This is not a picture of a real hospital. This is a picture of Mystic Falls hospital, from the CW show “The Vampire Diaries”. If I remember correctly, the guy on the left is an evil vampire hunter (the vampires in the show are mostly heroes, except when they’re evil and trying to take over the world), and the doctor on the right is maybe a vampire? Or she might just be friends with a vampire but not realize it. Or she gets killed by a vampire. I forget and refuse to look it up. It's a really stupid show.
I suspect it IS a real hospital, depending on if the show was set in a hospital or not. If they only needed it for a few scenes, you just rent out a hospital or something that looks similar enough.
> the next time you have trouble booking a surgeon or even a gastroenterologist, you can remember that America’s supply of surgeons and gastroenterologists is being disproportionately used by the AARP crowd.
Because of demographics this is a problem we will have to confront regardless - do you think medicare/medicaid spending will become 80% of government spending?
Maybe with higher taxes and a reallocation of defense spending we’d be able to sustain a more humane society for longer.
Is it indefinitely sustainable? Not sure. I don’t know if it’s as easy as just extrapolating from recent trends because there may be countless unknowns from biomedical advances to climate destabilized societies to being turned into biological batteries for our machine overlords in the next few centuries.
Having medicare operate under a fee for service model will never be sustainable in the long run. We already spend $ 755 B on Medicare, which is roughly equivalent to the DoD's $ 767 B, and Medicare is notoriously wasteful[1][2].
I'm a younger (34) person with substantial healthcare needs (I have MS). Everything is always oriented towards the old, and I also pay taxes that are used to support them while getting nothing in return despite having similar needs.
Do you really get nothing? And who is paying for whose care? You mention taxes, but they've probably been paying taxes even longer. And why do you think health care is a strict quid pro quo anyway? Some of us believe care should be allocated where it's needed, not where it's paid for. Put another way: why is it a problem that they are getting care? Isn't it that you aren't? This doesn't have to be a zero-sum game. If you feel that you're in competition with someone else for care, the problem is pretty clearly that there aren't enough providing it.
Saying others have less right to health care is pretty terrible no matter which way the finger points.
I wish we (Americans) had universal healthcare, but at this point I'm pretty jaded about that ever coming to pass. So I agree with you there, and your point about them having paid taxes is also a good one.
That said, we do care for the elderly because of their vulnerability but we then shit on younger disabled people. Old people can have assets, most younger disabled people can't, and younger disabled people can lose their benefits by getting married. SSA also applies different criteria for disability and makes it functionally impossible to get if you're young enough versus in your 50s or 60s.
I'm frustrated at being expected to extend infinite grace to the elderly when receiving very little/none, despite us being similarly vulnerable. I also dislike that in general our culture takes care of the elderly/gives them their dues without asking them to take up the corresponding responsibility. As a group, they care very little about the future.
After years fighting/voting for better healthcare, very little has been accomplished. So am I just supposed to suffer and accept I matter less than an old person? That's kind of against basic animal survival instinct. My country seems determined to view it as a quid pro quo, including the elderly.
People who are net-contributors feel like they're likely to eventually be elderly, and unlikely to become disabled, I guess (so the inverse of your feelings)- combined with deception by governments that social security programs are like a savings account for the future, not a tax to pay for today's expenses.
From each according to his ability, to each according to his needs is the only solution for healthcare.
I support universal healthcare, I just don't think it's going to happen in America.
Right now the answer seems to be 'take as much from the young as you can and guarantee them nothing' and that's not sustainable. It's just that most of the young can avoid looking at this reality until they have a health problem.
> am I just supposed to suffer and accept I matter less than an old person?
Absolutely not. The situation is deplorable, and I hope we can get to a better one some day. Fight for all you're worth. All I'm saying is that others who receive care are not your enemies. (Or at least not because they receive care. There's bound to be some overlap.) The enemy is the people within the system who restrict the labor supply, drive up prices for everything else, make arbitrary rules like those you've mentioned, and so on. The politicians and profiteers, not the patients, define that system.
I agree with this. The problem for me comes in that elderly patients (again as a class/group, there are obviously exceptions) have no problem with this system. They don't care because they benefit. I've also gotten several snide comments from elderly people and heard numerous tales from other younger disabled people that it's happened to them too. That we're too young to be there/to be sick, snide comments about when/if we can't work, etc. In fact, given that the elderly are living off of social security + investments, they have common cause with the politicians and profiteers as they won't allow any action that either risks their property values or their investment income. If line go down, old people can't retire, so we can't do it.
I will never have access to my enemy until there's a critical mass of upset people, and the elderly seem willing to let younger people die of treatable problems as long as they're not effected, so the only way to get them to care and join us seems to be to make them feel as insecure as the rest of us, which sucks.
I believe the elderly have agency and for the ones who are still alive (since of course the people who live to 85+ to begin with are those who didn't have to ruin their health due to poverty and blue collar labor), they've used their agency to say 'we don't care about you'. Which is fine, but then they turn around and get all mad when they're not cared about in return. Either they want to be a part of a community, including accepting the responsibilities, or they don't. They need to stop wanting to have their cake and eat it too.
I had a strong reaction to that too. Of course we devote more health-care effort to people in the last 5-10 years of their life, which primarily (but not entirely) means older people. There is practically no world in which that wouldn't be the case, because everyone's health trajectory eventually trends downward. By the time someone reaches the ICU (other than as a result of trauma) not only the immediate problem but likely several others will have progressed to problematic levels. That's also where the most labor- and dollar-intensive treatments tend to be applicable. It's just basic statistics, really. Cars also cost more in maintenance late in their life cycles, and so do many other things. A flat age distribution in the ICU would be super weird and probably an even worse allocation of resources.
I don't think the author really meant that to come across as callous as it sounded. Probably just poor choice of words. I'm only addressing it because someone else reading it here might interpret it in more of an "older people stealing from younger ones again" kind of way for demographic or ideological reasons.
I didn’t read it as an indictment (why are we wasting all this money on people who are dead soon anyway?) but more of just a straight observation that makes sense if you think about it but probably isn’t what most people would expect if asked unprompted.
Funny, I pay even more than you mention to support my own mother in relative comfort in a nursing home, and I don't find it "painfully easy" to think that way at all. I certainly don't hope she dies tomorrow. You might want to reconsider saying such things in public.
Note: my mother, not my grandmother, and I have lived that ordeal for several years. Some interaction is still possible, but recognition has been beyond her for a while. As long as she seems to take some pleasure in her surroundings, no matter how dim or muted the signs, you won't catch me framing my thoughts about her in terms of dollars I could save.
I think a more generous reading of the comment you are replying to could be (and probably is reasonable): It is hard to pay a lot of money for somebody that is living in agony with no chance of getting better, where death might be a good option for them personally. I would not understand the comment to criticize supporting people living in relative comfort.
"Warehousing her body" suggests otherwise. When people talk about someone as a "body" they usually mean insensate IMX. People whose loved ones are in pain tend to use different, even more colorful, language. I know I did, when that was the case.
> People whose loved ones are in pain tend to use different, even more colorful, language.
The human experience varies wildly and I would not make such assumptions. Caring for somebody without the hope of improvement for years can make you bitter or even resent the person that no longer resembles the one you loved.
And that's OK? I happen to think it's not, that bitterness and resentment hurt everyone involved, and I know that it's possible to resist those feelings. How, exactly, does the person who succumbs get to play Good Guy?
Before you jump the gun like that again: The context is most likely about the suffering of the patient in question from simply existing in that state, and there being no way to alleviate the suffering (only prolonging the life). Not about saving money.
So it’s a lose-lose: the patient suffers and society has to pay for their privilege to suffer (without recourse, most likely).
And maybe you disagree fundamentally with things like assisted suicide. But someone who posts something like what you replied to most likely do not.
Then why even bring it up, let alone cite it as something that change[ds] one's views?
> maybe you disagree fundamentally with things like assisted suicide
In fact I do not. There was a time when my mother wanted to end it, and I wasn't the one who stopped her. I respected her right to make her own choice. Her condition subsequently improved to the point where she no longer wished that, leading to the current status quo, but that's already far more than any of the pissants in this thread deserved to hear about it. Expressing one's own wish for a supposedly-loved one to die is indefensible, even if they also wish it for themselves.
It's politically toxic to discuss but a ton of money goes to keeping people not dead (not really alive either). You could give a lot more people medicare/medicaid if we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.
I don't think its politically toxic, but rather, extremely humane that we care for our elderly. The real unfortunate part is that we, in the working class, have to make due with sharing slices of the pie so more money can go to our exploiters and owners - especially in the US, we are such a wealthy nation, and yet here we are bickering around who deserves care based on age. Sad.
Ever hear of the Obamacare death panels? The ones where doctors would decide if your loved one was too old and shouldn’t get treatment?
Yeah. That’s this.
What it really was that Medicare would pay for consultation with doctors (?) to discuss end of life care and setup living wills and DNRs and such if the person wanted.
That way if something happened and they were taken to the hospital they could be treated the way they wanted to be and not stuck in a coma on a vent for the rest of their life if that was against their wishes.
But the Republicans branded then “death panels” (which for political purposes was brilliant). So the choice of having help making those decisions was removed.
I disagree, spending on these things is growing at 2x GDP growth so yes more of the pie is going to this. What I'm suggesting is that at some point the pie isn't big enough for this. No matter what happens eventually standard of care will roll back/fewer people will be covered etc. Ideally we can innovate out of this situation but after spending 8 years working in healthcare I've gotten cynical about it.
If our society really cared for the elderly, they would be integrated and respected, not segregated and shunned. We do the latter because we fear age, sickness, and death. Fear isn't caring.
In the US. It's perhaps the most striking difference that hit me during my stay overseas. In the Old World we occasionally get people completely panicking about their own death. In the US, seemingly _everyone_ is like that.
I'd wager: not very differently. But not out of fear. The social isolation of old age is the same everywhere. Young people have their own lives to live.
> The social isolation of old age is the same everywhere
That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.
Well, yes I see what you mean. What I meant was: it's the same in the US and western Europe. But certainly if you go to more "old fashioned" places, the elderly usually live with the family and are taken care of. To be fair, this still happens even in "advanced" western societies. I seem to recall this also goes together with a lot of elderly abuse.
> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.
Often it's a 4 week old baby.
For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.
You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.
My human dignity does depend on whether I have to endure the rest of my life pooping my pants, not remembering my own name, and hooked up to some noisy machine telling my lungs to breathe and my heart to beat.
You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...
Wow: just sample bias! We need to also look at the old people who had expensive care and survived (95% of costs in that article). Money does gets spent on hospital care just before death (5%), but predicting how to avoid “wasting” that money is hard.
Many of the top causes of death, per the CDC, are from diseases that can be prevented or naturally mitigated. We're all going to get old. We're all going to die. But carrying two or more "pre-existing conditions" into your later years is going to decrease your quality of life, as well as your use of healthcare.
My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.
Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.
It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.
> My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy.
The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.
I think the root of it is recognition that mental health is as important as physical health, and that losing weight isn’t as easy as many people assume, and shouldn’t be done the way many people try - so actively shaming and criticizing fat people for being fat is of negative health utility overall.
> o actively shaming and criticizing fat people for being fat is of negative health utility overall.
Fair enough. But then what do you suggest we do as an alternative to normalizing diabetes and obesity?
To your point - kinda - about losing weight. Changing behavior isn't any easier when there are too few environmental signals to nudge behavior in a more healthy direction. As humans, we are wired to assume the norm we see around us. How do we reverse the tide when abnormal (and unhealthy) has been normalized? When everywhere you look, there are people just like you?
I do agree. Mental health is important. But a component of that is (dealing with) adversity. I'm certainly not condoning repetitive malicious bullying, but the current climate has outlawed any/all references to traits connected with being unhealthy. At this point there are no social deterrents, are we really better off?
I think that it's also important to realize that maximizing "health" is not some kind of absolute goal. Not every aspect of life needs to be optimized to the highest level.
Of course, obesity is a huge issue (especially in the U.S. compared to many other "developed" countries) that can affect people's lives negatively and causes further medical issues such as diabetes, and ultimately can prevent people from leading a life that is as fulfilling and meaningful as they would have liked.
But we are still dealing with people here, not rats in a laboratory experiment, and I think the issues that directly follow from being obese are already bad enough that it does not help to pile on more shame by treating those people as being "weak-willed" or something of the sort, or denying them basic human dignity and respect for being outside the sacred norm. Do we really have to add artificial negative consequences for being overweight? Does that help those people have a more fulfilling and meaningful life?
I don't think people will just forget the direct negative physical/social consequences of being overweight by not being reminded of them all the time in a moralistic tone (and even just reminding people of such information can be moralizing, depending on the context in which the information is provided).
It's pretty well know and often discussed that up to 1/3 of Medicare spending is wasted. Being fee for service doesn't help but neither does spending 13-25% of all medicare dollars on end of life care[1].
What's worse is how much of Medicare's wasted spending goes to harmful treatments.
I assume we start by getting more information from patients about their wishes, and then following them accordingly. A large number of elderly people don't want hopeless and unpleasant medical interventions, but end up having them anyway because no one asked them.
Any form of euthanasia runs into the legal and moral problem of who decides? And why?
You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.
Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.
Great, well written article, I wish your father a speedy recovery.
Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.
There was an interesting article that showed "state of the art delivery rooms" from the 1950s - and they were ALL oriented around the doctor and nurse's convenience.
Now we've moved back toward "birthing centers" which focus on the mother and the baby; perhaps it is time for something similar to grow across all aspects of care.
> There was an interesting article that showed "state of the art delivery rooms" from the 1950s - and they were ALL oriented around the doctor and nurse's convenience.
And women are still giving birth lying down, fighting gravity, for the doctor’s convenience.
>Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.
After ACL reconstruction surgery many (~30) years ago, I was required to stay overnight due to both the general anaesthesia and the lateness (late afternoon) of the procedure.
I had a similar experience with the nurse coming in every two (2) hours to take my vitals. I was trying to sleep, but she kept waking me up. I groused about wanting to rest, but was informed (direct quote) "this isn't a hotel!"
And it's not. Rather it's a money printing facility for the owners of the health care system that runs the hospital.
I went to the hospital for debilitating shoulder pain.
Came out 3 hours later with an xray that showed nothing wrong and a bottle of Ativan. Still no idea why they gave that to me. I didn't take any of the pills.
It's hard to pin it down to a single drug. Having had both my grandmother (80) and mother (60) in the ICU, and both got hallucinations without Ativan. It could be so many things:
* The aftermentioned lack of sound sleep
* Anesthesia
* Painkillers
In the case of my grandmother, hallucinations and incoherence lasted about three months after she was home. My mother's lasted about 2-3 weeks. It was scary. They both eventually recovered. But it is true that nobody in the hospital bats an eye when acute dementia-like symptoms are mentioned. "It's normal," they say.
The solution to difficulty booking doctors isn't to pontificate on how to allocate their time, the solution to difficulty booking doctors is to make more doctors.
There's lots of levers that could be pulled in the US. Cut down on undergraduate requirements, incentivize large health systems to fund more training (people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything).
Medical care suffers under the bizarre idea that central planning and capacity management will control costs. Meanwhile, costs are spiraling up and up and up. Train more doctors and all the stupid games being played to optimize their utilization start to go away, because it is less worth it when demand is less than supply.
Just getting accepted to a medical school is pretty hard unless you’re amazing/very good at the tests.
Had a cousin and a friend (both I would characterize as smart and hard working) take several years after undergrad and eventually “settle” for physicians assistant schools.
I personally want my doctors to be amazing and very good. For now tests are a fair proxy, it's the 8 years that seem ridiculous, esp when looking at non US countries.
It just strikes me as something that wouldn’t be particularly hard to answer with a detailed study, and probably is a pretty high value question to answer, so I wouldn’t be surprised if there was a study.
I would argue that having onerous tests are not a great proxy. Not only do they not necessarily measure how good a physician a student would be, but it also encourages undergraduates to intentionally enter easier/less rigorous coursework to focus more on the exam aspect (though GPA plays a large role as well). I'm sure a psych major may make a fine physician, but I don't want doctors to only be educated in a rather dubious field. If undergraduate education is only a stepping stone towards medicine, then just integrate medical education with undergraduate studies, rather than adding a ritualized acquisition of a bachelor's degree.
Nah, doesn't matter. There are still the pre-med requirements (organic chem etc -- recall recent bruhaha about that at ?NYU) that can't be sidestepped for easier courses
Everyone takes the same premed courses though, and you need to be able to teach yourself any MCAT content that wasn't covered by coursework. Sure people will game it, but it's your science GPA that counts, and having people from a diversity of backgrounds is a good thing.
I get what you're saying, but I don't think more doctors is the answer. Hospitals will only hire the absolute minimum number of doctors they can possibly get away with, other than the ones who actually bring in new business.
This is the reason: as soon as the medical industry has established a consensus price for some procedure or other item of care, the hospital administration starts to work on figuring out how to do it for the least possible cost. The price has been set in stone, no need for further justification. Medicare or whoever WILL pay that much. The price is fixed so the only knob left to turn is cost, and cost will be reduced all the way down, until service is just above a level so poor that patients would decide to stay home.
Totally agree. Also, let people open more medical care facilities. Right now "Certificate of Need" legislation is killing lots of viable options for care _outside_ hospitals.
> people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything
Agreed, but I would go further and say that if demand by students for the training provided by residency exceeds the demand by hospitals for the work provided by residents, I don't see why residents couldn't pay for their training just as they do for medical school. The whole "residency funding" thing seems like a red herring as an explanation.
To be clear, I'm not saying that medical graduates should have to take on more debt to pay for residency, but rather that the reason this doesn't happen is not obvious according to typical economic reasoning.
If you've spent on average ~200K for medical school, how willing will you be to pay to work for 3 to 8 more years before you get a paycheck? Resident doctors already make less than nurses with 4 year undergraduate degrees.
So? People really, really want the prestige that goes with being a doctor. If they could pay for it they would. Physician compensation is heavily weighted towards middle and late career as it is and that hasn’t stopped people beating down the doors to get into medical school. Half the people who currently apply to medical school could look at how crap it is and decide not to and there would still be intense competition.
The below article on how awful medicine and medical school are was written a decade ago and nothing has gotten better. People really like social status.
I know a lot of doctors and medical students, for the vast majority prestige is not a primary motivator, not sure why you think its the prestige motivating everyone.
Knowing these people, I also get the feeling that if pay were worse / debt was higher they would have pursued alternate careers. If your goal is to make more physicians you don't want to make the job less desirable. There are already paid residency positions that go unfilled every year (not because there arent enough students, but because the students dont want them). I don't know why you think people would pursue positions that they have to pay for.
To your other point on the intense competition: If half the people currently applying to medical school quit applying the quality of your average future doctor would drop.
Although I agree with you on a distaste for the foolishness of central planning, lLet me provide an alternative perspective.
A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.
> Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.
The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.
Not making American doctors do 4-years of an undergraduate "premed" degree will not meaningfully lower standards. Nor will creating more residency slots.
We don't need better outcomes. We will happily take the existing outcomes but cheaper.
> the "premed" undergraduate degree (which doesn't exist)
Yes there's no undergraduate major named "premed". There's no need to be pedantic. But US medical schools generally require a 4-year undergraduate degree (BA or BS) and certain coursework (biology and chemistry, among others). [1][2]
> will somehow lead to reduced healthcare costs
And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.
> And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.
It's "controversial" because you are conflating two issues.
Shortening the path will at most lead to a very minor supply increase at the time it is implemented; the gains don't compound. Without increasing the total number of admission spots (or more critically, residency slots), the overall supply will not be meaningfully increased.
Removing a prerequisite (bachelor's degree; which I point out in another comment is not actually required at many schools) is generally unrelated to the supply of US physicians and this is why you're getting pushback.
Yes you have to remove the other bottlenecks in the system too (I talked about residency spots in another comment). This seems like an easy win without any accusations of lowering standards.
> the gains don't compound
You give doctors, on average, an additional 2 years of their life to practice medicine instead of spending them in college on a pointless degree (not to mention, slightly lower college debt when starting out). Multiply that over however many doctors we graduate every year, and it'll add up over time. It's not "compounding" in the mathematical sense of the word, obviously. If you assume that a medical career is about 35 years, that's like an 8% increase in available doctor-years over 35 years (or something like that - the math is a bit handwavy). Without doing literally anything else.
I saw your other comment about degree requirements and I'll respond here. In addition to the consulting website, I also looked at Johns Hopkins and they do have a degree requirement. Thanks for providing that counter-example. I wasn't aware and I'll update my understanding of this.
However, your own source said "a baccalaureate degree...is strongly preferred". So it has to be asked - how many non bachelor's degree holders actually get into med school?
Every US-trained doctor I've had has gotten a bachelor's degree (I read bios when they're available). The ones that don't were foreign-trained. If the number of med school applicants greatly exceeds the spots, I'd imagine nearly all serious applicants are going to get a bachelor's degree to improve their chances. It sounds like you're a doctor - what proportion of people in your class got in without a bachelor's degree?
It’s unclear to me how removing the requirement for an undergraduate degree (side note, it is not actually required at many or most US medical schools) will lower healthcare costs.
> it is not actually required at many or most US medical schools
Source for this? That's surprising to me and a brief Google search tells me the exact opposite.[1]
You really don't understand how reducing the number of years it takes to train a doctor, after they complete high school, will lower healthcare costs? Are you unfamiliar with supply and demand, or the relationship between the cost of production and pricing?
> Every U.S. medical school requires the completion of a four-year degree from an accredited college or university.
However, if we look at the University of Chicago's Pritzker School of Medicine as just a single example [1] we see the following:
> "A baccalaureate degree is not required but is strongly preferred by the Admissions Committee."
Given that your reference, "Shemmassian Consulting", appears to be low-quality given that it makes categorically false statements, I won't bother to search for other schools. Suffice it to say that I am aware of quite a few, including my own, that do not require 4-year bachelor's degrees.
Finally, I understand supply-and-demand quite well, and I agree that increasing the supply of licensed US physicians may decrease healthcare costs (but it may not, as excess dollars in the system likely will be vacuumed up by administrators). However, this discussion is about decreasing entrance requirements to medical school, which is completely orthogonal.
I don't have much personal experience with hospitals, but there's a trend I've noticed across several articles now where the medical system is characterized by an unpredictable and frequent alternation between extreme competence and extreme incompetence.
The author's dad was being seen by a variety of highly trained specialists all working to treat him, but "people need to sleep" seems to be a recent discovery in the ICU world, and if his family hadn't been there to help, every new nurse would have tried to give him the same medication that gave him a bad reaction, over and over, just because there wasn't an established place to write that (obviously important) information down.
I've read that food with better nutrition than regular hospital food may reduce mortality rates by as much as half [0]. That's such a huge effect that it's shocking that hospital food is just expected to be bad. Everyone says nutrition is vital for health, but hospitals don't seem to care.
I think the root problem is cost-cutting. Management cuts costs until the brink of disaster, and tries to hold it there for as long as possible. This is not a system that strives for the best outcome for patients within reasonable limits of the resources available; this is a system that attempts to extract as much value as possible from the patients, and patient death is only prevented as a means to that ends.
>The author's dad was being seen by a variety of highly trained specialists all working to treat him
The training doesn't really matter. Context is very important as is caring about doing a good job. You'll find a severe lack of both in hospitals. You eventually have to stand up and defend yourself against bad healthcare... or search endlessly for good healthcare which is terribly difficult to find.
From reading the abstract you are completely mischaracterizing this study.
For the average person healthy food usually means food with fewer calories and more micro-nutrients, like eating more broccoli and less white bread.
This study is about malnourished patients who need more calories than they can even digest from an average meal so they need specialized high-calorie foods that are customized for their own metabolism. It's essentially exactly the opposite of what "healthy food" means in any other context.
So it has nothing to do with any narrative about cost cutting and the quality of ingredients used in hospital cafeterias.
A closer reading of the intervention shows that it wasn't _just_ "more calories".
But I think that is missing the forest for the trees, what this study showed is that when a patient is left on their own, they consume an inadequate diet that _puts their health at risk_ in a hospital. By a big margin!
I would imagine, though the study didn't show this, that the primary factor in recovery here was having a human (dietician) actually paying attention to your recovery. On intake they put together a plan, and followed up routinely to ensure that the patient has consuming their diet.
The GP's point is valid, hospitals are missing out on a 50% increase in health outcomes because they're letting patients fend for themselves with regard to nutrition. You're right that it isn't as easy as spending $6 per meal vs $3 to buy "better" food. But what it means is that hospitals are failing their patients because they aren't thinking and acting with a holistic eye towards patient outcomes.
Sleep is almost impossible with regular check-ups... 30 min or 60 min, don't remember. Excepting the comatose and most medicated(maybe not?), a person's sleep cycle is unable to reach REM when a stranger approaches and fiddles on regular intervals. I would think monitoring from afar(sensors, cameras) would be more beneficial, but I was informed the liability factors preclude such remote monitoring.
edit: to add context, I slept in the room on separate occasions with 2 family members. While tests were not performed, the regular checks were mandated. I was exhausted after my shifts ended.
Last time I was in the hospital (in 2016 with a broken arm) it was very difficult to sleep because the bed had some device that pokes you every so often to make sure you don't develop bedsores from lying too still.
This makes sense for someone who might be in there for weeks, but I was barely there overnight!
More than 10 years ago now, I was in the ICU for myocarditis, leading to bradycardia, a very slow heart rate.
During the night, it would drop to 40 (which is still fine), but sometimes below 30, at which point my heart monitor would blare an alarm, waking me up and scaring the absolute bejesus out of me, raising my heart rate immensely. A nurse would walk in, see that I was fine, and leave again.
I don't understand this post. It reads like "have your cake and eat it too". The the heart monitor did not blare an alarm, maybe you died. Which one do you want?
I don’t think the problem is cost cutting. I think the problem is just the same problem that every human enterprise has.
Most people just don’t give a shit outside thier immediate responsibility.
Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task.
Many people who do give a shit get this crushed out of them early in their career by the negativity you will face if you try.
Much easier to just accept the status quo.
Occasionally you get a group of people who really care and come together determined not to let things be crappy and they can form an organisation that is significantly more effective for a time. But once the rot of “We can’t fix things” sets in, it’s really really hard to turn things around.
Everything you said is spot-on, but, brining things full circle, the lack of “shit giving” could be due to cost cutting. People don’t have an incentive to care. The end result, vis-a-vis their personal situation, is unchanged whether or not they go the extra mile. Part of this is because they exist in a rigid corporate structure hyper-focused on value extraction and not at all focused on the development of human capital.
I work in a hospital, and occasionally in ICUs. You're wrong. Most workers are very much jaded, but they do care. Problem is, the system crushes you to death if you don't set pretty harsh limits to protect yourself. In a lot of cases, that means de-humanizing your work, put your feelings aside and work like a machine. Good little machines are just what management wants, right? Now higher management... wow, those people really don't give a hoot about anything that's not themselves!
A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!
You'd be surprised to see what happens to staff going against waking up patients all night. You get the "dangerous sloth" sticker on your forehead real quick on the morning grand rounds.
With all the focus on EHR and billing, they can't have all the machines taking vitals hooked up and in a ready only state thats sent to the nursing station?
This is the type of stuff I have a gripe with. Sinecure and fiefdoms of power.
Silencing monitors is actually forbidden by law in many places. Staff is supposed to be near the patient at all times => monitors beeping. That's certainly a bad state of things, but not a "fiefdom of power". It's so ingrained in our education that most staff don't even think about it but would certainly agree if asked whether the patient would sleep better without it.
Not saying monitors should be silenced. You can monitor someone without waking them up.
Fiefdoms of power - nursing union not wanting to give up the night shift premium pay when the job description changes to monitoring a screen and half the physical workload vs. day shift.
I’m not sure where you’re getting this from. I / my nurses silence alarms at literally every hospital I’ve ever worked at (granted they’re temporary silences by design so you have to hit silence q1h/q30mins depending on the alarm).
Stanford Healthcare recently installed a system where all alarms/notifications get sent to a hospital assigned device the nurse carries rather blasting in the sleeping patients room as 90%+ are false alarms (aka IV or SpO2 sensors).
The real issue is that hospital technology is outdated and most places don’t have the option for this level of telemetry.
I’ve never been told / instructed my staff to “be near the patient at all times”.
In fact, most places have 1:8 nursing coverage on the ward…
You're right that silencing alarms is strictly forbidden in anesthetic territory only, not ICU. I'm biased bc I'm in Switzerland, and here the coverage ratio is usually 1:1. The country is so rich, that many things are different here... they really are near the patient at all times. To give you an idea: the day COVID really hit, we received 180 shiny new Hamilton respirators complete with additional staff overnight, in an ICU that's usually ~30 beds. And you can't order "your nurses" around, because they've got a lot more power. Yes, in most places it's different and I should have mentioned that.
I want to clarify two points given the language used in your response:
1. I used the possessive “my” in reference to nursing staff for simplicity in writing and clarity to the reader rather than to indicate ownership, we are on a team. This is akin to saying “my goalkeeper wears Nike soccer cleats”.
2. I do not “order nurses around.” I verbally communicate and leave medical orders in the chart that nurses act on. It is not about a power struggle, we are all trying to do our jobs and do what’s right by the patient. I’m grateful when nurses question my medical orders (as long as it’s a positive/educational discussion, which it is 99% of the time) as they catch my mistakes and we all learn together.
If you are concerned that you can’t order nurses around, I strongly suggest reflecting on whether this leadership style is the most conducive to providing quality patient care as this can increase barriers and hostilities in the workplace resulting in communication breakdown and adverse events.
Any doctor who says they treat nurses as valued professional colleagues should be presumed to be lying unless you have seen it yourself, in person. Doctors treating nurses like shit is the norm, not the exception. How badly varies a lot.
pretty much every patient in the intensive care unit - that’s kind of what the “intensive” is referring to.
If nothing else, you either take the blood pressure the normal way with a pressure cuff, which is going to wake you up. Or you put an intra arterial catheter, which reads continuously without bothering the patient, but has a small risk of damage to the vessel, infection etc
Based on my knowledge of US based urban (downtown) / suburban metro hospitals - vast majority of beds / patients aren't in ICU/CCU beds. I would say only 30% are in a critical state under observation - ICU/CCU/post-op/etc.
Cost cutting is definitely to blame for how understaffed hospitals are. Then Covid happened and it got even worse. It's definitely not all due to Covid though. Even the "not-for-profit" medical group in my area has been pushing doctors and PAs to take more and more patients, well past what they're comfortable with. Nursing staff has been cut down to nothing compared to 10 years ago. Wages haven't gone up to match the increase in workload.
Again, this started before Covid, the pandemic just highlighted how much these cuts screwed over both healthcare professionals and patients.
I don’t know why the haldol reaction didn’t go in his chart, but the whiteboard in the room (which is present in every high level hospital room I’ve been in) is exactly where the TV information and other patient preferences should be, and is the second best place after the chart to put a drug reaction. Cost cutting has nothing to do with “nobody wrote it on the place for writing it”.
From personal experience, one of the most frustrating things about the ICU (if you're there for any anything beyond a day) is dealing with the variability in the availability, skills, and temperaments of the nurses on duty. The 'right' nurse can make a huge difference in how fast the patient recovers and how difficult the stay is.
When when one of my parents had a stroke years ago, we spent a week in the ICU. It was a special ICU for stroke victims. The care and staff were exceptional. We were lucky such an ICU was in our area.
On the other hand, subsequent hospital visits (non-ICU) were a cluster fuck. Noise, lights on, nurses constantly waking my parent up, could-care-less doctors, etc. And getting healthy enough to be transferred to an extended care facility was a shit show. It's was like the hospital but worse. Both experience seemed to have little to do with health and recovery.
My point is, the article author is in for a shock once his dad gets out of the ICU and into the "general population". I can't imagine that's going to be better than the ICU. I hope I'm mistaken.
My take away from this experience is:
1) Make choices that maximize your health the best you can.
2) If you can, be rich - like fuck you money rich. The kind of rich where your "general population" hospital experience will be like being in the ICU.
Rich people always get the worst possible care, in my experience. Life-prolonging care, yes. But at what cost? Those are the people that get the most "experimental" medicine out there. Rich people select for the most greedy docs, not for the most capable ones.
> There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though. It’s all shooting in the dark, and most of the time I felt like I could have done just as good a job on these longterm issues...
This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...
if(return_value == 5):
return_value = 4
...to fix it, and being satisfied. What I want is something like in the television show House. The main character is unhinged and anti-social and takes extreme risks, but at least he demonstrates curiosity to really figure out and understand the root of what's going on. To be fair, I don't actually think that doctors lack curiosity or are incapable of doing this, the medical system as it's set up just doesn't allow it. For chronic issues, I've usually figured them out for myself, as a layperson, by persistently keeping track of things, searching the web, reading, and experimenting over months and years.
The main thing that House MD has, that no other doctor in the world has, is not so much his superior intellect. It's that he and five other doctors spend 100% of their time on a single case, and can sit around all day discussing it, trying different things. If real world doctors had even a fraction of that luxury, you would see a lot more of what you describe.
Jeez, no kidding. I imagine if they made a realistic doctor show they'd be constantly showing the doctor at the bar (on days off) trying to make money on side gigs like health startups.
Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".
It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.
Also I'm not kidding but I would LOVE such a show.
You should check out The Resident. The first several seasons are about the doctor invested in a device that is a fraud, a private equity group buying the hospital, it eventually failing.
Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.
New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.
I rank New Amsterdam and the Resident better for the hospital politics; Chicago MD is more short episode drama (though does touch on mental health and social services more.
Back when ER was a hit show, there was survey among medical professionals and hospital staff asking for their favorite medical drama series and the reasons for it. Grey's Anatomy, and similar series, constantly beat ER. The reason was that medical staff considered ER way too realistic. Makes sense, why would I entertain myself during my off hours with what is basically a documentary about my on-duty hours.
Yeah, that's what I mean by the medical system just not being set up to allow this. I generally see a different doctor every time I make an appointment, because I'm assigned to a team in a clinic with constant turnover, the appointments are 20 minutes long, and the doctor easily spends more time on boiler plate stuff in the computer system than examining and listening to me. I don't even think they have time to look over the basic medical history, let alone have a whiteboard session to consider all the pieces of the puzzle and brainstorm possible explanations.
You would not. 5 doctors talking about your case wouldn't help much.
People really don't understand the dire and primitive state of current medicine.
We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.
If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.
I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers.
What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.
You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...
If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.
I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful.
As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
Medical treatment is obviously not fully-solved, or anywhere close.
But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.
I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners.
> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care
> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).
I appreciate your perspective as a professional in this area.
Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.
Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again.
Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.
I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.
Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do
Are all doctors working these hours? I thought these were the hours for residency, not the average general practitioner or specialist working outside of a hospital. If they’re working 15 hours a day, why are they only open 8?
What I meant is that I can follow it for myself, not do it for others. I don't have the training to know every medical decision tree by heart, but I can look up ones for problems I have and apply them.
I am a bit biased because I have several medical professionals in my family, but a common refrain is definitely that most doctors/nurses aren't going to be that engaged and helpful, and are more of a input/output device to navigate rather than someone you want to completely defer to.
You still have the problem of writing a sufficiently detailed tree. I had a blood test last year and when I discussed the result with the doc, he asked me the clinic location where the blood was taken, because then he could estimate time between blood draw and lab test and interpret the result accordingly.
It might be different where you live, but where I am, the vast majority of blood tests are not done at the hospital.
Family doctors and lab test centres do it.
Yes, it's so tiresome and frustrating. I once had a period of a few months where my sleep was down to around 5 hours/night (normally I would get 8-9), I was exhausted and my body just wouldn't sleep more than that. Went to a doctor who offered a couple of thoughts "some people only need that much sleep" and "there's only one thing it could be, but that's not what it is". He wasn't even going to test the "one thing" until I asked if he would. Turns out he was correct that that wasn't what it was, but obviously there was at least one other thing. My sleep ended up returning to normal though I still have similar periods where I can't get enough sleep.
The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).
I think when dealing with chronic issues, it might be better to optimize for luck. [0] A little ridiculousness like homeopathy might be worth it to find the thing that actually works.
Thank you for this link. Well written and mirrors a lot of my experiences though I am still looking for my 'miracle cure'. I think this could be helpful for sharing with other people in my life who don't understand why someone would stray from an empirically/scientifically sanctioned approach.
Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.
For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.
I was not familiar with keyboard layouts including DEGREE SIGN handily, so I though there was at least a decent chance you had deliberately gone fancy. (I double-checked that it was ° and not º U+00BA MASCULINE ORDINAL INDICATOR, which I would expect to see on some keyboards, and “Nº” is incidentally distinctly better than “N°”, since it’s the shape of an o rather than a circle.)
To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n.
I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.)
P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.
Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him.
Creativity also has a role for non-critical conditions when standard treatments aren’t working.
So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.
Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised.
I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
House is not real, it falls under "arguing from fictional evidence"; House's patients are written by a writing team to have obscure and surprising - yet easy to fix - ailments. They are generally young with acute short term symptoms leading to a race against time and a boolean toggle outcome healed/dead. They are rarely the 70+ year old ICU inhabitant with age related complications who is mentioned in the blog post with long periods of 'boring' illness to keep track of and treatment rotating between many doctors.
House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.
House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.
House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.
Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".
In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.
One thing that this article touches on, but I think needs to be emphasized even more is that the stark reality is that the only advocate for the patient is the patient themselves, or perhaps a caretaker.
The burden is on me to ask questions about fertility and sperm banking because my oncologist is well... an oncologist not a fertility expert. I have to ensure that every department is communicating with every other department.
Hospitals and physicians are fantastic at solving discrete issues, but the bigger picture is often lost in the chaos. I can do it as a technically adept 34 year old, it's horrifying to think about how someone closer to 80 goes about it.
I was in an ICU for a week after a cardiac arrest. I don't remember much of it other than a lot of hallicunations.
I had family there to advocate for me, but there's no way in hell I would have been able to advocate for myself. I was literally seeing things around me in the ICU room that didn't exist. My family were probably the only ones that realized that that wasn't the real me.
The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery, and I have full working memory of that normal patient room.
> The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery
To be fair (and this is also true for the article itself), it might be difficult to distinguish cause and effect here. Being moved into less intensive care means that you are more stable which might lead to other issues becoming better in the following days regardless of whether you are in the ICU or not.
For older patients and those with significant co-morbidities, we often advise against intubation and ICU admission in the UK. Usually if the disease process can't be reversed on the ward with current therapy, it is often unlikely in this group of patients for it to reverse on ICU. However, it does depend on the context. There was an interesting article that talks about doctor's choices as an end-of-life patient [1] - they often choose not to opt for aggressive life-prolonging treatments because they know how it is like. I think that doctors need to improve the way we talk about death with patients, and doctors can be just as guilty as everyone else at ignoring the inevitability of death.
Elephant in the room, related to the article's first point: We have to tackle ageing. Many of the other diseases (cancer, heart conditions etc) and causes of mortality are highly correlated with it.
Heart conditions, for one, aren’t caused by aging - they are caused by being around for a long time so that the slow process of atherosclerosis has time to become dangerous. We need to prevent that process from happening by following standard health advice, really.
For point #4 (about sleep) and point #5 (about delusions) - these are probably related. If you don't get enough sleep you get rather paranoid.
Having been in the ICU with various family members I notice they check on you A LOT and that often will wake you up. This lack of consistent sleep (either from injury, illness or checks) make people rather paranoid. Further, sitting still and waiting often makes people a bit stir crazy.
My wife just gave birth and it was my first multi-night hospital stay. The midnight pokes and checks were infuriating. It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed. Constant nurse changes were difficult too.
On the plus side, I was surprised at the decent quality of food given to my wife. Steamed vegetables and mid grade proteins with every meal.
After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early. Best decision we made and my wife recovered great. With the built in iOS medication reminder app and a blood pressure monitor I was able to manage her just fine.
> After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early.
In my country you don't even stay a single night if everything goes fine. There is no medical need for parents and child to stay at any hospital if there were no complications
Congratulations! We just went through the same thing and decided to leave after one night in post-partum. It's much better to be at home if there's nothing concerning that needs medical attention.
Side note: it was surprising how well the "dad chair" served as a place to sleep after being awake for 24 hours.
> It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed.
Yes, and? You're free to go to the cafeteria and buy food or leave and go buy food. And there's usually at least a chair. What do you expect, a Marriott?
The father is the wife (and baby's) advocate in the hospital, and should leave as little as possible. You need to be there for every test and consultation.
So yah, they should be bringing the father food, and there should be a bed for him because the father is critical in having good care for the wife.
These threads always have lots of people jumping on doctors and their decisions/callousness/lack-of-reason/etc.etc.etc. My wife is a physician (OBGYN) at a major city hospital that primarily serves a very poor population. I'd like to share her schedule, and see if you think what kind of care you could perform under these circumstances:
Monday - Friday
- Wake up at 4:30 AM
- Get to hospital by 5AM to start rounding on patients
- Sometimes work inpatient all day sometimes clinic thrown in, but usually not done working until 7 PM, without even a 15 min break or a chance to eat a meal (15 hour day)
- Come home and do about an hour of notes
- At least once per week, wake up in the middle of the night to deliver a patient who asked for that kind of continuity of care.
Saturday:
- Wake up around 5am to be in by 6am to start the day
- Work inpatient, usually without time for a 15min break for food, until 10AM SUNDAY (28 hours shift)
Repeat 49 weeks/year (days of 24/hr shift can vary and she usually gets one weekend off/month). Her average time at the hospital last year was 96 hours/week.
How much confidence do you have that you'd be able to take care of a complicated pregnancy at the end of a 28 hour shift, having not eaten for more than 24 hours, having 10 other patients on your mind, and having had only a couple of hours sleep the night before? It's no wonder to me anymore to me birth outcomes are so bad in understaffed hospitals in poor areas...
It's kind of amazing anyone chooses to go into healthcare having to work like this. It's the absolute last field I would ever want to go into, even as an engineer who wouldn't need to actually practice medicine. Seems like you need to practically give up your life to save countless others. Your wife, and those like her, are truly performing an innately critical job at an absurd cost to themselves - God bless.
The AAMC should increase the number of students they admit. The average medical school is turning away 95% of applicants. The top 10 schools in America are excepting <2.5%.
Doing this would make the problem worse by increasing the amount of unemployable newly graduated doctors that can't practice because they can't match into a residency program. Medical schools have exploded in number the past few decades compared to the actual amount of residency spots that have been opened.
The limiting factor isn't medical school admissions, it's residency spots. We'd need to increase medicare funding if we want more residency spots.
Conceptually, I'd agree with you. I don't think medicare alone needs to fund residency spots (its just currently tied to the amount of spots last I checked). I'm more concerned about the total number of residency spots.
That is insane. For some reason, airplane pilots have very strict rules about how long they can be in the cabin, how much they must rest, and similar stuff. (Also, they have checklists, plenty of checklist, but medical doctors don't like checklists.)
Even bus and truck drivers have a more sane maximal shifts restrictions.
My wife is a physician who works in a critical care setting. She did not read or approve this post; these are my thoughts as someone who hears a lot about the other side of this environment:
For the most part this seems like a sensible and reasonable article communicating what must have been an extremely difficult situation for the author. In case the author reads this: I'm really glad your dad got better and I know everybody working in the hospital appreciated the amount of patience and restraint it seems like you showed in helping him without being that patient family member who goes off the handle about everything. (There are so many of those.)
Many of the issues the author points out are very real - constantly-rotating doctors, attending disregarding consults once the consult leaves the room, the ICU not being set up for anything but bare survival - all of that is totally true from what I understand. I think, if anything, the author fails to understand how systematic and critical those issues are when he says things like this:
> So, digestive issues, hormonal issues, and mental issues all get short shrift. Basically, if there’s an obvious symptom, a consult will come in to try to treat the symptom. Then they’ll take another test in a day or so, see what happens, and go from there. There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though.
I don't think this is giving the medical practitioners a fair shake here. Doctors do a huge amount of this kind of reasoning and research, even in the ICU. The trouble is often not a lack of reasoning, but a matter of, as with everything else you note, resources. Like you realized, the goal of the ICU is "keep patients alive at all costs, and worry about their comfort once they're able to be alive without our help for a while." Judgments are made with that in mind. It's not that they can't do reasoning about complex problems, it's that spending time on a complex but non-fatal problem means somebody with a potentially fatal problem won't get that time, and that's not what the ICU is for. Anything that can be solved later... will be solved later.
So the real question is not "Why didn't they help this patient with his digestive issues?", it's "Why didn't they move this patient out of the ICU once he reached the point where non-life-threatening digestive issues were relatively of any importance?"
It’s also impossible to infer the logical process from a superficial observation of the tests being done - that would be like inferring the code architecture from what’s displayed on an output device, in rare cases it might be possible, but usually not
The author even mentions that a long term stay like their father’s is rare. A lot of the criticisms are about what is, and I apologize for the expression, an edge case.
As a counterpoint, my experience with my dad being in the ICU was great. They saved his life a couple times when he needed to have his heart paddle-started. And they managed to stabilize him and let him get sleep as much as possible so he could be transitioned out of the ICU. I never once got the impression that anyone was incompetent, or that they were having trouble remembering strategies, reactions to medicine, etc.
But this was Kaiser. Other hospitals may indeed be a shit show.
I wonder if there's a selection effect where on the one hand particularly demanding people avoid Kaiser because of the somewhat impersonal policies and practices, and on the other hand as an HMO Kaiser enjoys a much lower percentage of indigent and high-risk patients, which altogether permit Kaiser to build a system around the 80% instead of the 20%.
It's a tough situation, and I'm glad his father is finding help.
I've spent a fair bit of time in ICU's on both sides. I think the observations and conclusions show misunderstandings. Generally, opinions are not ignored, nurses don't go wild, the patient population makes sense for an ICU, the institutional memory is actually fantastic, etc.
And most importantly: "There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though" This is complete and utter hogwash, borne of a difficult experience.
They key idea is this: in complex cases, doctors have to identify the condition that matters most, and prioritize that. Collaboration is necessary to get the picture and give care, and perhaps to consider alternatives, but it's not how you make decisions.
It's hard to see symptoms ignored or under-treated. But it's very likely that delusions do not make a difference in the patient's recovery, but something like lung surfactant matters most. So everything from fluid intake to drug dosage and activity are direct accordingly. Unless they're symptoms of the main issue, discomforts can be prioritized later after the main issue resolves.
"Identifying the main condition" means understanding the actual insult and the healing process for this patient; understanding how symptoms, labs, and imaging reflect all the conditions i.e., how it presents (and skews labs or self-perception); and understanding how all the interventions may interact with the disease/disability states, from drug interactions to liver and immune-system complications, etc.
It's not uncommon for other doctors and nurses and patient advocates to have some slice of this complex picture, but it's the attending who has it all, and the experience of other cases and knowledge of the underlying conditions and interventions.
And, for the most part, the attending is not responsible for explaining their understanding or reasoning to anyone. They do offer reasons and make records, but there's no place or time or even audience for comprehensive account of why other alternatives weren't considered or followed.
Science, and medical trials, try to isolate single factors to get reproducible outcomes. Medicine in the ICU has to accommodate multiple factors, by focusing on the main disease/healing process and optimizing for that.
As for value to society: good ICU attendings are key to good outcomes for patients and their families. It takes decades to get good. They produce far, far more value than they're paid, largely because they do it as a mission. If they see people, particularly those who enjoyed the benefit of their dedication and service, disrespecting and misunderstanding them, it's likely to dissuade them from continuing or dissuade others from their difficulties.
So complain all you want about digital advertising and go full-disruptive to fossil fuels, but please be very, very careful when attacking health care. Otherwise we'll end up with Russian hospitals where you bring your own materials and pay your friends of friends for side work.
> So, when it comes to prescribing (...) Giving psychiatric medicine “as needed”? Go wild.
This implies a lack of duty of care which is painfully unfair.
As a counter story to this I have a friend of mine who is a _former_ ICU nurse with a gigantic scar on her forearm.
I much later in our relation found out that the scar is from a patient who basically ripped her forearm biting down on it while she was trying to stop him from tearing out a central line in his own neck.
It's ironic that in trying to stop a patient from having a massive central line bleeding she ended up bleeding herself.
Outside hospitals we fail to realize how disoriented and irrational patients can get when coming out of anesthesia or with certain diseases.
So yeah 'as needed' is absolutely right because everyone is entitled to work in a safe environment.
his "go wild" sounds like it's blaming the nurses, which it is partly, but I think moreso he's trying to point that this situation is just pretty awful. Or at least he should be trying to focus on the bigger picture. I certainly don't blame the nurses for showing up to work and trying. But I think we can all see how the 'path of least resistance' and financial incentives also leads us to this 'medical factory' type of treatment of people. And that's not the nurses' problem, that's just all our problem.
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[ 3.1 ms ] story [ 516 ms ] threadWhat a horrible sentiment.
Is it indefinitely sustainable? Not sure. I don’t know if it’s as easy as just extrapolating from recent trends because there may be countless unknowns from biomedical advances to climate destabilized societies to being turned into biological batteries for our machine overlords in the next few centuries.
[1] https://www.healthaffairs.org/do/10.1377/hpb20220506.432025/
[2] https://vbidcenter.org/wp-content/uploads/2021/10/jama_shran...
>In FY 2022, the Department of Defense (DOD) had $1.64 Trillion distributed among its 6 sub-components.
Where are you getting this 767B number?
[1] https://fiscaldata.treasury.gov/americas-finance-guide/feder...
I wonder if that means they're subtracting portions of the DoD budget that aren't technically military operations.
I'm a younger (34) person with substantial healthcare needs (I have MS). Everything is always oriented towards the old, and I also pay taxes that are used to support them while getting nothing in return despite having similar needs.
Do you really get nothing? And who is paying for whose care? You mention taxes, but they've probably been paying taxes even longer. And why do you think health care is a strict quid pro quo anyway? Some of us believe care should be allocated where it's needed, not where it's paid for. Put another way: why is it a problem that they are getting care? Isn't it that you aren't? This doesn't have to be a zero-sum game. If you feel that you're in competition with someone else for care, the problem is pretty clearly that there aren't enough providing it.
Saying others have less right to health care is pretty terrible no matter which way the finger points.
That said, we do care for the elderly because of their vulnerability but we then shit on younger disabled people. Old people can have assets, most younger disabled people can't, and younger disabled people can lose their benefits by getting married. SSA also applies different criteria for disability and makes it functionally impossible to get if you're young enough versus in your 50s or 60s.
I'm frustrated at being expected to extend infinite grace to the elderly when receiving very little/none, despite us being similarly vulnerable. I also dislike that in general our culture takes care of the elderly/gives them their dues without asking them to take up the corresponding responsibility. As a group, they care very little about the future.
After years fighting/voting for better healthcare, very little has been accomplished. So am I just supposed to suffer and accept I matter less than an old person? That's kind of against basic animal survival instinct. My country seems determined to view it as a quid pro quo, including the elderly.
From each according to his ability, to each according to his needs is the only solution for healthcare.
Right now the answer seems to be 'take as much from the young as you can and guarantee them nothing' and that's not sustainable. It's just that most of the young can avoid looking at this reality until they have a health problem.
Absolutely not. The situation is deplorable, and I hope we can get to a better one some day. Fight for all you're worth. All I'm saying is that others who receive care are not your enemies. (Or at least not because they receive care. There's bound to be some overlap.) The enemy is the people within the system who restrict the labor supply, drive up prices for everything else, make arbitrary rules like those you've mentioned, and so on. The politicians and profiteers, not the patients, define that system.
I will never have access to my enemy until there's a critical mass of upset people, and the elderly seem willing to let younger people die of treatable problems as long as they're not effected, so the only way to get them to care and join us seems to be to make them feel as insecure as the rest of us, which sucks.
I believe the elderly have agency and for the ones who are still alive (since of course the people who live to 85+ to begin with are those who didn't have to ruin their health due to poverty and blue collar labor), they've used their agency to say 'we don't care about you'. Which is fine, but then they turn around and get all mad when they're not cared about in return. Either they want to be a part of a community, including accepting the responsibilities, or they don't. They need to stop wanting to have their cake and eat it too.
I don't think the author really meant that to come across as callous as it sounded. Probably just poor choice of words. I'm only addressing it because someone else reading it here might interpret it in more of an "older people stealing from younger ones again" kind of way for demographic or ideological reasons.
ETA: it already happened as I was writing this.
The number of tests people want to run on someone we all hope dies tomorrow is insane.
Note: my mother, not my grandmother, and I have lived that ordeal for several years. Some interaction is still possible, but recognition has been beyond her for a while. As long as she seems to take some pleasure in her surroundings, no matter how dim or muted the signs, you won't catch me framing my thoughts about her in terms of dollars I could save.
The human experience varies wildly and I would not make such assumptions. Caring for somebody without the hope of improvement for years can make you bitter or even resent the person that no longer resembles the one you loved.
And that's OK? I happen to think it's not, that bitterness and resentment hurt everyone involved, and I know that it's possible to resist those feelings. How, exactly, does the person who succumbs get to play Good Guy?
Prolonging that existence is not a kindness in any sense, and I hope you don’t have to go through such an ordeal.
So it’s a lose-lose: the patient suffers and society has to pay for their privilege to suffer (without recourse, most likely).
And maybe you disagree fundamentally with things like assisted suicide. But someone who posts something like what you replied to most likely do not.
> Not about saving money
Then why even bring it up, let alone cite it as something that change[ds] one's views?
> maybe you disagree fundamentally with things like assisted suicide
In fact I do not. There was a time when my mother wanted to end it, and I wasn't the one who stopped her. I respected her right to make her own choice. Her condition subsequently improved to the point where she no longer wished that, leading to the current status quo, but that's already far more than any of the pissants in this thread deserved to hear about it. Expressing one's own wish for a supposedly-loved one to die is indefensible, even if they also wish it for themselves.
Alzheimer’s and dementia are incredibly cruel experiences for everyone involved. There’s no reason to prolong the situation.
Ever hear of the Obamacare death panels? The ones where doctors would decide if your loved one was too old and shouldn’t get treatment?
Yeah. That’s this.
What it really was that Medicare would pay for consultation with doctors (?) to discuss end of life care and setup living wills and DNRs and such if the person wanted.
That way if something happened and they were taken to the hospital they could be treated the way they wanted to be and not stuck in a coma on a vent for the rest of their life if that was against their wishes.
But the Republicans branded then “death panels” (which for political purposes was brilliant). So the choice of having help making those decisions was removed.
If our society really cared for the elderly, they would be integrated and respected, not segregated and shunned. We do the latter because we fear age, sickness, and death. Fear isn't caring.
In the US. It's perhaps the most striking difference that hit me during my stay overseas. In the Old World we occasionally get people completely panicking about their own death. In the US, seemingly _everyone_ is like that.
That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.
> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.
Often it's a 4 week old baby.
For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.
You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.
If I'm in pain, am delirious, and am unable to operate in the world. I've lost my dignity.
My human dignity does depend on whether I have to endure the rest of my life pooping my pants, not remembering my own name, and hooked up to some noisy machine telling my lungs to breathe and my heart to beat.
You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...
https://www.statnews.com/2018/06/28/end-of-life-health-spend...
My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.
Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.
It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.
The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.
Fair enough. But then what do you suggest we do as an alternative to normalizing diabetes and obesity?
To your point - kinda - about losing weight. Changing behavior isn't any easier when there are too few environmental signals to nudge behavior in a more healthy direction. As humans, we are wired to assume the norm we see around us. How do we reverse the tide when abnormal (and unhealthy) has been normalized? When everywhere you look, there are people just like you?
I do agree. Mental health is important. But a component of that is (dealing with) adversity. I'm certainly not condoning repetitive malicious bullying, but the current climate has outlawed any/all references to traits connected with being unhealthy. At this point there are no social deterrents, are we really better off?
Have we robbed Peter to over-feed Paul?
Of course, obesity is a huge issue (especially in the U.S. compared to many other "developed" countries) that can affect people's lives negatively and causes further medical issues such as diabetes, and ultimately can prevent people from leading a life that is as fulfilling and meaningful as they would have liked.
But we are still dealing with people here, not rats in a laboratory experiment, and I think the issues that directly follow from being obese are already bad enough that it does not help to pile on more shame by treating those people as being "weak-willed" or something of the sort, or denying them basic human dignity and respect for being outside the sacred norm. Do we really have to add artificial negative consequences for being overweight? Does that help those people have a more fulfilling and meaningful life?
I don't think people will just forget the direct negative physical/social consequences of being overweight by not being reminded of them all the time in a moralistic tone (and even just reminding people of such information can be moralizing, depending on the context in which the information is provided).
What's worse is how much of Medicare's wasted spending goes to harmful treatments.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:tex....
You could give a lot of people medical treatment with a proper healthcare and tax system. Why don't we try that first?
30? or 21, if you prefer the book ;p
You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.
Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.
Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.
Now we've moved back toward "birthing centers" which focus on the mother and the baby; perhaps it is time for something similar to grow across all aspects of care.
And women are still giving birth lying down, fighting gravity, for the doctor’s convenience.
After ACL reconstruction surgery many (~30) years ago, I was required to stay overnight due to both the general anaesthesia and the lateness (late afternoon) of the procedure.
I had a similar experience with the nurse coming in every two (2) hours to take my vitals. I was trying to sleep, but she kept waking me up. I groused about wanting to rest, but was informed (direct quote) "this isn't a hotel!"
And it's not. Rather it's a money printing facility for the owners of the health care system that runs the hospital.
Consider asking nurses to stop administering it after you do your own research.
https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details#...).
Came out 3 hours later with an xray that showed nothing wrong and a bottle of Ativan. Still no idea why they gave that to me. I didn't take any of the pills.
And the bill came out to over 7 thousand dollars.
* The aftermentioned lack of sound sleep
* Anesthesia
* Painkillers
In the case of my grandmother, hallucinations and incoherence lasted about three months after she was home. My mother's lasted about 2-3 weeks. It was scary. They both eventually recovered. But it is true that nobody in the hospital bats an eye when acute dementia-like symptoms are mentioned. "It's normal," they say.
There's lots of levers that could be pulled in the US. Cut down on undergraduate requirements, incentivize large health systems to fund more training (people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything).
Medical care suffers under the bizarre idea that central planning and capacity management will control costs. Meanwhile, costs are spiraling up and up and up. Train more doctors and all the stupid games being played to optimize their utilization start to go away, because it is less worth it when demand is less than supply.
Had a cousin and a friend (both I would characterize as smart and hard working) take several years after undergrad and eventually “settle” for physicians assistant schools.
Is it? Is there a study demonstrating the correlation to pre med test scores to patient outcomes?
It just strikes me as something that wouldn’t be particularly hard to answer with a detailed study, and probably is a pretty high value question to answer, so I wouldn’t be surprised if there was a study.
Maybe I’ll poke around this weekend
This is the reason: as soon as the medical industry has established a consensus price for some procedure or other item of care, the hospital administration starts to work on figuring out how to do it for the least possible cost. The price has been set in stone, no need for further justification. Medicare or whoever WILL pay that much. The price is fixed so the only knob left to turn is cost, and cost will be reduced all the way down, until service is just above a level so poor that patients would decide to stay home.
I anticipated your argument in my other comment...
https://www.theatlantic.com/ideas/archive/2022/02/why-does-t...
Agreed, but I would go further and say that if demand by students for the training provided by residency exceeds the demand by hospitals for the work provided by residents, I don't see why residents couldn't pay for their training just as they do for medical school. The whole "residency funding" thing seems like a red herring as an explanation.
To be clear, I'm not saying that medical graduates should have to take on more debt to pay for residency, but rather that the reason this doesn't happen is not obvious according to typical economic reasoning.
The below article on how awful medicine and medical school are was written a decade ago and nothing has gotten better. People really like social status.
https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...
Knowing these people, I also get the feeling that if pay were worse / debt was higher they would have pursued alternate careers. If your goal is to make more physicians you don't want to make the job less desirable. There are already paid residency positions that go unfilled every year (not because there arent enough students, but because the students dont want them). I don't know why you think people would pursue positions that they have to pay for.
To your other point on the intense competition: If half the people currently applying to medical school quit applying the quality of your average future doctor would drop.
A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.
The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.
We don't need better outcomes. We will happily take the existing outcomes but cheaper.
Yes there's no undergraduate major named "premed". There's no need to be pedantic. But US medical schools generally require a 4-year undergraduate degree (BA or BS) and certain coursework (biology and chemistry, among others). [1][2]
> will somehow lead to reduced healthcare costs
And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.
1. https://www.shemmassianconsulting.com/blog/medical-school-re...
2. https://www.hopkinsmedicine.org/som/education-programs/md-pr...
It's "controversial" because you are conflating two issues.
Shortening the path will at most lead to a very minor supply increase at the time it is implemented; the gains don't compound. Without increasing the total number of admission spots (or more critically, residency slots), the overall supply will not be meaningfully increased.
Removing a prerequisite (bachelor's degree; which I point out in another comment is not actually required at many schools) is generally unrelated to the supply of US physicians and this is why you're getting pushback.
> the gains don't compound
You give doctors, on average, an additional 2 years of their life to practice medicine instead of spending them in college on a pointless degree (not to mention, slightly lower college debt when starting out). Multiply that over however many doctors we graduate every year, and it'll add up over time. It's not "compounding" in the mathematical sense of the word, obviously. If you assume that a medical career is about 35 years, that's like an 8% increase in available doctor-years over 35 years (or something like that - the math is a bit handwavy). Without doing literally anything else.
I saw your other comment about degree requirements and I'll respond here. In addition to the consulting website, I also looked at Johns Hopkins and they do have a degree requirement. Thanks for providing that counter-example. I wasn't aware and I'll update my understanding of this.
However, your own source said "a baccalaureate degree...is strongly preferred". So it has to be asked - how many non bachelor's degree holders actually get into med school?
Every US-trained doctor I've had has gotten a bachelor's degree (I read bios when they're available). The ones that don't were foreign-trained. If the number of med school applicants greatly exceeds the spots, I'd imagine nearly all serious applicants are going to get a bachelor's degree to improve their chances. It sounds like you're a doctor - what proportion of people in your class got in without a bachelor's degree?
Source for this? That's surprising to me and a brief Google search tells me the exact opposite.[1]
You really don't understand how reducing the number of years it takes to train a doctor, after they complete high school, will lower healthcare costs? Are you unfamiliar with supply and demand, or the relationship between the cost of production and pricing?
1. https://www.shemmassianconsulting.com/blog/medical-school-re...
> Every U.S. medical school requires the completion of a four-year degree from an accredited college or university.
However, if we look at the University of Chicago's Pritzker School of Medicine as just a single example [1] we see the following:
> "A baccalaureate degree is not required but is strongly preferred by the Admissions Committee."
Given that your reference, "Shemmassian Consulting", appears to be low-quality given that it makes categorically false statements, I won't bother to search for other schools. Suffice it to say that I am aware of quite a few, including my own, that do not require 4-year bachelor's degrees.
Finally, I understand supply-and-demand quite well, and I agree that increasing the supply of licensed US physicians may decrease healthcare costs (but it may not, as excess dollars in the system likely will be vacuumed up by administrators). However, this discussion is about decreasing entrance requirements to medical school, which is completely orthogonal.
[1] https://pritzker.uchicago.edu/admissions/entrance-requiremen...
The author's dad was being seen by a variety of highly trained specialists all working to treat him, but "people need to sleep" seems to be a recent discovery in the ICU world, and if his family hadn't been there to help, every new nurse would have tried to give him the same medication that gave him a bad reaction, over and over, just because there wasn't an established place to write that (obviously important) information down.
I've read that food with better nutrition than regular hospital food may reduce mortality rates by as much as half [0]. That's such a huge effect that it's shocking that hospital food is just expected to be bad. Everyone says nutrition is vital for health, but hospitals don't seem to care.
I think the root problem is cost-cutting. Management cuts costs until the brink of disaster, and tries to hold it there for as long as possible. This is not a system that strives for the best outcome for patients within reasonable limits of the resources available; this is a system that attempts to extract as much value as possible from the patients, and patient death is only prevented as a means to that ends.
[0] https://www.sciencedirect.com/science/article/pii/S073510972...
The training doesn't really matter. Context is very important as is caring about doing a good job. You'll find a severe lack of both in hospitals. You eventually have to stand up and defend yourself against bad healthcare... or search endlessly for good healthcare which is terribly difficult to find.
For the average person healthy food usually means food with fewer calories and more micro-nutrients, like eating more broccoli and less white bread.
This study is about malnourished patients who need more calories than they can even digest from an average meal so they need specialized high-calorie foods that are customized for their own metabolism. It's essentially exactly the opposite of what "healthy food" means in any other context.
So it has nothing to do with any narrative about cost cutting and the quality of ingredients used in hospital cafeterias.
But I think that is missing the forest for the trees, what this study showed is that when a patient is left on their own, they consume an inadequate diet that _puts their health at risk_ in a hospital. By a big margin!
I would imagine, though the study didn't show this, that the primary factor in recovery here was having a human (dietician) actually paying attention to your recovery. On intake they put together a plan, and followed up routinely to ensure that the patient has consuming their diet.
The GP's point is valid, hospitals are missing out on a 50% increase in health outcomes because they're letting patients fend for themselves with regard to nutrition. You're right that it isn't as easy as spending $6 per meal vs $3 to buy "better" food. But what it means is that hospitals are failing their patients because they aren't thinking and acting with a holistic eye towards patient outcomes.
Sleep is almost impossible with regular check-ups... 30 min or 60 min, don't remember. Excepting the comatose and most medicated(maybe not?), a person's sleep cycle is unable to reach REM when a stranger approaches and fiddles on regular intervals. I would think monitoring from afar(sensors, cameras) would be more beneficial, but I was informed the liability factors preclude such remote monitoring.
edit: to add context, I slept in the room on separate occasions with 2 family members. While tests were not performed, the regular checks were mandated. I was exhausted after my shifts ended.
This makes sense for someone who might be in there for weeks, but I was barely there overnight!
During the night, it would drop to 40 (which is still fine), but sometimes below 30, at which point my heart monitor would blare an alarm, waking me up and scaring the absolute bejesus out of me, raising my heart rate immensely. A nurse would walk in, see that I was fine, and leave again.
This occurred nightly for a few days.
Most people just don’t give a shit outside thier immediate responsibility.
Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task.
Many people who do give a shit get this crushed out of them early in their career by the negativity you will face if you try.
Much easier to just accept the status quo.
Occasionally you get a group of people who really care and come together determined not to let things be crappy and they can form an organisation that is significantly more effective for a time. But once the rot of “We can’t fix things” sets in, it’s really really hard to turn things around.
A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!
This is the type of stuff I have a gripe with. Sinecure and fiefdoms of power.
Fiefdoms of power - nursing union not wanting to give up the night shift premium pay when the job description changes to monitoring a screen and half the physical workload vs. day shift.
Stanford Healthcare recently installed a system where all alarms/notifications get sent to a hospital assigned device the nurse carries rather blasting in the sleeping patients room as 90%+ are false alarms (aka IV or SpO2 sensors).
The real issue is that hospital technology is outdated and most places don’t have the option for this level of telemetry.
I’ve never been told / instructed my staff to “be near the patient at all times”.
In fact, most places have 1:8 nursing coverage on the ward…
1. I used the possessive “my” in reference to nursing staff for simplicity in writing and clarity to the reader rather than to indicate ownership, we are on a team. This is akin to saying “my goalkeeper wears Nike soccer cleats”.
2. I do not “order nurses around.” I verbally communicate and leave medical orders in the chart that nurses act on. It is not about a power struggle, we are all trying to do our jobs and do what’s right by the patient. I’m grateful when nurses question my medical orders (as long as it’s a positive/educational discussion, which it is 99% of the time) as they catch my mistakes and we all learn together.
If you are concerned that you can’t order nurses around, I strongly suggest reflecting on whether this leadership style is the most conducive to providing quality patient care as this can increase barriers and hostilities in the workplace resulting in communication breakdown and adverse events.
If nothing else, you either take the blood pressure the normal way with a pressure cuff, which is going to wake you up. Or you put an intra arterial catheter, which reads continuously without bothering the patient, but has a small risk of damage to the vessel, infection etc
Again, this started before Covid, the pandemic just highlighted how much these cuts screwed over both healthcare professionals and patients.
On the other hand, subsequent hospital visits (non-ICU) were a cluster fuck. Noise, lights on, nurses constantly waking my parent up, could-care-less doctors, etc. And getting healthy enough to be transferred to an extended care facility was a shit show. It's was like the hospital but worse. Both experience seemed to have little to do with health and recovery.
My point is, the article author is in for a shock once his dad gets out of the ICU and into the "general population". I can't imagine that's going to be better than the ICU. I hope I'm mistaken.
My take away from this experience is:
1) Make choices that maximize your health the best you can.
2) If you can, be rich - like fuck you money rich. The kind of rich where your "general population" hospital experience will be like being in the ICU.
This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...
...to fix it, and being satisfied. What I want is something like in the television show House. The main character is unhinged and anti-social and takes extreme risks, but at least he demonstrates curiosity to really figure out and understand the root of what's going on. To be fair, I don't actually think that doctors lack curiosity or are incapable of doing this, the medical system as it's set up just doesn't allow it. For chronic issues, I've usually figured them out for myself, as a layperson, by persistently keeping track of things, searching the web, reading, and experimenting over months and years.Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".
It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.
Also I'm not kidding but I would LOVE such a show.
Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.
New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.
People really don't understand the dire and primitive state of current medicine.
We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.
If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.
What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.
You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...
As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.
I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care
> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).
https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/
I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.
Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.
Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.
I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.
12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.
I am a bit biased because I have several medical professionals in my family, but a common refrain is definitely that most doctors/nurses aren't going to be that engaged and helpful, and are more of a input/output device to navigate rather than someone you want to completely defer to.
GP orders test. I go to a test center to get the blood drawn. They have couriers taking samples to labs a few times per day.
The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).
[0] https://www.lesswrong.com/posts/fFY2HeC9i2Tx8FEnK/luck-based...
Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.
For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.
To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n.
Looking through <https://en.wikipedia.org/wiki/Numero_sign#Usages>… hmm, French AZERTY? I see now that it does have ° readily accessible.
I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.)
P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.
Creativity also has a role for non-critical conditions when standard treatments aren’t working.
I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.
House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.
House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.
Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".
In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.
One thing that this article touches on, but I think needs to be emphasized even more is that the stark reality is that the only advocate for the patient is the patient themselves, or perhaps a caretaker.
The burden is on me to ask questions about fertility and sperm banking because my oncologist is well... an oncologist not a fertility expert. I have to ensure that every department is communicating with every other department.
Hospitals and physicians are fantastic at solving discrete issues, but the bigger picture is often lost in the chaos. I can do it as a technically adept 34 year old, it's horrifying to think about how someone closer to 80 goes about it.
I had family there to advocate for me, but there's no way in hell I would have been able to advocate for myself. I was literally seeing things around me in the ICU room that didn't exist. My family were probably the only ones that realized that that wasn't the real me.
The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery, and I have full working memory of that normal patient room.
To be fair (and this is also true for the article itself), it might be difficult to distinguish cause and effect here. Being moved into less intensive care means that you are more stable which might lead to other issues becoming better in the following days regardless of whether you are in the ICU or not.
[1] https://www.zocalopublicsquare.org/2011/11/30/how-doctors-di...
Having been in the ICU with various family members I notice they check on you A LOT and that often will wake you up. This lack of consistent sleep (either from injury, illness or checks) make people rather paranoid. Further, sitting still and waiting often makes people a bit stir crazy.
On the plus side, I was surprised at the decent quality of food given to my wife. Steamed vegetables and mid grade proteins with every meal.
After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early. Best decision we made and my wife recovered great. With the built in iOS medication reminder app and a blood pressure monitor I was able to manage her just fine.
In my country you don't even stay a single night if everything goes fine. There is no medical need for parents and child to stay at any hospital if there were no complications
Side note: it was surprising how well the "dad chair" served as a place to sleep after being awake for 24 hours.
> It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed.
Yes, and? You're free to go to the cafeteria and buy food or leave and go buy food. And there's usually at least a chair. What do you expect, a Marriott?
So yah, they should be bringing the father food, and there should be a bed for him because the father is critical in having good care for the wife.
Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to start rounding on patients - Sometimes work inpatient all day sometimes clinic thrown in, but usually not done working until 7 PM, without even a 15 min break or a chance to eat a meal (15 hour day) - Come home and do about an hour of notes - At least once per week, wake up in the middle of the night to deliver a patient who asked for that kind of continuity of care.
Saturday: - Wake up around 5am to be in by 6am to start the day - Work inpatient, usually without time for a 15min break for food, until 10AM SUNDAY (28 hours shift)
Repeat 49 weeks/year (days of 24/hr shift can vary and she usually gets one weekend off/month). Her average time at the hospital last year was 96 hours/week.
How much confidence do you have that you'd be able to take care of a complicated pregnancy at the end of a 28 hour shift, having not eaten for more than 24 hours, having 10 other patients on your mind, and having had only a couple of hours sleep the night before? It's no wonder to me anymore to me birth outcomes are so bad in understaffed hospitals in poor areas...
I have seen administration do some blatantly illegal shit around physicians with COVID, but I don't want to write that up here.
But yeah, there's a good reason why suicide rates are so high for doctors...
Accepting
The limiting factor isn't medical school admissions, it's residency spots. We'd need to increase medicare funding if we want more residency spots.
Even bus and truck drivers have a more sane maximal shifts restrictions.
For the most part this seems like a sensible and reasonable article communicating what must have been an extremely difficult situation for the author. In case the author reads this: I'm really glad your dad got better and I know everybody working in the hospital appreciated the amount of patience and restraint it seems like you showed in helping him without being that patient family member who goes off the handle about everything. (There are so many of those.)
Many of the issues the author points out are very real - constantly-rotating doctors, attending disregarding consults once the consult leaves the room, the ICU not being set up for anything but bare survival - all of that is totally true from what I understand. I think, if anything, the author fails to understand how systematic and critical those issues are when he says things like this:
> So, digestive issues, hormonal issues, and mental issues all get short shrift. Basically, if there’s an obvious symptom, a consult will come in to try to treat the symptom. Then they’ll take another test in a day or so, see what happens, and go from there. There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though.
I don't think this is giving the medical practitioners a fair shake here. Doctors do a huge amount of this kind of reasoning and research, even in the ICU. The trouble is often not a lack of reasoning, but a matter of, as with everything else you note, resources. Like you realized, the goal of the ICU is "keep patients alive at all costs, and worry about their comfort once they're able to be alive without our help for a while." Judgments are made with that in mind. It's not that they can't do reasoning about complex problems, it's that spending time on a complex but non-fatal problem means somebody with a potentially fatal problem won't get that time, and that's not what the ICU is for. Anything that can be solved later... will be solved later.
So the real question is not "Why didn't they help this patient with his digestive issues?", it's "Why didn't they move this patient out of the ICU once he reached the point where non-life-threatening digestive issues were relatively of any importance?"
I noticed that the incessant beeping all night has decreased quite a bit, of late (at least in my local hospital, St. Francis Heart Center)
But this was Kaiser. Other hospitals may indeed be a shit show.
I've spent a fair bit of time in ICU's on both sides. I think the observations and conclusions show misunderstandings. Generally, opinions are not ignored, nurses don't go wild, the patient population makes sense for an ICU, the institutional memory is actually fantastic, etc.
And most importantly: "There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though" This is complete and utter hogwash, borne of a difficult experience.
They key idea is this: in complex cases, doctors have to identify the condition that matters most, and prioritize that. Collaboration is necessary to get the picture and give care, and perhaps to consider alternatives, but it's not how you make decisions.
It's hard to see symptoms ignored or under-treated. But it's very likely that delusions do not make a difference in the patient's recovery, but something like lung surfactant matters most. So everything from fluid intake to drug dosage and activity are direct accordingly. Unless they're symptoms of the main issue, discomforts can be prioritized later after the main issue resolves.
"Identifying the main condition" means understanding the actual insult and the healing process for this patient; understanding how symptoms, labs, and imaging reflect all the conditions i.e., how it presents (and skews labs or self-perception); and understanding how all the interventions may interact with the disease/disability states, from drug interactions to liver and immune-system complications, etc.
It's not uncommon for other doctors and nurses and patient advocates to have some slice of this complex picture, but it's the attending who has it all, and the experience of other cases and knowledge of the underlying conditions and interventions.
And, for the most part, the attending is not responsible for explaining their understanding or reasoning to anyone. They do offer reasons and make records, but there's no place or time or even audience for comprehensive account of why other alternatives weren't considered or followed.
Science, and medical trials, try to isolate single factors to get reproducible outcomes. Medicine in the ICU has to accommodate multiple factors, by focusing on the main disease/healing process and optimizing for that.
As for value to society: good ICU attendings are key to good outcomes for patients and their families. It takes decades to get good. They produce far, far more value than they're paid, largely because they do it as a mission. If they see people, particularly those who enjoyed the benefit of their dedication and service, disrespecting and misunderstanding them, it's likely to dissuade them from continuing or dissuade others from their difficulties.
So complain all you want about digital advertising and go full-disruptive to fossil fuels, but please be very, very careful when attacking health care. Otherwise we'll end up with Russian hospitals where you bring your own materials and pay your friends of friends for side work.
This implies a lack of duty of care which is painfully unfair.
As a counter story to this I have a friend of mine who is a _former_ ICU nurse with a gigantic scar on her forearm.
I much later in our relation found out that the scar is from a patient who basically ripped her forearm biting down on it while she was trying to stop him from tearing out a central line in his own neck.
It's ironic that in trying to stop a patient from having a massive central line bleeding she ended up bleeding herself.
Outside hospitals we fail to realize how disoriented and irrational patients can get when coming out of anesthesia or with certain diseases.
So yeah 'as needed' is absolutely right because everyone is entitled to work in a safe environment.