Throwaway05
6mo ago
The last time I saw stats on this Psychiatry (which would be making these decisions in most jurisdictions) is the second most liberal specialty in medicine. That said political beliefs aren't going to be really relevant here, even pro-gun/right leaning (of which their are a ....few but they do exist) Psychiatrists are going to heavily lean towards restricting gun rights, the reason being liability. If your choices are "take away his guns" or "somehow be liable for a 30 million dollar judgement even when you didn't do anything wrong," they'll take away the guns every time.
Throwaway05
6mo ago
I'm not sure if this is happening in nursing homes specifically but within the last five years healthcare has had a massive problem with outside investors (most notably PE in emergency care) buying stuff up, extracting as much money as possible and then leaving the thing to go out of business (not that this wasn't a chronic issue it's just gotten a fuck load worse).
I suspect the issue is similar here where these places cut costs like crazy, provide terrible care, and then croak but only after someone has already run off with the bag.
example:
While everyone else is talking about the supply/demand portion this additional portion is important - yeah if your ED physician group goes out of business those doctors will find other groups or jobs most likely, but the amount of unnecessary friction caused gets people killed and creates a lot of economic loss.
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.
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
10mo ago
We have a joke in the field that goes something like this: if you get hit by a truck while testing a new drug those Super Bowl advertisements are going to start saying "may cause you to get run over."
This exaggeration but not by a lot.
As you say, OP's data is meaningless without more context.
Throwaway05
2mo ago
Two additional things to consider:
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"They" did in fact "interfere" with the election, and publicly admitted to it (see: "fortifying" type claims). This may not count legally as election tampering or whatever but may feel that way to the right and disgruntled moderates.
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Many voters know someone who hates Trump enough to do this and feel justified doing so. I have several family members and friends involved in government, some of whom I straight up asked "if you had the ability to stop Trump from being elected would you do it?" to which the answer is "yes absolutely, he's literally Hitler." It doesn't take much to believe that some people in the position to do something had the same thoughts.
I earnestly believe that anyone who doesn't get why people have concerns is being obtuse.
Throwaway05
8mo ago
Apologies this response is going to be briefer than I would like secondary to me being on vacation.
Also apologies I don't like diagnosing people second hand, but..... based off of what you said in the past and here this person almost certainly has cluster-b personality traits and very likely has borderline personality disorder.
This means a few things.
-People with this sort of personality structure have mangled coping mechanisms. They don't handle stress in a healthy way and that often includes lashing out in seemingly irrational and inappropriate ways, for instance "splitting" (people are "all good" or "all bad"). Now that the board is the adversary they are super evil and awful and therefore certain kinds of behavior is both justified and necessary. "Projection" is also very common.
-Self-harm, "fake" suicide attempts, and "real" suicide attempts are all common responses to distress in this population. It is questionable whether these behaviors are ever an appropriate response, but it's very commonly super duper out of proportion with the cause of stress here. They don't generally have very serious attempts though "if you break up with me I'm going to overdose...on melatonin" but do still have higher rates of completion than population average.
-If things aren't going well with people like this, they are super fucking frustrating. Don't feel about your response not being up to your standards. These people are hard to deal with and even professionals in a professional setting need to constantly stop themselves from going "Jesus fucking christ shut your fucking mouth."
-These people are very good at hijacking social justice, the legal system, and other avenues to get revenge, make changes to something, whatever. This is often distressing for everyone else.
In sum you didn't do anything wrong and while this person deserves some pity and human decency for being both a human being and mentally ill, they are still a threat to you and doing things that absolutely should drive you bonkers (and you shouldn't feel bad about it). Borderline is essentially the female equivalent of anti-social personality disorder (gross oversimplification but still) and while both deserve kindness you should take steps to protect yourself and not feel bad about it.
Outside of social justice communities most people have experiences with a person like this and kinda get the vibe.
Throwaway05
2mo ago
You have summoned a crankier doctor than the one I think you are looking for but I'm sure he will chime in at some point.
Some thoughts:
-It's generally standard of care to recommend that patients on psychiatric medication (or just cross through that and make it just meds in general) abstain from alcohol use. This is for a variety of reasons, chronic and acute alcohol use both have impacts on certain kinds of drug metabolism. Some medications have specific interactions with alcohol (ex: Benzos). Alcohol and Marijuana appear to have a problematic effect on underlying conditions (no shit booze is a downer). This also applies to non-psych things. We are going to suggest you stop drinking.
-Just because it's standard of care doesn't mean it's mandatory, but again if we are speaking in official capacity we are going to tell you not to do it.
-SSRIs are (with some exceptions) pretty fucking safe. Older antidepressants have some issues. We have mostly switched for a reason.
-Alcohol is a poison with a very variable effect on the human body. Sick? Tired? Just worked out? Empty or full stomach? Haven't drank in a while? Random luck of the draw nonsense? You'll have a bad time. Easy to blame on the social boogieman if you do two doubles on an empty stomach.
-Personal anecdote: I've run into a "date rape" drug level alcohol response in settings where I know nobodies shit is tampered with, so I'm certain this class of thing exists, including one time where it was me and my own bottle of rum (and I later connected the dots that I recently had diarrhea and that may have been responsible for my bad time...).
-People are variable (duh) and have variable responses to things AND also variable awareness. There are a lot of people in this world who struggle to realize they are drunk until they are absolutely obliterated. You can easily see how those types (or other adjacent groups) might feel they were drugged if they got really drunk secondary to some other non-sketchy circumstance.
-Mixing uppers and downers is a huge problem and a lot of young people don't take the combination of stimulants (including all that Starbucks) and alcohol seriously. That combo can cause severe reactions and more people abuse those things now.
Throwaway05
5mo ago
This is so fucking weird. The primary impact of OSA is on the patient's health (hypertension leading to increased complications, increased of respiratory depression when combined with BZDs etc).
It's more like diabetes than epilepsy.
Now it's true that most patients hate the CPAP and try not to use the damn things so I "love" this from that perspective, but the overreach is absurd and if this becomes widely known people will just refuse sleep studies and STOP-BANG is by no means definitive (I love medical acronyms).
I do wonder if this is one of those "hey I heard about this shit online" or "my one relative..." type policies that will get evaporated with any public pressure.
Throwaway05
1mo ago
You may find it fruitful to read some of the work done by non-woke Psychologists and Psychiatrists (ex: Life at the Bottom by Theodore Dalrymple), if for no other reason than to go "my god other people have noticed this!"
Everybody who deals with these people has experienced this stuff but having the tools to diagnose and label what these people do is helpful (and may at times give you some insight in how to work them for your needs).
Throwaway05
4mo ago
Others have already touched on this but if you haven't interacted with any of these kinds of people in the wild it's hard to understand how bad at making decisions they are. Taking a step back, think about how bad well educated, intelligent people are at committing crimes (for the most part) based off of what you hear in news reports. You'll be saying ARE YOU KIDDING ME ninety percent of the time, and that's people with a lot more reserve and resources.
People who get involved in this kinda thing are stupid, uneducated, incapable of foresight/planning, and obsessed with face and status in a very shallow way. If any of these weren't true...they wouldn't do it.
Even when you see some type of criminal activity with an enormous amount of skill and success (like SF car break-ins) it's because of a "monkeys on typewriters" type exploration of options by everyone seeing what they can get away with as obsessed to someone coming up with a good plan.
It's also important to keep in mind that the majority of people involved in the drug trade make like zero money, any form of job whatsoever would be more lucrative and stable. They aren't sending their best. The ones who do make money are typically off the street, not at risk, and capable of doing the things you are interested in seeing.
Others also hit on some of the "honor culture" aspects also - you get a lot more face from sneaking up behind someone and shooting them in the face.
Many quotes from the Wire serve as a microcosm, but Stringer's "are you taking notes on a criminal conspiracy" is a good example, especially when people are trying to apply sense but it's ultimately cargo cult thinking.
Throwaway05
1yr ago
Involving physicians is a soft-ban. Docs are overwhelmingly left/pro-gun control and afraid of getting sued.
If they can get sued for someone committing a crime (which they will be) then they'll hit NO on everyone they possible can (and will be rational to do so).
Throwaway05
2mo ago
Additionally the level of affirmative action in medicine is extremely intense, I haven't looked at the data in a few years so I don't know where it's at now, but it used to be absurd - something like 90% percent of black med students would not have ended up in medicine if put on a fair playing field.
Throwaway05
3mo ago
The Twilight Zone has some episodes that are absolute classics of the genre (and written by some of the best SF authors), the best approach would probably to try and google one of the lists that notes great episodes and go from there.
For follow-up you can watch SFDebris episodes on the content.
In case you didn't know The Outer Limits is basically TZ's younger brother.
Throwaway05
7d ago
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Never, ever, EVER, sleep with someone you can diagnose with BPD easily. You're welcome. cries
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Excuse me what the fuck with that head bleed.
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Social media autism.
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All these people are probably borderline.
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Once you have training to look for mental illness you'll see it everywhere, especially on the apps.
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Tell them Tylenol is the absolutely worst way to die and to use Melatonin instead.
Throwaway05
16d ago
Dr. House doesn't really exist, the equivalent in real life is something like a specialty tumor board at a premier research institution, which is a group of knowledgeable specialists "discussing" the specific approach to a known problem (and rarely trying to figure out what the problem is or arguing over what it is).
Your situation is different in that you know what the problem is, and it's a basic diagnosis, but you can't seem to get it treated. It's not unreasonable to be like "okay what's up we need more options, more heroic measures."
However, my suspicion is that you need to go back to basics.
Basically - you need therapy. Medication may not help in the way you want it to help.
This doesn't mean you should give up on medications, you can always try more/different SSRIs etc. to find something that hits for you, but at a basic level you have to keep in mind that some things are more responsive to medication than others and this includes in psychiatry.
The classic example non-psychiatric example is insomnia (well some consider this psych). We have meds. We have a lot of meds. We have really expensive meds. We have really dangerous meds you should never use but people demand anyway and have really bad outcomes. What works for insomnia? Behavioral modification and therapy. Works (maybe an exaggeration, maybe not, I'd have to review the data) orders of magnitude better than meds.
In psych - for people with certain types of depression (terminal cancer? live in an active war zone and your family all got blown up?) medications aren't going to work for a lot of people. Therapy is generally going to do more.
Back to anxiety.
Anxiety often requires higher doses of medications (sometimes to the point where the side effects outweigh the value), but best practice is essentially to have medications lighten the load enough for therapy to be useful and helpful.
You don't need a genius psychiatrist, you need an excellent therapist (can be a psychiatrist), which is not the same thing and is something you can absolutely pay for if you wish in most metro areas (and a cheap, serviceable therapist may do). It is possible that a slightly more clever psychiatrist would throw something on that would solve the problem but that should be a secondary goal.
Now I don't know what your relationship with therapy is but you might be skeptical about it and might be asking why that would suddenly be a thing you would need now later in life after medication worked for so long. Additionally, if you are posting here you are probably intelligent, high resource, and rational - and thinking because of all that therapy shouldn't be needed. Unfortunately that's not how this work.
For example: a lot of anxiety related behaviors and experiences are basically just good old Pavlov fucking with your nervous system. Don't matter if you are mucho smart, if the bell goes off you'll salivate.
I wonder if a process like that happened here - you went off the med and expected something to happen or something happened, you felt like the safety net was gone, you had experiences, they rapidly reinforced themselves now you are in an anxiety spiral..... one you'll be able to get out of with time and space maybe, but faster and more effectively with some skills training, CBT, whatever - all with medication as a supportive factor. The meds are often a crutch, and therapy skills can be more definitive treatment (one of the reasons why you may want to avoid meds for anxiety).
Keep in mind that other conditions often work very differently.
It may also be reasonable to see your PCP to rule out any medical problems (not that they are likely) and assuage any health anxiety.
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
3mo ago
I recently overheard an argument between several Plastic Surgeons and a Psychiatrist where in the surgeons argued that seeking plastic surgery is pathognomonic for body dysmorphia. They asserted that wanting to adjust your own appearance to submit to external (or internal that is informed by external) standards is inherently dysmorphic. It can be relatively harmless in the case of a rhinoplasty, but can be radical as seen here.
I should note that both surgeons seemed very happy to feed the dysmorphia aka Get Paid.
The psychiatrist tried to define what "illness" is and use that angle, but appeared to be on the losing end of the argument.
I haven't thought about this enough to have landed on one side or the other, but I think it is very reasonable to think of this as a sliding scale and a fuzzy one at that.
If we are paying for top and bottom surgery why not this? The conversation on this particular topic is of course very unhealthy, and the people who advocate for dysmorphia treatment are typically allergic to formal analysis and typology on these topics which complicates the matter.
We don't have a good handle of what mental illness and it makes it hard to have a formal judgement as to if this behavior (and others) are okay or not and how to handle them on a legal and financial level.
Throwaway05
5mo ago
It's one thing to be living in Gaza and say "I haven't seen anything weird" while being interviewed on live TV, it's another to come back to your home country and while there try and argue with everyone that no bad stuff is going on.
It's the attempt at persuasive advocacy that bothers me. That makes it complicity instead of keeping your head down.
Throwaway05
3mo ago
I've found Kanye to be a good illustration of how politically captured large swathes of my field (medicine) are.
Everyone hates Kanye. A lot. Even if you point out that it's clearly mental illness. Even to psychiatrists. In fact you may end up a pariah just for reminding everyone that Kanye has mental illness and that this informs his behavior.
It makes me feel gross.
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
5mo ago
I think the professional thing to do is say something like that...
"I'm here to treat patients not spy" is what they should be doing but in my experience they have a tendency to be ideologues who support Palestinians if not Hamas (and sometimes support the latter) and will actively and persuasively lie instead of saying something along the lines "I didn't see shit and if I did it would be unsafe to tell you."
The docs in this environment mostly specifically chose to be there and that means they have INTEREST and a related lack of objectivity and tacit or explicit support for bad behavior.
Throwaway05
2mo ago
And then I face-palmed when the final quiz began asking questions about HIPAA, which is not a thing in India and not covered in the course itself, strongly suggesting the course had been designed by ripping off a US source, or perhaps the latter hadn't localized it particularly well.
Jesus fucking christ.
Anyway - thank you for in essence covering my thoughts better than I did.
I think what I struggle with is that people should be allowed to make mistakes, but they should not be allowed to be fooled (or at least we should try and be more proactive in preventing that) but we have this issue where so many big topics are misleading, or political (as the sterilization is) and therefore people may need more protection.
Throwaway05
2mo ago
This is certainly a big narrative point but it doesn't match my experience with boots on the ground seeing patients (which isn't to say it's incorrect, the data is out there, but I want to call out other factors).
Keep in mind that America has additional problems that do not exist elsewhere: our particular brand of inner city life and crime seems to generate a lot of drug addictions (you'd be shocked at how many bangers are also addicts, or maybe not), a lot of the use in the US persists in inner cities that refuse to attempt to solve the problem or economically depressed areas in coal country and so on that don't really exist in the rest of the west I think.
Also research shows that Americans are weirdly pain intolerant in comparison to other countries.
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.
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