This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
If it's any consolation, I'm sure right-leaning students handle this the way we always have: go through the motions, then make fun of it all behind their backs when we're hanging out on our own time.
But it is worrying. What separated us from the Soviets during the Cold War was you didn't have to be an activist to do things like medicine.
They do still exist but changes to the pre-matriculation "requirements" have decreased their numbers, and being "outed" as conservative or woke-questioning will kill your social life so they tend to be super locked down.
Add on the requirements to publicly go through the motions during times of profound stress and exhaustion.... you get people who legitimately convert or experience permanent changes.
Remember that medical school clinicals and residency is not far off from outright torture in a lot of ways and people get 1984'ed while going through this.
Salary and taxes walk some people over a few decades but it is less than it used to be.
Why do they torture students so?
A lot of things are going on here, some of which are a bit more complicated to get the full picture on like the historical issues with hierarchy and abuse.
Two simpler bits:
-You don't decide where you work and learn during training and if you leave, quit, or get fired you are done. Sometimes with upwards of 500k in debt. Programs know this and will mistreat trainees knowing they can't vote with their feet and their lives are pretty close to over if they don't suck it up. Suicides and deaths from things like sleep deprived car accidents aren't common per se but are frequent enough that we all know multiple people who went out those ways.
-Unlike most high education/high skill labor you need a lot of 24/7 coverage and physicians are very expensive and in high complexity specialties like surgery you have to do a FUCKING LOT of stuff to become independently proficient in a reasonable number of years. The solution is typically to rely on trainees and long hours. On paper Residents aren't allowed to work more than 80 hours a week, must get at least 4 days off in a month, and aren't allowed to work more than 24+4 hours in a row. On paper. Very common for people to violate one or more of those in an easy specialty at an easy program. In something harder like procedural specialties? You might work 80-100 hours a week with an average of four days off a month.
For 5 years.
Shockingly!!! Substance abuse, mental illness, and medically measurable premature aging (fun study that one) are rampant.
This breaks people down and I think could be reasonably considered torture.
Add on the fact that you can't leave, and many other aspects of the training can be considered abusive (said things that are a bit harder to explain)...
Wow I had no idea the state of medicine was so bad. Jesus.
So are you saying that the state of residency is sort of justified by the difficulty of the profession?
How would you do it differently if you had the magic wand of 'fix up the medical training system'?
/images/17246063318586245.webp
Plenty of other crap is going on and much of that presents easier targets - excess regulatory burden, administrative overreach, wellness modules, U.S. malpractice environment, etc.
A large swathe of the central problem is that Americans doctors are expensive (so hiring more staff for instance is...difficult) and at the same time Americans won't work in American healthcare without those salaries (because of things like the American patient population, malpractice and so on). It makes bigger fixes extremely hard.
Many kinds of surgeons are just fucked - medicine has improved, which means we do surgery less often and the types of surgeries we do are more complicated and harder to learn. It's an order of magnitude or more easier to learn how to remove something from an option approach (think just cutting someone open) than a laparoscopic approach but the latter is much much much better for the patient. Finding ways to make this not extend training time is a nearly intractable problem.
However, a sensible target is malpractice insurance. Doctors do fuck up and do fuck up in ways that should involve penalties but functionally these seems to be entirely separated from who actually pays and gets penalized in our current system. Malpractice insurance alone for OB can be over 150,000 dollars a year. That's insane.
Stronger unions for residents and attendings is probably also a good idea. Unions can absolutely be bad but we are far off from the point where that's an issue.
Likewise kill some various forms of rent seeking and other bad behavior like egregious non-competes, physician boards that costs of tens of thousands of dollars, substance abuse programs that also costs tens of thousands of dollars if you somehow manage to get caught smoking weed, etc.
On a structural level you can probably free up money that can be use to improve healthcare and reduce burden on doctors by targeting various middlemen and administrative horseshit. Fire the front desk staff to pay for an extra useless diversity or infection control administrative and the doctor just adds that job to the list of things they do.
Walk that back, the ratio of clinical to administrative staff is insane and grows worse every year.
I'll try not to blather too much but however bad you think it is it's a lot worse. A classic example is the fact that the population of people we've selected to be doctors might be offered the option of working in NYC or getting paid 300k more a year to work 2.5 hours to the northwest and they'll pick the city. Shit's fucked.
Sidebar: 24+ hour shifts were taken away and then brought back because most people (including residents) thought they were better than the alternative. Which sounds insane and is.
Wait but you were saying earlier that it's hard to hire people and doctors need more support because it's expensive. Wouldn't the admin staff help with this??
Oh trust me I am pretty severely blackpilled on the Western medical institution, although I do admit that modern medicine has miracles aplenty. My mother's life has been saved on three different occasions by relatively recent medical inventions. So I'm grateful.
But I also wasted over $20k in my early twenties trying uselessly to figure out my chronic pain issues with TMJ, sciatica, RSI, and other various health stuff. Was told by multiple doctors I'd need surgery if I ever wanted to use a keyboard and mouse again. I'm pretty close to recovered now but... anyway that's a story for another day lol.
I didn't realize they were taken away! Ugh yeah it's so fucked. I've seen studies on like the efficacy of doctors based on how long they've been on shift and it's terrifying. Going to the hospital seems like such a crapshoot luck of the draw type situation in some respects.
Think admin like university admin - hospitals are laden with nursing executives, management and so on who at best ensure compliance with various regulations but often are just money drains. Admin in the sense of support staff would be great. Feminism has caused some of the pain here - support staff used to be competent women because it was women's work, now it is often people who can't get other forms of work (not saying I think the change is bad, just noting it).
says nothing about aggressive, trigger happy proceduralists
With respect to patient safety basically the research says that hand offs (to new doctors) are bad and sleepy doctors are bad. About as bad. It's cheaper to overwork the doctor so we go with that. If you've ever studied overnight or stayed up late gaming it is tempting to think of it as the same thing. It is not. Saving (or risking) a patient's life in a fugue state on hour 30 of no sleep and not realizing you'd done anything at all until 20 minutes after the fact is fucking horrifying.
In any case the specific thing with duty hours is that in the 16 hour max shift world you'd just be expected to stack 16 hour shifts indefinitely. With 24s you typically manage to get a "post-call day" meaning you'll do something like 8am-to 10am the next day, but have the rest of the day off "to live your life" aka pass the fuck out, which enables something resembling recovery.
These days the option is typically to take the sleep deprived resident/fellow or have a midlevel who works nights. I don't know a single doctor who'd ever take the midlevel over the physician, no matter how tired.
Ahhh I see. Ty for all the explanations.
Wow this sounds horrific. I can't imagine. No wonder doctors are emotionally repressed and not able to handle healing modalities that incorporate emotions. Brutal. I actually am gaining a lot more sympathy for doctors reading your responses.
Do you have any recommendations for like picking a good time to schedule a surgery for instance, as a patient? Or finding a good/competent doctor?
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link