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Revealed preferences in the real world: black doctors.
I wonder if anyone has studied this? What is going to happen to all the black doctors who are being admitted to med school with inferior credentials and who will likely be socially promoted through residency/licensing as well.
I'm sure a large degree of affirmative action has already affected the supply of doctors, but the post-Great Awokening world seems to have taken that to a new level. Apparently rates of test-failing have increased by nearly 10x in some subjects at UCLA's medical school post 2020.
https://x.com/aaronsibarium/status/1793657774767022569
This is obviously forbidden information. I wonder how many schools will simply cover it up and graduate people as normal despite failures.
I hate to say it, but if I or a loved one was seriously ill, I would try my best to get a non-black doctor. If I wanted the best, I'd probably follow Peter Griffin's advice. I imagine others have similar revealed preferences that we would never admit in public. In the future, will black doctors magically have tons of open appointments while the cue to see Dr. Rosenblatt grows ever longer? I think probably.
Every field has bad apples, the way medical education is structured it is very hard to get through without a certain floor level of competence.
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, because those people get kicked out of medical school or residency....unless they are a favored minority group.
In my career I've run into a handful of white/Asian doctors who are truly incompetent, while I've run into plenty of great URM (underrepresented in medicine) doctors, a noticeable percentage of URMs should never have been advanced through training. It's not a lot, but it's way way way more than the near zero for other demographics, and all of the absolutely catastrophic idiots have been URMs.
From asking it around it seems like the attitude is that it's easier for a programs reputation to advance an incompetent URM student than deal with the flack from trying to put the person through remediation and/or termination (in part because medical education now includes a lot of mandatory education in toolkits these students can use to complain).
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.
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."
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.
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.
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.
I'm ever more grateful thay a quick poke with haloperidol and lorazepam solves most of my "emergencies".
Ah, truly the specialty for me.
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.
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.
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.
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.
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.
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).
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.
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.
I'm not that lazy so I asked GPT-4:
A senior doctor likely provided this advice based on several important considerations regarding the safety and effectiveness of treating acute agitation in patients with psychosis:
Effectiveness of Current Medication:
Drug Interactions:
Safety Concerns with IM Administration:
Clinical Guidelines and Best Practices:
Minimizing Polypharmacy:
In summary, the senior doctor's advice is grounded in clinical safety, evidence-based practice, and the principle of minimizing harm while effectively managing acute agitation. By using more of a medication that is already working, like Zyprexa (olanzapine), and avoiding the combination of IM olanzapine with benzodiazepines, the approach aims to optimize patient outcomes while reducing the risk of serious adverse effects.
I suppose that's the gist of it?
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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
Thank you, while you Americans have an abominable addiction to brand names, I can understand that those are principles that'll come in handy.
I can Google that, but you're in a teaching mood, so might I know why from the horse's mouth?
Never seen it happen, and I've been here longer than I'd like. It's the usual benzos to cover the acute withdrawal, and it matches up with NICE guidance to boot.
Good stuff. I'm taking notes, albeit with the cafeteria being the way it is in the NHS, I might be tempted to steal the sandwich. Certainly not paying for one out of pocket, do I look like I make US money haha. I do prefer practical and common sense interventions where possible, Scott's story about the lady with OCD and hairdryer stuck with me.
More from hanging out in /r/drugs to watch in sheer awe at the people who choose to abuse deliriants, in the case of Benadryl, but Haldol? That's good old haloperidol and I love it like me mum.
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This seems kinda backwards from an organizational perspective. Being a doctor requires that you be really smart because they're all really busy because there aren't enough doctors, so we can only admit really smart candidates to medical school.
Wouldn't lowering standards and increasing the number of doctors improve things significantly if that's the argument?
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.
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Yes! Except people always want the best doctors, so you need a way to gatekeep access to the top of the crop, either by making them more expensive to the consumer or by mandating you have to see Dr. Washington or Dr. Lopez before you're allowed to see Dr. Swami or Dr. Smith before you are allowed to see Dr. Wang or Dr. Leibowitz.
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The problem is about to get much worse.
If professors were afraid to fail an underperforming URM in 2010, imagine how much more afraid they'd be in 2020. Once the new crop of doctors hits the market, it's going to start looking pretty bad.
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.
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A friend of mine recently went to a specialty conference, she described a lecture she saw that was talking about the difficulty in giving feedback to students these days, a student at the end asked "wait is that why all of my friends and I are told we are doing great the whole rotation and then get a 3/5 on our evaluation at the end?" Everyone just nodded.
Good teaching requires being able to safely give feedback and that just isn't possible anymore. The problem isn't limited to minority students.
Okay fine this a bit of an exaggeration but still.
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