Throwaway05
5d ago
They are better than the USA, which is the key benchmark. Canada is much more similar than Western Europe and also has historically out-performed the USA, although our healthcare system is getting fucked on pretty hard right now so idk how the stats match up post-COVID.
Don't fall for the propaganda here, the U.S. has worse outcomes on many metrics but a population that is more unhealthy and those worse metrics are driven by a social goal (you have the freedom to accept lifestyle diseases). When you get sick you are better off here than everywhere else in every way except the pay check. You'll get faster care if it's outpatient, and better across the board. You might have worse outcomes because you eat too many Big Macs but that is a public health and cultural problem instead of a medical care one. The expense is higher is really the only problem.
(And note well: those lifestyle disease worsen outcomes on everything, example diabetes fucks with wound healing and metabolic process of all kinds, obesity makes surgery impossible, etc.)
I'm torn on this, if the USA also captures most of the world's pharma profits than this is a net gain no? No idea how the math works out there though.
I don't know either but good thinking.
This is true but hilarious. Americans are violently against "taxes to pay for healthcare" but are completely fine with "employer subsidized insurance premiums that mean they get less cash in hand in exchange for access to healthcare" which is functionally just taxes but with more middlemen??!!?! And poor people I guess get less services versus single-payer, but then everyone subsidizes them anyway via higher medical bills to offset all the non-payments from the aforementioned poor people.
This manifests in all kinds of ways. Don't want to take vaccines and want to accept the bad outcomes? American individualism. Clearly dying grandma with 95% 30 day mortality rate? Spend EVERYTHING. Etc.
Are death panels real anywhere? I also feel like prices/medical bankruptcy (66% of all USA bankruptcy filings) are kind of analogous? If you can't afford chemo you sell everything you have until you run out of money to pay for it and die. Also you absolutely do have rationing, it's just in the form of prices versus bureaucratic limits. It can be debated which type of rationing is better, but the human demand for healthcare is infinite, supply never will be.
The usual way this shows up in real life is in other countries under spending on end of life care (which is super expensive and with where I am in my life now.....yes I'd want that for me) and delay of care. Canada is notorious for this. I need major hip or knee surgery in the US and I can get it within the week, but Canada though? Months. People also die from cancer and other diseases or have worse morbidity because it takes awhile to be seen and treated.
U.S. has a lot of profit motive and well payed people so they get to both care about patients and actually hustle when it's necessary and the system allows it because $$$.
Also, since I don't really get to talk about my favorite medical topic here but now is a perfect time - Trauma!
No better place in the world to get fucking shot (at least in a civilian context)!
Throwaway05
5d ago
Their are two problems with this line of thinking:
- Are those systems actually that good?
- Can we make that happen here?
The U.S. is fundamentally a different place than Western Europe - we spend a lot of money on illegal immigrants, have a maximal amount of cost disease, we are more unhealthy (and importantly as other countries catch up they look more like us), we subsidize the rest of the world's medical research (maybe not fair, but we are the wealthiest country and nobody else will pick up the slack if we go away), we are more independently minded (people don't want to be forced onto insurance or into making certain decisions), medical malpractice is a huge drain, we don't have death panels and rationing, you can get care fast if you can afford it, etc. etc.
Fundamentally our healthcare system doesn't resemble anyone else's in both bad and good ways (don't believe the reddit left - the best care is in the USA).
Even putting aside those things good luck changing our system to resemble other's once reality comes into play (for instance forcing people onto plans).
Throwaway05
5d ago
The whole situation is a mess, I like to think of healthcare economics like communism - yes you can absolutely up end the system and make it way better than what we have now, but when has that ever happened successfully?
The thing that probably gets the most complaints over in doctor land is that changes to the current medicaid structure is likely going to result in a further decline in safety net and rural hospitals. This trend has been ongoing for some time but loss of medicaid dollars will probably accelerate it greatly and people are expecting to see that with the current wave of budget cuts.
Two specific things off the top of my head that you'd have to watch for:
-It is very easy for the hospital to help you by signing you up for medicaid. Private insurance would likely find ways to block this. Hospitals rely heavily on this.
-Medicare and Medicaid are much lower overhead on the clinical side of things and less paperwork. Private insurance is a lot more work (although Medicare is trying to change that! Yay). Don't expect a reduction in medicaid to reduce bureaucratic costs and middleman costs.
Throwaway05
5d ago
Yeah you can absolutely get some things done faster by heading over to the U.S. but keep in mind that the times where it's really useful (ex: cancer workup, need a new knee) it will become cost prohibitive and unreliable very quickly.
I assume the reality of the situation is Canada is not as bad as some of the stories would make it seem but those stories are still quite alarming.
It's also worth noting that while US care is expensive EMTALA and others things ensure you will get care for most types of maladies even if you become bankrupt afterwards. Many countries don't ensure this this outside the affluent west.
Throwaway05
16d ago
Thank you for sharing this!
I enjoyed that in a large part he seems to be sunk by the fact that he can't name his blood pressure medication.
This is vindicating to me, given the number of times I have asked a patient what life saving medicine they are on and gotten the response of "dunno."
Throwaway05
19d ago
All of this below is somewhat moot in the sense that I'm not convinced that Ellison had Bipolar.
Disturbances in cognition exist on a spectrum from "this is not recognized pathology and is just my personality structure" (like a preference for scrambled eggs, a love of baseball, or being an asshole to your girlfriend because you are insecure about your small dick) to "this is purely something with an organic cause and blaming the person for their behavior is asinine" (a classic example benign example is a granny who is violent in the hospital because she's delirious and thinks she's is in a Nazi camp because of a UTI, a classic scarier example is someone who engages in a mass shooting because they have a golf ball sized tumor pressing on a few key structures in their brain).
Cases of the former are much more legitimate to blame (whatever that means) if love of eggs cause problems. Realistically insecurity about the small dick requires some sort of sex therapy or something if the person wants to stop hurting others and have a bit better of an experience of life.
Murder granny gets put in restraints and we treat her UTI and then everyone goes about their business and forgives her afterwards.
When it comes to things in the middle of those two extremes (that is, classic mental illness) we have a similar range. On one end you have personality disorders, like borderline personality disorder. These are in truth diseases of personality construction and really tease at what a "disease" is. It's easy to not feel bad for them (although I encourage you to) and this is true to the point where people don't want to give the diagnosis because of stigma (they give bipolar instead, relevance to Ellison?).
At the other end is one of: schizophrenia, schizoaffective disorder, and bipolar disorder. You could debate which one and they are certainly interesting and have interesting impacts on how much sympathy and guilt we should feel (what do you mean a symptom of the disease is that he doesn't think he has a disease and that's why he doesn't take medication and then ends up hurting people?),
True Bipolar 1 with psychotic features is the most stark here. Again I doubt Ellison had this but this the most sympathy you can have. This is a person with a monster inside them that comes up abruptly and severely because they run a 5k and their metabolism of their lithium changes.
They go from total normal nice person to a violent felon who doesn't sleep, spends their entire family's money and does X,Y, and Z ends up in jail with HIV and then gets started on medication and then goes completely back to normal.
Some people do things that put them at higher rate of an episode, but many people commit no mistakes and still lose.
Living with that should increase sympathy, no?
Most people aren't as stark as the straw patient above, but that is what it can be like.
Throwaway05
24d ago
I have to imagine that the Dems have gotten very good at knifing each other for perceived thought crimes and insufficient demographic achievement. Only those who have been around long enough manage to avoid this through the accumulation of political power manage to survive in this environment.
Too much eating their own.
I do know a lot of young dems who in other times would be stepping up, but they seem to be too white and/or male and therefore stick with the think tanks or party strategist roles (and lead the elders into unpopular decisions).
Throwaway05
16d ago
Reading between the lines (and using some experience with the interaction between medicine and the legal system) my suspicion is that the court and multiple involved parties are aware of this and are more or less working together to block this guy in a paternalistic but likely ultimately wise way.
Throwaway05
3mo ago
So, I can often be found posting on here complaining about bias in medicine (although I disagree about some of the kinds of bias with quite a few posters here).
We do have something of an update to a long running story that’s worth sharing.
Meddit link for more discussion and detail: https://old.reddit.com/r/medicine/comments/1jotpzz/follow_up_on_the_study_showing_discrepancies_in/
Basically, awhile back there was a headline about how black babies received worse outcomes when care for by white doctors. Apparently, this went so far as to get cited in the supreme court.
Sometime later someone on Meddit (which is still quite pro-woke) noticed that they forgot to control for birth weight, which would likely completely kill the effect size (explanation: white physicians have more training and take care of sicker babies who have worse outcomes). At the time there was a significant amount of speculation essentially going “how do you miss this? That would be the first you would control for.”
Well, it turns out that someone filed a FOIA request and well, to quote Reddit:
“A reporter filed a FOIA request for correspondence between authors and reviewers of the article and found that the study did see a survival benefit with racial concordance between physician and patient, however it was only with white infants and physicians. They removed lines in the paper *stating that it does not fit the narrative that they sought to publish with the study.” *
While I often criticize medicine for being political, I’m often found here telling people to trust the experts when it comes to (certain aspects) of COVID or whatever, and well this kinda stuff makes it very very hard.
The initial findings were passed around very uncritically and sent up all the way to the supreme court.
How can people trust with this level of malfeasance? How do we get the trust back? How do we stop people from doing this kind of thing? I just don’t know.
Throwaway05
1mo ago
This post was beautiful and uncomfortable and made me need to forcibly reboot my brain in order to go about my day in the way that the best Old-Scott posts did.
Well done and also screw you for dredging up those feelings from that time in such a rich way.
Throwaway05
5d ago
elective surgeries for cheap
Doubt on this front, the Western standard is for when things go wrong, which is rare - but if you get something like a T&A done in your 20s in a major academic hospital in the U.S. and have a major complication, you will likely be fine. In Mexico? No dice.
Throwaway05
1mo ago
As others have stated the bad behavior by ill behaving cyclists is just so so bad.
The other day I watched a guy on a bike run a red light in a LARGE busy intersection and nearly get hit by a car no less than three times while doing so.
How this person remained so unfazed (and also alive) is a mystery to me.
Brainless degenerates seem to be a minority of people behind the wheel of a car, but a common occurrence on bikes (probably driven by things like delivery drivers who do an outsized amount of cycling but are more dangerous than most).
Throwaway05
14d ago
The way states usually handle this is that the person has to have some thing happen like a: has a psychiatric illness b. is a credible threat to themselves or someone else.
The presence of criteria for a psychiatric illness is important here and does most the political protection.
A really common teaching interaction is something like "haha, yeah man this patient is delusional because he is Trump supporter and thinks Obama isn't a citizen" attending puts on a very serious face "no, absolutely not. Political beliefs are not delusional unless they are totally culturally dystonic and fixed, the fact that he won the election is proof that is isn't delusion blah blah...."
Psychiatry is in general a pretty pozzed specialty but they don't fuck around when it comes to that kind of stuff.
You will absolutely see patients get discharged who are odious, violent, domestic abusers, substance users and all kinds of other crap because they don't actually meet commitment criteria and aren't psychiatric.
Now you are more like to see something like "this patient does meet commitment criteria yet we'd usually let him go because it's probably safe to do so however he was using racial slurs towards the staff so in he goes." This is unprofessional but still unfortunately legit.
Throwaway05
15d ago
I understand that drug names are not necessarily intuitive and while they have some tricks those will be impenetrable to patients.
That said, you need to know what you take, when, how, and why - otherwise you are at significant risk of increased bad outcome (although this obviously depends on what conditions you have).
What we usually recommend the elderly do is have a sheet with that information written out and store it in your wallet so it becomes easier to read out, can be retrieved if you are not arousable and so on.
This advice is good for anybody however.
With respect to this specific patient - we see a class of older men who have a large number of medical problems and put no effort into understanding what those are for, what they are doing about them, how to avoid making them worse and so on. While some of these people are stubborn or anti-medication most just have very low conscientiousness. Not ideal for a first time gun buyer at 80 something.
Throwaway05
12d ago
Frequently (by no means all the time but often enough) that's grossly insufficient.
-Some patients remain essentially untreated. You don't need to take medication (there is however a slow process for forcing patients who are sufficiently dangerous). Nybbler murder patient may in fact want to murder no-one other than Nybbler, and behave more or less while in the hospital while refusing treatment. After the initial period further involuntary commitment involves a judge - the judge may say "well he hasn't done anything bad since he got here, maybe he won't murder Nybbler?" and off he goes. Walks out of the hospital, buys the gun, murder goes. This is not theoretical, it happens (sometimes even with mass shooting events but does also show up in the local news when the death count is low). Solution: force people to get treatment without their consent. Or force them to stay in the hospital until they consent. Both are significantly more rights destroying.
-Some patients are only dangerous when they use drugs. While intoxicated and for a while after they are a psychiatric problem but outside that the health care system has no control over them. People who keep smoking PCP and want to murder people while on PCP should probably not be allowed to own guns. This should be fixed by arresting people who use and sell PCP but society isn't really electing to do this these days. Solution: reengage the war on drugs. Not a popular option.
-Much more common and much trickier is that it is common for people to be committed, accept treatment, temporarily get better, and then relapse. They then become a threat again. Sometimes quite quickly. Much more quickly than any court process would go. Charitably (and in truth pretty commonly) this happens because medication works well at reducing things like hallucination and aggression but not the negative symptoms lack apathy and avolition. When your symptom is that you can't be motivated to take medication and you don't care if the other symptoms come back, well then it is hard to stay on medication. And then the risk comes back.
Making a public and credible threat to murder someone for reasons that are universally not given as acceptable (ex: for no reason at all or for reasons of delusion) should be exclusionary to owning guns. We aren't talking for political reasons or because the neighbor slept with your wife, we are talking because you are convinced the neighbor is Proxima Centauri.
Nybbler's issue seems to be (although he won't clarify it) that it didn't go through a legal proceeding. But opening up legal proceedings is a huge can of worms.
Let's say someone (police, healthcare worker, concerned person, whatever) can open a complaint about someone's safety to own weapons. That's time consuming, expensive, might involve temporarily seizing guns or the person, will involve litigating if expression of political beliefs counts... way more abusable than present state.
The fact of the matter is that the vast vast majority of people who are involuntarily committed* really should not be allowed to own guns. Failures are rare. Should you find one (for instance someone who did a shit ton of PCP for ten years and then spent 50 years not using PCP and wants some guns) the expungement process works pretty well.
The modal involuntary patient isn't actually suicidal or homicidal, instead they are something like a schizophrenic who is so severe they just can't feed or care for themselves. Someone that disorganized isn't safe to own anything remotely dangerous, and if they had the financial ability to own a car (most don't) they probably shouldn't.
*assuming you agree with the suicide end of things, that's a bit trickier.
Throwaway05
2mo ago
Sometimes I look at this stuff and wonder if this what it was like to be pro Civil-Rights back in the day. Just watching all of these pillars of society being told "don't be racist" and hearing "no" in response while much of the influential nod their heads along like it's a good thing.
It is a chilling feeling.
Throwaway05
28d ago
As for additional driving scissor statements, I prefer to back into a parking spot, or pull through a double spot to be facing out. Some people call it “getaway parking,” others deride it as “ghetto.”
I also do this, I had no idea anyone would deride it.
Throwaway05
16d ago
While each patient is different, much of what you alluded to in your description of events pattern matches to a subset of patients struggling with the way their personality interacts with the world, depression, and anxiety. Modernity blows and that's part of it.
Treating those things through a psychiatric lens is lower impact and cheaper/less risky than more direct intervention, which you will always find people willing to do.* The former works just fine with appropriate buy-in.
However since much of this is likely mediated by modernity...it is also not shocking that you feel better by finding some other way of viewing the world and your experiences.
Be careful with your approach however, you want to make sure it is well formed and can sustain itself should you have more stressors in the future.
*Proceduralists will often operate under the assumption that adequate preparation and work up has been done before their involvement. This is not a good assumption, and ultimately these physicians are those with hammers looking for nails.
Plenty are more diligent and careful but they tend not to get sent more marginal cases for a multitude of reasons.
Throwaway05
1mo ago
Catastrophically bad and regular bad are not the same thing.
You can't compare a half assed stop at a stop sign in a car to blowing through a stop sign or red light at full speed on a bike.
Yeah the former is common for cars, but the latter is common for bikes and not cars.
Throwaway05
1mo ago
Any time I walk in a city I see a cyclist do something brain dead and dangerous. Every time I see a cyclist I see someone running a red light or stop sign. I do not see someone do something brain dead and dangerous every time I drive a car. I do not see someone running a red light or stop sign every time I drive a car.
I am aware of the existence of catastrophically bad drivers, I've seen videos online. I've never seen one in real life.
I've seen catastrophically bad cyclists many times.
Throwaway05
11d ago
To add to these examples, in later rounds of the US physician licensing examination (USMLE Step 3) they will sometimes ask questions which are designed to be novel - no way you know this specific fact or have seen it in a board prep resource. You are then asked to determine what would be the most likely answer based off of your understanding of the underlying biology and so on.
These are hard to do so you don't see too many of them, but it is possible.
Throwaway05
14d ago
Some people will give us that info but it's usually pretty useless as make and manufacturer issues mean that the level of variety is high.
Throwaway05
1mo ago
Are you just mad they get to and you don't?
They don't "get to." They are required to stop, just as I am (at least where I live). Some cars chose to disobey this, most to all bikes do. One of the reasons we have this as a requirement is because people can't be trusted to determine when it is safe to blow through stuff.
It's not safe and it is illegal and bikes break the law at much higher rates than cars do (with the exception of highway speeding for the obvious reasons).
Throwaway05
29d ago
I now interrupt your regularly scheduled WWIII/Nothing Ever Happens to ask a question:
So, the Bike discussion down below generated a lot of angst and heat, so I'd like to poll The Motte on our driving habits a bit (in the CW thread because I do fear we are going to get some strong feelings).
How do we feel about the following:
-
You should turn on your turn signal every time you switch lanes or otherwise would be expected to use it, even if nobody is around.
-
Stop signs and red lights need to be fully stopped at, even if nobody is around and you know there isn't a red light camera.
-
Speed limits should be followed to the letter when possible.
-
The left lane is for passing only, and also, if you are in that lane and not passing and someone cuts you off or rides your bumper, that is fine.
-
If someone does not make room for you and you need to come over (and properly signaled) you can cut them off guilt free.
-
I can break some of these rules (or others) but other drivers should not.
-
Any other possible driving scissor statements?
If you'd like to be mad at me: Yes, Yes, No, Yes with qualification, Yes, No.
A common pathway for something like this is:
-you nearly bleed out
-medical attention arrives
-in the meantime multiple organs are not getting enough blood and therefor oxygen
-this may include the brain
-you are taken to the hospital which keeps you alive
-but you are already dead OR
-while in the hospital swelling, tissue death, infection from all of the damaged areas causes problems leading to formal death later
tons of stuff like this can happen.
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