Throwaway05
3d ago
Midlevels are ass and have no organized educational standards. They also appear to objectively hastening the demise of US healthcare through over utilization of referrals and unnecessary testing.
They also literally do not have the same practice and malpractice standards, which is just so so absurd.
Throwaway05
3d ago
A very large chunk of US healthcare expenditure is on end of life care that other countries more strictly ration.
EMTALA is also very expensive.
Throwaway05
3d ago
I think some of these people feel they will survive his mayoral term and then what whatever comes next will be perfect for them for years.
This probably isn't wise, Mamdani is a damn smart operator.
Throwaway05
3d ago
I think it's somewhat confused because some of the very wealthy donor class are actually (passively) all for him winning - they think he's going to be such a fuck up that it sets back socialism for awhile.
Not sure this is wise but I know for sure that some are thinking that way.
No.... I think you are taking away the opposite from what I'm trying to impart?
Pharmacists are not the appropriate choice they have limited training in clinical medicine and diagnosis. Their job is to explain medication, mechanisms, and interactions not know when to prescribe or not to prescribe.
Throwaway05
3d ago
"You had a fever for a week, you tested negative for the few viral things they tested for, and they didn't want to explore it further at all or put you on an antibiotic as a precaution?"
As presented (which it may not be! One of the things we get paid for is to know what information is important) um, to put it gently they need to reconsider what they are doing or if they are specialists they should refresh on general medicine. Antibiotics target a specific organism, random antibiotics is effectively never a good idea in an outpatient setting. Empirical supportive care is fine for a variety of things. Things like an extended viral panel would be low value but critical for having an informed opinion. Knowing your Centor score (which a Telehealth doc can't do either) would be important.
To be charitable maybe they haven't been following practice guidelines. Or maybe I haven't been following practice guideline updates since I'm not in primary care, but viral illness is the primary cause of sore throat and with rare exceptions we don't have any way to treat viral illness.
Any kind of fever of unknown origin work up is a bonk straight to idiot jail with your timeline.
In any case, as I've mentioned before, we don't get paid to manage stuff like this - usually go home and relax is the treatment. We get paid to manage your aunt who is on 8 medications for chronic conditions including hypertension, diabetes, heart failure and s/p hysterectomy for 3a cancer who we see every 4-6 weeks instead of once a year.
Most of the job is not the kind of thing that relatively young and healthy people are seeing us for.
Outpatient administrative burden is usually because of regulation and actually has value (at least in my experience). You won't catch many (if any) physicians supporting the existence of the assistant infection control nurse for the 15th-20th floor but I'm zeroing in on the implied attack on physicians bit.
Throwaway05
3d ago
While that's something of an edge case, again watchful waiting is the treatment for most human illness by the numbers. That's appropriate, but annoying. Most doctors are used to doing something because patients demand it but that doesn't mean it's a good idea, just that they don't want complaints/bad reviews/lawsuits/etc.
So; just more ridiculous inefficiency in the inefficient healthcare system.
What about this was inefficient?
You want doctors to order expense interventions that are not risk free just because you demand them?
You want to do what most countries do instead which is provide significant care rationing and shortages?
You got to rapidly see several providers, in most countries you'd just be waiting for days to weeks or even months and then they would tell you they weren't going to do anything most of the time.
Maybe you want to be able to decide your own care. A few countries allow that but they are never countries remotely like the U.S. - usually some combination of much poorer (so few people can afford to dictate their own care), much healthier (and critically with less comorbidity so stupid decisions are less risky) and perhaps most critically: anti-intervention. I've heard from Indian doctors that their patients refuse to take medication most of the time. Americans overuse. It just wouldn't work here for a million reasons.
Lastly, who would they sue when things went wrong? Can the government sue you for fucking things up? Can we order your death because you chose to do something stupid and destroyed your kidneys for no reason?
Fundamentally most people can't be trusted to manage anything technical - if you poll people on a plane that's being delayed for deicing a good chunk would want it to take off and get themselves killed. Even most doctors can't be trusted to sensibly manage their own care because they are too close to it. People off the street? Jesus.
Recently experiencing mild inconvenience is not a good reason to advocate for disastrously stupid policy.
Throwaway05
3d ago
Ah, earlier than I thought - don't worry more good shit is coming.
Throwaway05
3d ago
I don't know your specific situation the abx thing is meant to be an example of more general problems, often brought up around here, including elsewhere in this thread.
Also, I want you to look up the professional credentials of the people who saw you and check if they are actual doctors. Bad doctors exist (although I don't know if you got bad care here) but several times a week I see questionable decisions and the patient says "my doctor blah blah" and I check and it's not actually a doctor.
The point I'm making here is that I didn't do that, because I was just trying to use the healthcare system as prescribed, and that i was an inefficient joke.
The thing is you didn't do what you were supposed to do. I don't blame you, this happens for all kinds of reasons - an expansion of options making it unclear what is supposed to happen, advertising dollars, certain locations not having resources, a desire for convenience, poor planning. All kinds of stuff.
The system is designed such that you have a PCP, you see your PCP, they know you. Urgent care is almost always bad, and the range of things you should be using it for is minimal. It shouldn't exist but it exists because people refuse to have PCPs. Sometimes this is because of a shortage and insurance issues but usually its because of people not actually sitting down and finding a PCP, their are almost always university systems taking new patients for instance (and likewise Telehealth companies if they have physicians at all are shit quality care farms and not providing anything resembling acceptable standards of care).
But this means you need to establish with a PCP and do things like go to a well visit yearly when you don't have any complaints.
Then if you have issues you call your PCP, they have spots on their schedule for sick patients and you come in, or they tell you to go an ER because that's what you need to do (or they need to say to protect their license from lawsuits).
This does involve at times waiting with discomfort, which people do not want to do, but 100% on demand healthcare is expensive or low quality.
Lastly, the vast majority of run of the mill illness has a treatment of "supportive care" aka we can't do shit so just wait and rest. Even if that is not your illness the best resource stewardship generally involves waiting for awhile before doing anything because it costs everybody less money and involves "do no harm" by not doing extra, unnecessary stuff that causes avoidable illness.
People don't want to sit and wait and be sick but it is often the correct thing to do.
Throwaway05
3d ago
I feel like you really can't put a Pathologist, a Hospitalist, and a Trauma Surgeon in the same category.
I don't think many jobs in the world are cooler than a trauma surgeon, transplant surgeon, or literal brain surgeon....but being an endocrinologist or nephrologist is rather maximally lame.
Throwaway05
3d ago
As usual I'm probably pissing into the wind here but this is so much more complicated than your over simplification. You aren't paying healthcare workers to answer simple questions, you are paying them to do things like know when something isn't actually simple - ex: your shoulder pain isn't your shoulder it's your gallbladder and you need surgery not pain killers for your arm.
Patients will always ask for antibiotics even if we know in advance the issue is viral and antibiotics won't do anything, and that's not counting the goal of abx stewardship, or just minimizing side effect burden. No medications are safe, if you give everyone in the country a full course of antibiotics people are going to lose their kidneys, have joins explode, or just flat out die.
All lab testing has sensitivity and specificity and someone needs to know when it should be ignored.
And so on and so forth.
And if you went to an urgent care you probably saw an NP/PA who doesn't know what they are doing but was put in place as a misguided cost saving and simplification mechanism.
Throwaway05
3d ago
It's a real problem with research done on it - check out abx resistant in STDs (and by this I mean the details) MRSA vs. MSSA is a huge issue also.
We are in the growing warning stage with tons of money being pumped into avoiding the problem but as always man on the street won't notice until something boils over.
We have plenty of back up agents but often it means a switch to something less convenient, has worse side effects, or in the case with MRSA may result in increased sepsis fatality rates because of complicated things like time to static blood concentration, interaction with comorbid end organ dysfunction and other blah blah boring but important stuff.
Having an illness that goes from no big deal to no big deal but 1.2 out of 10k have a joint explode is not something the average person is going to notice but is an avoidable problem if idiots would stop pretending like they know everything and their doctors thousands of hours of education was meaningless.
Likewise you have stuff like some drug addict, illegal immigrant, or even just a regular person with the wrong insurance getting housed in the hospitals for 6 weeks because IV antibiotics is the only thing that works now instead of oral.
All these small things grow and contribute to the collapse of American healthcare.
In other countries rampant with problems (India, China) they just let people die a lot more. I'd like to keep our system.
Also hospital specific antibiotiograms are a thing.
Throwaway05
3d ago
One of the most obvious examples if STDs, which is a known (and serious and growing) issue that's been magnified by homosexual sex norms (especially now that we have HIV medication).
Throwaway05
3d ago
Historical research into PTSD and other conditions exists and has answers to some of these questions - life was better in some ways is something worth remembering (working with your hands, having nature around you, strong community). Also keep in mind that people with lots of conditions just tended to die or get killed if they weren't rich/powerful (ex: bipolar, schizophrenia).
Throwaway05
3d ago
Plenty of people in my oil can't refer to him by name or refuse to reference him as the president, including some more moderate democrats. Could be a regional issue, but it is a real one.
Throwaway05
3d ago
My understanding is Rubio is both in charge and has a detailed understanding of the region (and has been killing it down there). If I had to guess (based off of no particular special knowledge other) our move is in response to the oil dispute with Guyana.
Throwaway05
3d ago
Structural but non-content spoilers, might do something though since I read on a chapter not book basis and I'm not 100% sure where you are:
It sounds like you spotted some of what made me raise an eyebrow tho.
Throwaway05
4d ago
Can we build a Golden Gate Bridge today? Can we still go to the Moon?
We have the money. We have the technology. In theory, we still have the know-how.
But we don't have the will. It's graft all the way down.
For sure cost disease and other considerations are problem, but on a positive note - when I-95 got shut down a few years ago near Philly it did get fixed real fucking fast.
I suspect if the need is there we can fix stuff quite ably, we just don't bother to or need to most of the time.
Throwaway05
5d ago
I feel like I usually see "he's perfect and would never do that to me" +/- "except for that one/fortieth time" in the early stages with later stages being even more awful than that.
Throwaway05
5d ago
I think it's truly the most banal of explanations - all those other riots, those didn't put them at risk. They saw the burning but the burning was for other people. But this one? Oh god that impacts me! Add a media class that identifies as part of the same DC elite that was terrified, and then you get the push.
Throwaway05
6d ago
I mean, I get why people take the Soma, but also it becomes a self-fulfilling prophecy.
Additionally most people don't have that insight into why they are doing it.
Throwaway05
7d ago
Ughhhh for medical work a deep dive involves citation which sounds like a lot of work. Maybe at some point, but for now some thoughts:
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Weed is a drug. Maybe more on the alcohol tier, but it's still a drug. If you talk to people who use many of them sound like addicts. It's not a mistake to notice this, they are. You can have withdrawal (although it's in many ways not as bad as some other withdrawals). People in denial of having a problem... Also, cannabis hyperemesis syndrome is a thing. You'll see patients come in multiple times a month with profuse vomiting and we know the exact cause and they have zero ability or willingness to calm down. Total addiction.
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It hampers human flourishing. For many people the primary problem is that it makes them feel okay with their life being ass. To some extent that's a good thing but I know plenty of people who didn't try to fix stuff as a result. That's bad.
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Plenty of people (as with alcohol) use a little bit and don't have any problems at all. Moderation is possible. This creates a context of false sense of security.
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The association with positive impact on the supposed indications is questionable. Anxiety and insomnia are best treated by addressing root issues. Use a drug is a crutch that prevents recovery. For many it actually worsens these things, and passing out does not mean "sleeping."
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Most importantly, like with alcohol a particular subset of the patient absolutely cannot. Psych patients. These people will go by even more unsafe street weed these days if they can't get it at dispensary (usually stepped on with a....variety) so hard to stop it, but it worsens all kinds of shit and can make recovery and tons of these people think its an adequate treatment.
Nearly every patient with a psychiatric diagnosis you see in the hospital - and I'm talking on medical floors too, has a massive weed addiction.
Some of these people also appear to have been created by weed.
Additionally, when I was young I remember people going "pshh they are overstating the risks, but risks exist?" with drugs. Lots of young people today are "this is perfectly healthy."
Throwaway05
8d ago
Personally I thought what you are talking about works fine, my concern is just pacing issues. The ideas are explored with the usual higher degree of competence than I would expect from random web author.
Throwaway05
8d ago
Don't worry I'm still loving it! This book just went in a very different (literal) direction.
I'm not sure what you mean, but an excess in consults is driving people out of practice, raising costs, lowering quality and all kinds of other shit. It's a mess.
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