ebrso
2yr ago
Medical exams are hard (and not like most exams you see), someone who was in the top 5% of their class at a respectable undergrad institution can spend two years studying for Step 1 and still barely pass it.
In 2021, before USMLE Step 1 moved to pass-fail, 98% of 1st-time takers from MD programs passed per here. By comparison, the first-time pass rate for the California bar exam (to practice law in the state) is roughly 45% per here.
ebrso
2yr ago
The problem is about to get much worse [due to preferential treatment of URMs].
Separately, I'm concerned about the effectiveness of medical (and pre-medical) training performed remotely during the pandemic. I also think the integrity of admissions / promotion standards are potentially compromised by pandemic-era shifts, particularly rampant cheating and grade inflation.
ebrso
2yr ago
When I think about "bad" doctors the ones I run into are generally lazy/burnt out types, or outright malicious/unethical types. Traditional incompetence is rare,
This is my impression as well, although I attribute it to gatekeeping effects (entry into American medical schools is traditionally so hard as to exclude truly incompetent candidates, and entry to practice in America from foreign training has similar gatekeeping).
By the way, I've always found it interesting that Scott, who seems like a brilliant and caring, almost ideal physician, attended medical school in Ireland - was that personal preference, or could he not get admitted in the U.S.? I remember him mentioning that he had a very difficult time achieving placement into a U.S. residency afterwards.
Traditional incompetence [among American physicians] is rare, because those people get kicked out of medical school or residency
I thought the stats showed that the overwhelming majority of individuals entering American medical schools are promoted to full privileges? Like, well over 95%. And presumably, a non-trivial part of those who don't get promoted aren't "kicked out" of medical school / residency for lack of competence, but rather leave due to other factors (medical problems, voluntary career change, etc.).
I'm sympathetic to the arguments that American medical school screening processes (appropriately) exclude candidates that lack the skills necessary to be successful as physicians. But alarm bells start ringing in my mind when I hear one set of people saying "admissions standards aren't necessary in the current system because we have such exacting training standards," while the other set of people is saying, "serious training standards aren't necessary in the current system, because we have such exacting admissions standards."
ebrso
2yr ago
More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).
Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy
It's worth noticing that this source is from the AMA, which is an American physicians' group that lobbies to protect American physicians' class interests, including preventing mid-level health care professionals (NPs, PAs, etc.) from encroaching on practice areas seen as reserved for physicans. The url itself identifies this article as part of an advocacy campaign. The article highlights:
The AMA is advocating for you [American physicians] The AMA has achieved recent wins in 5 critical areas for physicians.
That doesn't necessarily make anything it says wrong, of course. But I'd expect the article published by the corresponding NPs' association to emphasize different observations and to reach different conclusions.
ebrso
2yr ago
From the article
One professor said that a student in the operating room could not identify a major artery when asked, then berated the professor for putting her on the spot.
She knows literally less than a decent butcher.
The qualifier major is carrying a lot of weight here. There are thousands of named arteries in the human body, ranging from the aorta (which every medical student in clinical rotations really should be able to recognize, at least when it's exposed to plain view) to tiny branches that exhibit tremendous variation across individuals, and which even the absolute best students (and expert physicians) won't be able to reliably identify in cadaveric dissection (never mind in the operating theater). Viewing angle, anatomical posture, and similar (physical) factors can also make it much easier or harder to identify individual vessels.
So, even if we take this anonymous source's claim at face value (i.e., we assume that some incident occurred in which a medical trainee failed to identify a "major" artery on request, and then reacted badly), how should we understand the term "major," and why do we assume that there was a clear presentation? (And of course, one case, however egregious, doesn't establish a trend.)
ebrso
2yr ago
Thanks. The Inca Trail seems interesting - I'll look into that tomorrow. I make $240K/yr. leading a team of ~15 engineers.
ebrso
2yr ago
What would you do with a free 2 months?
At 41, probably as some kind of mid-life crisis, I've decided to go back to graduate school. I start in June.
I have a bullshit email job, and I'll give notice soon (tomorrow, perhaps). That leaves me 2 months free. I have no partner and no kids.
So, what are some ideas for things I should do with this free time? Money is no object. I'm open to pretty much anything. The last time I had a few months free I wasted it sleeping to noon everyday and playing online chess compulsively.
ebrso
2yr ago
Let's accept at face value that White jocks / cheerleaders support Trump. Then I still think there's a category confusion hiding in the insistence that analogies should "resemble observable reality."
I'll give an example. Say my friend were deciding between studying Russian and studying Hindi. Now say I tell him he should study Hindi because, per Wayne Gretzky, great hockey players "skate to where the puck is going to be, not where it has been."
Would it really undermine my argument to learn that more great hockey players study Russian than Hindi?
ebrso
2yr ago
You're right, I didn't understand what the word "instigate" meant. I thought you claimed that Ashkenazi Jews are the chief supporters / proponents of Zionism in modern Israel - but that was not your claim.
ebrso
2yr ago
You ignore the DNA evidence that Palestinians are the direct ancestors of ancient Canaanite and Levantine inhabitants of the land, and doubly ignore that Ashkenazim — the chief instigators of Zionism — are half-European in DNA.
How are Ashkenazim "the chief instigators of Zionism"? Mizrahi Jews in Israel make up over 60% of the nation's Jewish population, and their politics are to the right relative to the country.
Yeah, I think in ice hockey especially, fights aren't seen as pathological, but rather as an important part of a self-policing culture. I can understand that. What I don't understand is why the local district attorney would take that stance (and not prosecute offenders).
Baseball doesn't have the same opportunities to deliberately inflict injury within the standard ruleset of the game, so the same sort of culture never developed.
Interestingly, and consistent with your theory, my sense is that the proximate cause for most professional baseball fights is a perception of inappropriately aggressive play on the part of the opponent: high-and-inside fastball, sliding into 2nd base with spikes up, and so on. It's also interesting to me that in both baseball and ice hockey, the culture broadly prohibits using weapons in fights. The first thing a hockey / baseball player will do at the start of his fight is throw down his stick / bat. Again, this is consistent with the theory that fights serve to self-police / enforce expectations for conduct.
ebrso
2yr ago
hockey has long had a culture of policing things that aren't quite illegal, but considered excessive via player-based enforcement in fights.
Why are fights between athletes considered just part of the game, rather than serious crimes? I assume that if I were to take a swing at someone in my office, in front of a million spectators and filmed from fifty angles, I would (quite appropriately) face jail time. But this doesn't seem to hold for, e.g., baseball players.
ebrso
2yr ago
Hamas is backed, formally or tacitly, by a host of Middle Eastern nations, at least one of which (Iran) is a nuclear power.
I don't think Iran is known to be a nuclear power, at least as I understand the phrase (possessing nuclear weaponry).
ebrso
2yr ago
I personally haven't carried a phone (smart or otherwise) since sometime in July, when I dropped and broke my iPhone. Before that, I hadn't been without a smart phone since around 2012. I don't have a land line. If I need to make a call, I use Google voice on my laptop.
Mostly, I've been phoneless as an experiment. Overall, the experience has probably been net negative, and I'll likely get a phone soon.
On the plus side, I can focus somewhat better (on reading, or work, or watching a movie at home, or whatever) without the phone constantly interrupting me or threatening to interrupt me (or just being an attractive distraction). I also take satisfaction in the idea that I've opted out of a part of modern consumer culture. I think I'm reading books now when previously I would have been scrolling on my phone (this is an improved use of my time, in my opinion).
On the negative side, there've been a few times where I could've used a phone (e.g., I got locked out of my office, and had to just go home for the afternoon). I know it's an annoyance (and concern) to my family that they can't reach me at any moment. There are various sites (for banking and such) that use the ability to receive texts as a 2nd authentication factor. If I had a social life, I assume not having a phone would be a major impediment. I feel like I'm losing touch with friends whom I used to call and text. I can't call Uber. If I get lost, I don't have access to maps.
I will say that the first week without a phone felt very unnatural (ironically), but after that, I guess I got used to it.
ebrso
2yr ago
Israel would have (more of a) carte blanche to just indiscriminately whale on Gaza. After all, it would be easier to say that anyone who did not leave is a Hamas militant, or forced to stay by Hamas (so it’s Hamas who are responsible if they die)
Prohibiting the exit of Palestinian civilians from Gaza because keeping these civilians in Gaza limits Israel's scope of military operation seems consistent with Israel's complaints about the use of Palestinian "human shields."
Rest of the Arab world might hold Egypt partially liable for a new Nakba.
It's hard for me to see the Arab world blaming Egypt for allowing refugees to exit a war zone. Many Palestinians were permitted to flee to Egypt in 1948. Does the Arab world hold Egypt partially liable for the original Nakba?
If sufficiently many [Palestinians] leave, it would considerably advance the desired Israeli end state of a comfortable Jewish majority in the entire former Mandatory Palestine.
Is "a Jewish majority in the entire former Mandatory Palestine" really the "desired Israeli end state"?
ebrso
2yr ago
Thank you, this is an extraordinary answer.
Let's consider pediatric medical supplies with minimal potential for military diversion (e.g., neonatal incubators). Let's further assume that pediatric health will be harmed without access to these supplies.
Under this framework, at the current time, is Israel obligated to permit their passage across its border?
ebrso
2yr ago
Pour liquid propane inside could help I think. It displaces all the oxygen . . . they will run out of oxygen.
I'm not an expert, but I assume this would reasonably qualify as a chemical weapon (an asphyxiating gas). Separate from the legal questions, I would consider it an escalation in the conflict.
ebrso
2yr ago
Thanks. I've read all the threads here, and I still don't have answers to these questions. I've seen plenty of confident assertions (of course), but they often conflict and typically lack support.
For example, to respond to your answer, I've seen suggestions here and elsewhere that America and Israel have exerted pressure on Egypt to not open their border with Gaza to an exodus of Palestinian refugees / an influx of humanitarian supplies. Is this claim totally without basis?
ebrso
2yr ago
Some narrow questions about the current conflict.
I have some narrow questions about the conflict that I'm having trouble getting good answers to. None of these is intended as a "gotcha."
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Why can't Palestinian civilians flee to Egypt across Gaza's southern border? What considerations or pressures (internal or external) prevent Egypt from granting entry now to Palestinian refugees?
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What is the status of the Israeli hostages? Should we believe that they're still alive? Are they assumed to all be held in Gaza? Are they being detained together? Who coordinates their care? Do we have any knowledge of their treatment in detention?
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What is Hamas? Is it a political party? Is there separate civil and military leadership? Does it have a clear command chain? Are leaders identified publicly? Is it clear which particular leaders were likely involved in planning / authorizing Saturday's incursion into Israel? Do these leaders currently reside inside of Gaza? Are they in communication with one another, or are they isolated now? Do they continue coordinating activities, or are they relegated to being bystanders? Is there any line of communication open now between Israeli and Gazan political leadership? Leaving aside willingness, are there Gazan political leaders who would be capable of enforcing the Gazan side of a potential ceasefire?
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What are the strategic objectives of Israel's current bombardment / siege of Gaza? Is it aimed at weakening military capabilities in preparation for a ground invasion / occupation? Is it aimed at weakening military capabilities to limit Hamas's ability to launch another strike against Israel? Is it bloodlust / punishment / revenge? Is it a show of force to warn other regional actors (from the West Bank, Iran, or Lebanon) to stay away? Is it intended to "break the will" of Gazans, so that popular support will wane for military strikes on Israel? Is it aimed at disincentivizing future military strikes on Israel (by impressing upon prospective actors that the consequences of such strikes will be severe)?
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Is there significant continued Gazan military resistance to Israel's bombardment? Are missiles still being launched from Gazan territory? If so, are these coordinated actions, or are they actions taken at the initiative of small, independent groups of actors in Gaza?
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If Israel's total blockade of the Gaza strip persists, how will the civilian population be affected? Clearly, medically-vulnerable people will be severely impacted in the immediate term. But over what timeframe will the general population face life-threatening hardship (and not simple inconvenience)?
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Leaving aside ethical and moral obligations, is there a case that Israel has a proactive legal obligation to permit the influx of humanitarian supplies to Gaza along their shared border?
I assume that others here have their own narrow questions. If so, maybe they could go in this thread.
ebrso
2yr ago
Is a peaceful resolution to the Israeli-Palestinian conflict conceivable in this decade?
Warning: I know very little about the details or history of the Israeli-Palestinian conflict.
In business negotiations, there's a concept of Zone of Possible Agreement (ZOPA), which boils down to the range of possible negotiation outcomes that both parties would consider preferable to the alternative (i.e., preferable to a failure to arrive at any negotiated agreement).
Take the sale of a used car, for example. The buyer is willing to purchase the vehicle for a price up to $3000 (this figure is private). The seller is willing to sell for a price that's at least $2750 (also private). In this scenario, a Zone of Possible Agreement exists between $2750 and $3000, where both the buyer's and the seller’s minimal terms can be met.1
The important point is that any negotiated agreement will be somewhere in the ZOPA. The buyer's goal in the negotiation is to achieve an agreement on the low end of the ZOPA, and the seller's goal is to achieve an agreement on the high end of the ZOPA. It doesn't mean they'll arrive at an agreement, but at least both parties prefer to reach an agreement in the ZOPA than to not reach any agreement at all.
But not all scenarios admit a non-empty ZOPA. For example, if the buyer were willing to pay no more than $2000, then there is no ZOPA. Negotiation would be pointless.
Obviously, this framework tremendously over-simplifies the present conflict. Still, I don't know of a better one.
So, is there any conceivable resolution to the Israeli-Palestinian conflict that both sides2 would prefer over continued conflict (hot or cold)?
My sense, unfortunately, is that the most painful concessions that can be extracted from either side would be insufficient for the other side.
And thus, war remains as "the continuation of political intercourse with the addition of other means."
[1] This example is the one provided at the link, modified slightly for clarity.
[2] One way in which this framing is an over-simplification is that it ignores that each side contains multiple relevant constituencies, each with its own preferences.
ebrso
2yr ago
Alcoholism, despite the stereotype, almost always has an emotional component which, if resolved, removes the driving compulsion to drink, though not always the urge.
I'm still struggling to understand what claim you're making about the nature of alcoholism. You stress that wants and needs are (imperative) emotional components. So is it just that people stop being alcoholics when they stop wanting/needing to drink alcohol? But that's almost tautological.
I mean, sure, if someone leaves an academic program, then on some level it's related to academics. But even in cases where someone's involuntarily separated from their program due to bad grades, those bad grades don't necessarily indicate a failure of earlier-stage preparation or a deficit of natural ability. Often, bad grades are downstream from emotional problems, or from a general ambivalence about the training. I speak from some personal experience here, albeit outside of medicine (I don't think this is simply "ego defense").
I don't want to get too distracted from my main point, which is that, based on data and personal observation, I'm skeptical that American physician training requires as much intellectual horse power (or even hard work) as American physicians maintain it does. I do think it requires a high level of conscientiousness, which is surely related, but also different.
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