison).
Darwin may or may not realize what is doing or how what he is doing is perceived by others.
You may not recognize what you are doing and how it is perceived by others.
But I believe a reasonable person's (here: Dean) subjective experience of your argumentation style with respect to this topic could be labeled "lying," by virtue of the way you present it.
As others elsewhere is chain have noted, it seems like you are approaching this in a specific way (?legal rhetoric style?) that you have much practice in, and value, but does nothing for the people you are disagreeing with in this context.
You I suspect are a good lawyer, and your proficiency with this style disincentivizes people from replying with specifics because you frequently circle back to that style and use it well, which is not the conversation and discussion they want to have and feels like arguing about apples when they want to be talking about trains.
Throwaway05
1yr ago
Surprise billing legislation (while superficially well meaning seeming) is a scam invented by insurance companies as a negotiating tactic, which is part of why its implementation is limited.
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
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.
You should get insurance, this is what it is for. If you have a plan but it has a super annoying deductible....well yes that's how it works (if you don't and you were cash pay you should call the billing department as the other user pointed out, and then get insurance).
I'm not sure if this will help but you should consider that (while it may appear superficially similar) medicine is not going to be like going to a mechanic. When you go to your dealership the work of analysis and diagnosis is often not paid for, then they'll tell you how much it is to fix the issue and you can take it or leave it. The cost is the labor and parts and replacement and repair. When you go to the emergency room you are paying the staff for the time and resources it takes to figure out what is going on. The treatment is often cheap (medicine, a splint, whatever) but the imaging, labs, and professional fees are time consuming and expensive. As a layman you aren't going to know what is going on under the hood (for instance in this case adults generally don't get nosebleeds that are bad enough to bring them to the hospital, so it could be because it's hella cold and dry outside, or it could be because the patient is having issues with clotting blah blah).
If you have chest pain and go to the ER, and after talking to you they give you tums and tell you to avoid spicy food the bill isn't for the tums it's for making sure you didn't have a heart attack.
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