Throwaway05
31m ago
It's a good thing I took my Ritalin and have a psych textbook open, or I'd have permabanned for the aggressive attack with education at a vulnerable juncture /s
Excellent! Using the knowledge we just discussed, which PRNs would you administer to yourself for that aggression???
-Lowkey I use the generic vs. brand name basically based off what's easier/quicker to spell.
-B-52 is the medical slang for that PRN regimen, don't see people abusing it (if that's what you meant by that comment).
-Medical beer works great! We need to bring it back.
-In the U.S. we have sandwiches on deck for just this reason.
I see your other reply with chatbot Charlie but I'll ignore it because why more word when less word good.
On paper you have a risk of increased adversed events (most notably respiratory depression) when those two agents are mingled.
What ChatGPT won't tell you is that is likely not real and just a recommendation generated by an abundance of caution. Origin was probably adverse events in people with comorbid substance use, including alcohol.
Throwaway05
1hr ago
Unsolicited teaching time!!!!!!
I know your comment is meant somewhat facetiously but it's important to establish good PRN habits early, especially as you move to a higher resource community.
Some pearls.
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Haldol/Ativan/Benadryl (B-52! If you've never heard the term) works well and is popular for a damn good reason. It's fine as a default.
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Other PRNs exist however and you should be familiar with them and try and think about when to use them. Droperidol is big in the ED in the U.S. Thorazine is more popular as a pediatric PRN because it's thought to be more sedating.
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If the patient is on something that seems to be working (like say Zyprexa) you can consider using more of that for breakthrough agitation. Do not mix IM Zyprexa with benzos however.
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If you ever work in a consult setting or otherwise with medically ill patients you'll want to have a few tricks. QT related concerns are big in the U.S. even if they are questionably real so you have a lot of elderly dementia/delirium patients who need clever agitation management - low dose depakote can work for this.
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Know what's happening with the patient. Patient like the above will generate requests from idiotic physicians for benzodiazepines recs. Obviously that makes delirium worse. I believe all doctors who deal with agitated patients (read: basically all doctors) need a full length version of this rant for that reason. Less common problem (especially outside your field) are pure "behavioral" patients. If the agitation is all volitional antipsychotics aren't going to do shit.....choose more sedating regimens (but be aware of the risks of such).
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Unrelated question to check reading comprehension (this is a joke). Do they use hospital prescribed alcohol to manage withdrawal in India? It's so stupidly effective and simple and I don't know why we don't do it more anymore.
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Go assess the patient (skip if the bandwidth isn't there, admittedly). Nursing and ancillary staff are seldom reliable narrators for if a patient needs meds. Bonus points if you can learn which staff and teams are reliable for this. Sometimes you can save everyone trouble by throwing a pissed off person a sandwich. Also be aware of the risks of sedating someone you need to interview or examine later, can easily cause downstream workflow problems especially if it's a hospital setting and you are pulling in consultants.
Throwaway05
1hr ago
What's doubly farcical is that they're paid more than FY1 and FY2 doctors, who are both more competent, and in the latter case, actually capable of ordering followup investigations for whatever they suspect is the case.
This bit is one of the worst bits. So they get paid more than residents. Work literally half as much. Hoover up all the easy cases. Fuck them up anyway. And work strict hours with breaks so they don't get a lot of work done anyway and just leave midway through shit.
On some inpatient units adding an expensive mid level who costs as much as two residents actually makes things worse. It's insane.
I also just do not understand why it's so hard to convince people that doctors with tens of thousands of hours more training are in fact more competent than nurses with a small amount of shadowing experience and with little to no formal education in actual medicine.
Clown world.
Throwaway05
14hr ago
Editing the quote is not a sign of good faith engagement.
I encourage you to go back and reread some of the things I said and do some research to educate yourself on the areas you appear to be missing some knowledge and context.
Throwaway05
14hr ago
It's interesting you ask this. Of course, the average person working in consulting, finance, or tech will never make six figures.
You kidding me? Starting salaries in many jobs in those fields are six figures these days.
Same with the other post, I just don't think you have any idea what you are talking about.
Throwaway05
14hr ago
I guess I just don't understand this mentality. I don't see why you can't have fun in your 20s and also become a doctor. You seem to maintain that American medical training is uniquely hard and awful, and I'm just not convinced. I appreciate that many pre-meds think their training is hard, but I took orgo and biochem in college, and I can tell you, it wasn't any harder than the classes for my math major.
Alright you have to pause and ask yourself "do I know anything about what I'm talking about" here. Even most doctor haters are well aware of at least some parts of how bad medical education is.
Yes undergraduate it's fundamentally more or less the same classes, with the caveat that you have to get pretty much only get As (average GPA is somewhere in the 3.7 to 3.8 range) and the fact that you have a ton of demands on your time outside of class work (shadowing, volunteering, MCAT prep).
It's less common these days but most residents will violate duty hour restrictions at some point, even in cushy specialties. Regularly to every week in rougher ones.
What are duty hour restrictions?
Don't work more than 80 hours in a week, 28 hours in a row, and get four days off in a month. The term "resident" literally comes from residing in the hospital.
No other job works that hard.
You also don't get to pick where you go to residency. If you quit or get fired your career in medicine is over. You spend tens of thousands of dollars taking multi-day exams.
You know any other jobs where you'll be sewing up a corpse on hour 36 of being at work and awake while your attending shouts at you "hurry up you useless fuckhead he's dead already anyway, we've got to move on" until you finish?
Doctors in training of no time, money, or energy.
Throwaway05
15hr ago
People underestimate how bad working in healthcare is. Admin and regulatory bloat is the worst it is in any field. Perks are thin on the ground, the chair in my office during residency was older than I was, I frequently had to talk half a mile to the hospital at 4am, etc. Some people work a 24 hour shift every 4 days for years. You can get sued for anything. During residency if you quit or get fired your career is over.
It sucks. The pluses make it worth it, but they get eroded year after year and that includes the compensation.
Many doctors will tell kids interested in medicine not to do it. And that's with said salaries as they are.
People don't get it.
Throwaway05
16hr ago
If you sacrificed your college experience and didn't have any fun of any kind in your 20s and took on a half a million dollars in debt in order to become a surgeon then yes, obviously.
As I said in my other comment we don't need to speculate about this. Many medical trainees will refuse to practice in that environment and will drop out or just choose to make less money practicing in a bigger city with a worse patient population or job.
Granted your specific example isn't a good one because being in mid-Atlantic is attractive and there are a few nice healthcare providers in the area. Change it to anywhere in Indiana.
Throwaway05
16hr ago
Do the math. When do similar high education fields start cracking a million? I'm not talking about a partner at McKinsey or a top level google engineer. I'm talking an average person in consulting, finance, or tech making low six figures. Way way earlier if they aren't spending like an idiot. Compound interest is a hell of a drug and physician don't start getting compensated until into their 30s and have a done of debt.
Yes 4.5% is a lot of money in real dollar terms but it is a drop in the bucket in terms of percentage and you know it. It's politically popular sure, but there is so much admin bloat, insurance nonsense and regulatory bullshit which is way easier to target and a much larger slice of the pie. Salaries are empirically not the problem.
And said salaries are what's propping up the system. Doctors do almost all of the revenue generation and work stops without them.
People do not understand how bad working in healthcare is. Nursing are being offered six figure for 36 hours a week of work and they are just refusing to do it.
No other job asks you to do things like work 100 hours a week, 24 hours straight, get sued even when you did everything right with regularity etc etc. If you halved salaries then a lot of specialties would die on the spot. Nobody is going to procedural work or surgeries of any kind in the U.S. under that model. Nobody is doing radiology etc etc. Being a doctor in the U.S. requires too much sacrifice.
As always the problem is not a doctor shortage it's an allocation shortage. That's the issue we have right now. Because we won't pay to get people to do the things we need (primary care and rural medicine). Cutting salaries is the opposite of the solution. And we don't need to theorize what would happen if you just increased the supply. We already did that with mid levels. They made the problem worse.
Throwaway05
16hr ago
Again, any specialty other than (IM/FM, and historically psych) off the table.
Programs that aren't going to violate duty hours (work more than 80 hours a week) off the table.
Good locations (well, other than NYC shitty IM programs, which have high suicide rates) off the table.
Great outcomes are gone yes, as are the good and okay.
And many people go into medicine with sharp expectations as to what they want to do again, "all my life I've wanted to be a surgeon...."
Throwaway05
16hr ago
I've argued in the past that it's helpful for doctors to be intelligent and here I present an example that comes from a little bit of a different direction than usual, but most of the selection criteria are more about diligence, toughness, and hard work, all of which is best preserved.
However, even if you take case numbers down to say 15 inpatients for a hospitalist you still need a lot of those skills if you get a couple of rough admits at once.
You'll find most doctors (myself included) want more doctors, but the tone of this discussion online is always "wow doctors are useless and overpaid, let's just create more from the aether and dump their salaries which will solve healthcare costs" which is not how any of this works.
I rarely see people online weighing in who actually understand healthcare economics or seem to understand and respect what doctors actually do.
Throwaway05
20hr ago
If you fail Step 1 (well back in the day, the new situation is evolving quickly) you are relegated to Family Medicine in a poor location or a malignant Internal Medicine program unless you have something very very strong going for you. The vast majority of students don't want family medicine, and they don't want to be in Iowa, and they don't anything to do with those IM programs.
If you went to medical school to be a surgeon (or a dermatologist, or an oncologist, or to live with your girlfriend in LA) then failing the exam can be pretty catastrophic. Some do drop out after failing "because the dream is dead." Not that I necessarily agree with that decision.
Throwaway05
20hr ago
The NP model was designed around the idea that experienced nurses working with significant clinical background would go back to school to get some "finishing." This is not the case anymore, it's extremely common for nurses to go for NP immediately because bedside nursing sucks and the pay is higher for NPs. Online only programs also exist now. I've seen an NP student exactly once in my entire career, she was shadowing in a family practice office doing nothing while the med students saw patients (she wanted to be an NP so she could be a medical director at a spa).
Claws out? NPs absolutely fucking suck and I see outright malpractice on a regular basis. And you can't even sue them for their idiocy.
Physician vs. Nursing training isn't apples to oranges, it's apples to wrenches. Physicians spend years being abused and called idiots in order to develop caution, intellectual humility, and limitation awareness, only when mastery has finally started to arrive does the confidence get papered over that fear. The nursing model is centered around establishing early excess confidence (so you can speak up if you feel the doctor is off base) and the what, never the why. And nursing tasks, which are incredibly important but learning how to make an IV tower stop beeping has precisely zero to do with with "this patient isn't having a neurological emergency you just got Albuterol in their eye."
If I had a dollar for every time I saw an NP managing someone in the ICU nearly kill a patient because they did the thing they always did (not realizing that with the specific patients comorbidity it'd be fatal) I'd fucking retire.
Urgent Care and Emergency Medicine (well, with the way most patients use this service) are extremely algorithmic and that gives people (both patients and yes also nurses and other healthcare workers) a false confidence in the simplicity in the provision of medical care but shit is fucking complicated and nursing training doesn't teach you jack shit, no matter how much of it you have. 30 years working in construction doing labor is nothing like going to architecture school.
A good NP can operate on the level of an Intern (first year resident) a great one can operate at the level of a second year resident. I've never, ever seen an NP operate at the level of a more senior resident or attending.
And oh god psychiatric NPs. Again if I had a dollar for every time I saw a patient managed by a psych NP who was on Benzos for their anxiety caused by excess Adderall I'd retire.
Nurses have better PR and everyone likes to hate on the doctor because we don't have time to talk to the patients, make a bunch of money (not really true anymore) and COVID etc. but the midlevel lobby is an absolute racket that is accelerating the death of the system through an excess of unnecessary consults, poor patient management, and a lack of easier breather cases for physicians.
Every physician I know who doesn't have a financial stake in midlevels (and isn't in admin) tells their friends and family to only see doctors whenever possible. That's for a reason.
Throwaway05
21hr ago
Something I don't mention enough that might help contextualize the difficulty is this - one patient is not hard in most specialities. If you are a hospitalist caring for one admission that's pretty easy. I'd even hazard that a bright person with some epistemic humility, ChatGPT, UpToDate, and a low-moderate complexity patient could manage it.
You don't have one patient.
You might have 20. You might have 30. Two of them are actively dying on you. You have to juggle those responsibilities while trying to discharge five people on your census who are supposed to go home and 5 new admits you know nothing about. All while nursing, case management, utilization, and the billing department are trying to call you. Every day. Maybe it's a weekend and you've worked 14 days in a row. Maybe it's hour 28 of what's supposed to be a 24 hour shift. And you still have to write all your notes from yesterday.
Yeah being really smart will help you save one of your dying patients by coming up with something clever, help you diagnosis something incidental in one of your random patients, and help you spot that your healthy seeming afib patient is a bomb waiting to go off....but more importantly it gives you the intellectual reserve to handle the volume without letting things slide.
That's the biggest difference I see between the smarter and dumber doctors. Dr. House isn't required, but having the reserve to not be overwhelmed is.
Throwaway05
21hr ago
I mean what I say quite literally, you can be a top of your class science student at a reasonably good institution, study for two years specifically for the test (including a multi-month "dedicated" period where your only job is to study for this test), spend thousands of dollars on incredibly well designed test prep material and that still might not be enough.* Keep in mind that this is after multiple filtration points designed to weed out people who aren't good at hard work and studying.
The bar is designed to be acceptable to fail multiple times, law school is not set up exclusively around passing the bar, and while admissions can be rigorous at top institutions it's got nothing on the adderall snorting madness which is med school.
*and while the fail rate is low, failing it fucks you over incredibly, and getting an average score looks you out of entire specialities and regions for residency.
Throwaway05
21hr ago
American doctors also work twice as much as most Western doctors, have longer training, and more expensive start up costs (tuition, boards, regulatory overhead, malpractice, etc.), and as discussed before you have yet to acknowledge that American doctors don't make what you think they do. The average American doctor probably has a lower net worth than the average Australian doctor.
Doctors have relatively low net worths into their 50s, here's a citation. https://www.bfadvisors.com/net-worth-by-age-for-doctors/
Decreasing doctor salaries also does nothing substantial to decrease U.S. health care costs.
And your solution seems to me to be wildly immoral and you make no effort to defend it.
Throwaway05
21hr ago
A number of degrees and licenses have prescribing rights in the U.S. right now (including NPs and PAs in most states).
Keep in mind that an overwhelming fraction of the population will prescribe themselves into bad outcomes if given the ability to do so, and often demand that their providers do so (with variable success).
Antibiotics as you note, is the classic example. People will demand antibiotics for viral infections. They will demand antibiotics when they don't need them. They will demand stronger antibiotics. They'll blow up their tendons or give themselves C Diff or one of any other number of things.
People will take thyroid medication wrong, or even easy to avoid fucking up things like most blood pressure medication. They'll take two medications that are fine alone but will fuck up your kidneys together.
Patients are idiots. That includes high education, high intelligence patients because they have a lot of overconfidence (just as doctors have overconfidence in domains outside of medicines).
But most people aren't high education and high intelligence anyway and you'll get a ton of people killed and cause extremely expensive, avoidable morbidity if you take the guardrails away.
Throwaway05
21hr ago
Yeah as someone who agrees that AA has gone too far I don't think this anecdote proves anything. Surgeons are notorious for interrogating stressed out, sleep deprived residents and med students and then asking them questions until they get something wrong.
You can ask this question in a way which every last med student in the country should get the right answer, and you can ask it in a way that someone who goes to the anatomy lab for fun is going to fuck it up.
Throwaway05
22hr ago
95% and other similar stats are for U.S. MD programs specifically (as opposed to DOs, FMGs, and IMGs), however U.S. MD is probably what is in your mind when you think medical school. And yes medical schools are so exacting about taking applicants because they want to take someone who is certain to make it through the process. Figuring out the cause of dropping out is hard because people lie for ego defense reasons which complicates matters, I do know people who have claimed some other kind of hardship but it was academics. A big piece of medical school is filtering people down to less competitive specialties and programs, but if someone falls below the competence floor they absolutely do get kicked out, it happens, but schools invest a huge amount of research into never admitting these people in the first place.
The exception of course, is minority applicants. An MCAT score that would result in a white person having a 50% chance of getting in and an Asian person a 10% chance is a 95 percent change for a black applicant. It's really really rough.
I'm not sure what happened with Scott but my guess is that he was the kinda person who didn't take undergrad that seriously which limits medical school options (and you gotta like, have at least a 3.8 with no blemishes for most white students) and that he's not very much of a doctor type person (but very much a psychiatrist) which may have made most of medical education very painful.
Throwaway05
22hr ago
Let's just say for a moment that we want to take the 20% of all of the countries with good educations doctors. And that they want to come.
Is that remotely ethical? All practical and cost saving measures aside it seems kinda horrifying to just steal something so important to society like that.
Throwaway05
22hr ago
It's fair to say that obviously the AMA has an agenda, but it's also pretty objective that midlevels don't save any money (and in some cases cost more), it's just also popular with hospitals because they have a tendency to cost more in ways that benefit the hospital (like unneeded testing) instead of professional fees.
It's also pretty objective to say that NPs have 500 hours of training and doctors have 10k-20k. That gap is enormous and even if each hour of training is mostly worthless....it's a lot.
It's also true that NPs after graduating from a program can practice in whatever specialty they want with no specific specialty training, and changes fields with no training. Doctors require 3-10 years of extra training and retraining if they switch fields. Those years are generally 60 hour weeks minimum if not closer to 80 or beyond.
Even if you hate doctors that's a lllootttt of extra education.
Throwaway05
1d ago
Yeah most of the research industrial complex is bullshit, fair enough.....but the rest of it makes sense.
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. Shit is hard. Part of this is driven by how modern test questions are designed. Little of it is fact recall and questions are mostly second or third order. Some have multiple correct answers and you are supposedly to be figuring out what's most likely and even sometimes essentially from first principles (especially in Step 3). Step 1 is a bit hard to do this in because the material is more basic and it's (well, was) our primary "you get to go somewhere nice after graduation" exam because it happens earlier. Thus the vaguer content, but it does serve a purpose and every question ends up having clinical utility for someone, even if it's just a medical geneticist.
A good chunk of volunteering is bullshit but this requirement (absent the social justice end of things) is meant to establish life experience which you otherwise would not have because career changers are still pretty rare and medical education is all encompassing.
Letters for admission to med school are often the way you describe but letters for residency absolutely should involve someone who knows you well and has seen you work, if that doesn't apply for a student they were doing it wrong.
Throwaway05
1d ago
This one is a myth, example citation: https://www.mcgill.ca/oss/article/critical-thinking-health/medical-error-not-third-leading-cause-death
Throwaway05
1d ago
You get shit on so much in medical education that I find most people forget what the exams are for and minimize their value. A good chunk of preclinical learning is laying the ground work for later knowledge growth (Step 1, the relevant exam, included). We also need something that isn't pure pedigree or totally luck of the draw and subjective evaluations to provide candidate discrimination. It also needs to happen early enough for people to filter themselves to specialties that will be actually realistic for them.
Basically Step 1 + Clinical Evaluations (but not preclinical grades) and the usual Letters of Rec/Research/EC.....that shit worked great.
However Step 1 was enormously stressful and got harder to write questions for due to exam prep resource inflation. Someone uncharitable may also note that minorities tended to underperform. So they made it pass/fail.
This killed student motivation in preclinicals (which is again, supposed to be foundational knowledge) and was a huge win for premier med schools (and loss for lower tier ones).
If I had to change one thing I'd increase the weight behind Letters of Rec - they are unpopular these days and admittedly make things harder for those without a medical family (and I was one of those) but done responsibly they can do a lot to recognize good and well trained candidates.
Returning to Step 1 - people get upset because a big chunk of the exam is "low yield" but that's because everyone successfully learns the basic stuff. And they need to. And the old exam format forced them to. The low yield stuff is also things that doctors should be vaguely aware of because you'll see individual rare cases all the time, just not a specific rare case.
Oh yeah Benadryl use? Absolutely, with Haldol? That I haven't seen. You see a lot of Benadryl abuse in a correctional setting in the U.S. And really abuse of anything. Apparently Oxybutynin is popular in the women's prisons. And licking pesticides off the walls is popular whenever the prison successfully cracks down on drug imports. If it's at all anticholinergic life, uh finds a way.
Zyprexa is decently sedating. Benzos are sedating. That's probably it. You get a bad outcome and then it generates a black box warning or whatever and we get stuck with it (see: SSRIs increasing suicide risk).
While I usually like to complain about the lack of EBM in this case it's probably just defensive medicine. Be curious to see if they teach it in the U.K. which obviously has a different regulatory environment.
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