Throwaway05
15hr ago
or because he's the old-fashioned type.
Low-key I prefer it most of the time because if the pharmacy is out of whatever the patient can just roll to the next one. Clearly I am positively geriatric.
actual content
Okay soooooo
Puts on attending hat.
This is eventually going to become part of your bread and butter - you should feel very certain that amphetamines of all kinds are better than methylphenidate (or not!) and eventually be familiar with the considerations for use of one or the other (especially since it impacts your own personal life).
You should also stop reading Scott for these things, he writes for lay people and in a very entertaining way, but you have the toolset to actually do a lit review and deal with the less engaging/more scientific writing.
This is going to be important for a few reasons, one is that Scott often elides some of the practical concerns that we need to know about (like actual availability, as you ran into) and he cues into very specific old evidence bases at times which is fine for what/who he writes about but misses new innovation (lets see.....psych example....how about the conversation about Trazodone as a sleep aid?) and importantly isn't necessarily the standard of care - your attendings, billing processes, and potentially malpractice attorneys (yes yes UK) are going to look at you funny if you take him seriously.
He also has a tendency to miss or underemphasize some of the research errors (some spotted in this article! What they are is left to the learner lol).
IIRC Vyvanse is now generic in the U.S. but in short supply (as is basically everything else for ADHD), I don't know what it is like in the UK but for my money it is almost always the better choice if the patient can get it and afford it. Being a prodrug presents a ton of advantages and I'm mildly irked at the way Scott is minimizing it.
Very much my choice for "if my family member asked me what to get for ADHD I'd say try this first..."
Caveat: like all doctors I have my things I am very insistent and convinced about, others may not agree.
Throwaway05
1d ago
Y'all don't have eprescribing in the GB?
Also why no Addy (or better yet - Vyvanse).
Throwaway05
2d ago
One of the worsts parts of the extremism of wokeism (and #MeToo is the best example of this) is the way it enables people with mental health problems (especially Borderline Personality Disorder) to engage in the worst parts of their mental illness totally unopposed.
It's not good for them, it's not good for their victims, and it's not good for society.
Throwaway05
4d ago
Sir. On no day is neuroanatomy slide flashbacks on my dance card.
Easily the worst part of the entire run of medical education, I'll even take a surgical 36 over that shit.
Throwaway05
4d ago
Thank you for dragging me back to med school.
Throwaway05
4d ago
KG House: Keeping a gaming house.
VG House: Visiting a gaming house.
Hah!
This gives me mental images of some twitch streamer getting raided.
Throwaway05
5d ago
If you've ever tried to manage people in a large and complicated setting like a concert, a mass causality event and so on you know it's extremely hard to triage these sorts of things and get them to the right people. Even something as self-contained as running a single patient trauma or a two pilot aircraft can result in poor communication and distribution of information.
Consider how easy it would be to mentally write this off as "oh yeah that's one of the police sniper teams."
Now if you have one organization that should have a plan for how to handle "tips" like this and not fuck up like this it should be the secret service - but that's incompetence not malice.
Throwaway05
6d ago
There's actually a practical use here. Certain populations (two big examples in the use: inner city black men (see: "down-low" culture), and the prison population) will have sex with men and never ever say they are homosexual. In the case of the convict side of things they'll often never have sex with men outside of prison.
Awareness and use of this information ends up being relevant for certain kinds of health screening.
Throwaway05
23d ago
I think their is some truth to this but I also saw a lot of people saying things that amounted to "well if I can't provide abortions than I'll just leave the state and leave their mothers/babies to die" which suggests their is some mean spirited and political aspects to the whole thing.
Although, in support of your point (incoming vagueness because OPSEC) I was talking to a prominent medical ethicist a few months ago and he was telling a story about how he was doing something in two different states with mutually incompatible laws, and reached out to the state AGs for both to ask which situation took precedence (ex: when the patient calls the doctor from one place but the doctor is in a different state). Shocking both of them said "our rules!"
Nobody knows what would actually happen unless you run afoul of something and it actually goes to court, but actually following the rules is at times inadvisable and awkwardly at times outright impossible.
Throwaway05
23d ago
And in the case of the doctors and anti-abortion laws, it really feels like you're doing the thing so many people do where they assume they live in the "most convenient world" for their worldview. Like, how convenient that anti-abortion laws would never lead to any negative outcomes ever, if not for malicious compliance on the part of doctors.
Am doctor. Spend a lot of time here defending doctors.
The level of overreaction and fear mongering from the relevant physicians on social media was profoundly immense, these people are grossly ideologically captured, and I could absolutely see them letting someone die because of it.
Throwaway05
25d ago
Everyone points fingers at a variety of things but physician salaries are under ten percent of spending. A massive drop in doctor salary only gets you 3-4 percent less expensive healthcare.
The AMA historically was engaged in what you are talking about but then spent multiple decades lobbying for increased role for midlevel providers which is a de facto supply increase. It's finally moving away from that in the last few years but has yet to find a new passion lol.
Historically the limiting factor on doctor production has been residency spots which are mostly funded by the government, however plenty of states and private corporations will fund those spots because the labor is dirt cheap and they actually make a ton of money.
Additionally ability to increase spots in the higher paying/lower number specialties is limited because you need enough work to adequately train and all kinds of things have caused problems with that (ex: a reduction in surgical frequency secondary to an increase in medical technology meaning not enough cases). Lower paying specialties like FM and Peds have more room to grow but nobody wants to do them because of the poor (relatively speaking) pay.
Throwaway05
25d ago
A big piece of it is admin bloat, just as in academia the number of middle managers and other folks like that (assistant infection control nurse - whose job is to make sure we don't order any labs that may show signs of infection!). Also more general middlemen/industries of various kinds.
Examples: PBMs, billing staff, EMRs.
If you look at a surgery a small fraction of the cost is the surgeons professional fee - yes lots of labor costs but thats because their are literally scores of people involved. Supplies, instruments, equipment....all places where someone could be greedy (see: ortho vendors).
Executives in healthcare are increasingly MBAs or nursing and often have authority over the doctors that can lead to both increased cost and decreased quality (see: travel nursing).
Doctor supply issues may be a problem but they are pretty orthogonal to the overall cost disease problems.
Throwaway05
25d ago
- Healthcare:
Destroy the AMA’s supply-limiting bullshit, dramatically increase the number of doctors, dramatically decrease cost of healthcare.
Reminder that physician salaries are a low percentage of healthcare expenses, that the AMA has nothing to with supply restriction, spots can be expanded by local governments and hospitals (and have been!), and that the AMA has been lobbying for a supply expansion for decades.
Throwaway05
1mo ago
but a danger to her career by way of voluntary association
This sounds similar to that one scene at the beginning of Cryptonomicon (granted it's been a few years since I read it).
I think even at the time people knew what was up if they wanted to.
Throwaway05
1mo ago
Yeah you made do with what you had which was wise, but next time you are in a country where you can get a real one do so!
Cold cuts have a surprisingly high quality ceiling, and cheese is something that can taste incredibly different depending on what you got.
Throwaway05
1mo ago
There's a few layers of problems here.
First:
Yes I need to acknowledge that a lot of medicine is guess work and throwing up our hands and going "this makes sense" or "anecdotally this works." This is because proper research is extremely expensive, difficult, and is often unethical to do correctly (a lot of research in Peds is just not performed because nobody wants to test shit on kids). We do have things that we have really good quality research for, or know with a good deal of certainty. Medicine has some of the strongest validated research evidence and some of the weakest. It is totally a shit show and it's important to acknowledge that.
Second:
Again most medical care is centered around reducing mortality and morbidity. Optimization is considered less important and rewarding but it is what most people want since most people aren't actively dying at any given time.
Third:
Optimization is orders of magnitude more complicated. Individual genetics, lifestyle, life history, gut microbiome and so on radically impact the effect of these types of interventions. You'll see vegan or paleo diet advocates, touting the general wisdom of something that may have worked for that specific person. We don't have the research base and money for too much personalized medicine at this point which is a weakness of ours but any of this type of evangelism is fundamentally worse since people are bad at nuance and anyone involved in fad diets or whatever has a tendency to be extremely bad at "try it for a little bit and see if it works for you" type preaching instead of "behold, this is magic."
Fourth:
As alluded to above some people are capable of responsibly using this type of information, but by the numbers most people (or just enough) who get into "alternative medicine" (or however you want to label it) decide to abandon traditional medicine, and that includes the wealthy, intelligent, and educated. A common path is starting on a "fad" intervention and then just refusing mainstream medicine leading to future poor outcomes which can be extremely disturbing for the patient and care providers. This also makes most of us reflexively hate this shit which isn't productive but is the reality. Most people who are suffering are very willing to engage in black and white thinking and assume that mainstream medicine doesn't have much to offer them if this other plan helps with relief.
Vaccine refusal is a parallel - there's some nuanced discussion to be had on the COVID vaccines but any doctor who has seen a kid avoidably die from measles is going to want to put an anti vaxxer into a woodchipper because in their head it's the same crowd that is letting kids die.
Fifth:
One of the reasons for the difficulty in good research for this stuff is subjectivity vs objectivity. "I don't feel right" is a lot harder to chase, scale, and improve than "my blood pressure/sugar is elevated." This also means that the placebo effect and psychiatric impacts are extremely important and in all honestly might predominate.
People don't like to be told "this only works because you think it does" or "no there's nothing physically wrong with you it is a complicated psychiatric problem" but the reality is that many things are like this.
Unfortunately POTS is a good example, as is CFS/EDS/Long-COVID. People do appear to really have these diseases but the vast majority of people who say they have them, don't. This is magnified because of the importance of patient reviews and lack of time to actually speak to patients. Your doctor might be sitting in the back room going "yeah no way does this chick have POTS, but I don't have time for this fight so whatever I'll go along with it" and of course the fact that the physical and psychiatric side of things are tightly linked together doesn't help anything.
Ultimately almost all symptoms of these kinds of things (examples: tiredness, weakness, sleep problems, concentration problems) are equally or better explained by just depression/anxiety and are known to be symptoms of such. Treat the depression adequately and they go away, but identifying the issue as medical is more ego-syntonic and often impairs recovery.
You also see patients identifying as having ADHD because they can't concentrate and its really depression, bipolar, or personality and they refuse to acknowledge it but ADHD seems like a "better" disease to have and importantly has a clear treatment.
For a wildly different example: aging men demanding testosterone because they are feeling symptoms of aging or unhappy with their life course. It's not wise, but people refuse to not pursue it.
Fundamentally PEOPLE (all people) aren't really psychologically equipped to navigate these sorts of things in the modern world and it adds an enormous layer of complexity to the proceedings.
Sixth:
Assuming the previous point didn't turn you off the next layer is the assumptions of the math brain type person. If you've seen me post here before or on my previous account on Reddit you'll have seen me going at it with a bunch of hard science/math/finance people about how hard medicine is. People used to working in fields with way less ambiguity struggle to understand the realities of health and medicine (and research on the same). Your code runs or does not, the $$$ goes up or down. Why can't you turn medicine into an algorithm just like in our fields?
Medicine is an art as much of a science, translating what patients are actually saying, interacting with patients, figuring out how to interpret p-hacked and clearly biased research, navigating legal environments and regulatory burden all make the field way more complicated and subjective than you'd expect from something that seems to so firmly abut hard science.
Epistemic certainty on the vaguer things is going to therefore be shitty as hell.
Seventh:
Okay so what does all of that boil down to?
I have no idea if what you are doing is working because you think it's working, because it's turning some corner psychologically, or because it is doing something biochemically useful for you. I have no idea how likely it is that it would work for you specifically and you just got lucky.
Nor do I really care, and perhaps you shouldn't either. If it makes you feel better than power to you!
You just have to be careful and have some insight. Still get regular medical care. Don't overdo it. Don't do it if your medical status changes in some way that makes it unsafe.
B-vitamins are pretty benign but lots of people end up overdosing on some supplements.
Is your improvement really for the reason you think it is? Probably not...but maybe? However because actually verifying that is nearly impossible it isn't something we can reasonably roll out as population level advice.
I'll leave you with one final example - one of the common ways to hack research studies for novel psychiatric drugs is to take advantage of improvement in an inpatient setting. Turns out that being checked in on and cared for every day, being surrounded by peers and social opportunities, and getting regular therapy makes people feel a lot better. Do these things and dump a new psych drug on them and they'll get better! But uh, not clear it really is the medicine doing it.
Throwaway05
1mo ago
...you know that anecdote makes me wonder if another interpretation of the reality distortion is just nerds being shocked to interact with someone with actual charisma.
If you've ever met with someone high level (especially while young and impressionable) it can be quite stark, your ego gets totally consumed and you just go along with it (and for some people it's not even temporary).
Throwaway05
1mo ago
Sure thing. Quick tl;dr about chiropractors is that I had one and just found another one that was around $40 for an adjustment, so to go from moving gingerly because back pain to just a little soreness and full range of motion when I need it is worth that and then some for me when I need it.
Just keep em away from your neck lol.
Jobs
Hmmm you make a good case.
I think the counter argument would be going all map vs. territory invalidation and then pointing out that their didn't seem to be much functional impairment, but that's to some extent luck given the way Apple went and the obvious retort is "avoidable cancer."
I guess he does pattern match to "tortured genius artist" types, and outside of obvious bipolars that's gotta be cluster-b.
Throwaway05
1mo ago
RE: Chiropractors.
They can do some useful and real stuff but from everything I've seen everything they can do that is "real" is encompassed within the scope of practice of PTs and DOs doing OMM. And with much lower risk of random BS or ya know, sudden death.
RE: Jobs.
It's interesting you bring him up in that context, I was just thinking the other day about Trump and how he seems to exhibit a level of resiliency that is inconsistent with the way NPD seems to manifest itself. Obviously you could label him with some of the traits but everyone can get that accusation at times. So back to Jobs, the level of functional impairment in those two means they probably don't meet formal criteria...and then that makes me have a think about what kind of things pull people out of a formal disorder. In Jobs case maybe he that BPD brain but is absent the life history that manifests it in a clinically significant way? Or just that the visionary thought patterns and reality distortion stuff are correlated in some way?
This whole line of thinking isn't fully fleshed out but if you've got some thoughts, please share.
Throwaway05
1mo ago
You did a great job!
You can google some "official rules" but given your location that has no culture for this I have two thoughts.
-
A big chunk of this is aesthetics. If it photographs well you did your job (and personally I think yours does, but it is subjective!). Nerdy optimizers aside most people are just going to take a photo, share it on social media, and then devour the thing.
-
Use what's available. Don't use low quality salami because that's all you have. It's pretty common to use some fruit and a jam or something. But you aren't going to have access to Harry and David pears so don't try.
In America most of the time we use more of a variety of cheese and crackers but again use what you got. I have no idea if you can find an Italian specialty store in India that has some real cured meats but if you can that is the way.
Throwaway05
1mo ago
Same, I hear the way everyone talks about it and feel like I'm missing out on one of the great gaming experiences but.....I can't.
Throwaway05
1mo ago
Yeah. Unfortunately all this is not a theoretical problem, or annoying but harmless - seeing people come in with completely avoidable but fatal disease because they were led astray by alternative medicine isn't every day, but it is extremely common.
For some reason these people have no liability and it's nearly enough to make me want to fedpost.
Throwaway05
1mo ago
Haven't heard of him, but looking at it briefly looks like total quackery as per usual.
Here's why.
- Most of this stuff (and this is pattern matching accordingly) is not really "useful."
The advice "live a healthy life" is known to all, prescribed by doctors 100% of the time, totally ignored, and incredibly hard to intervene in. "You are missing some common sense lifestyle intervention X" is included within things like "eat a healthy diet for fucks sake." The few people who grab onto something (like thiamine or whatever) tend to ignore all else including extremely important medical intervention (fun fact: Steve Jobs died from one of the more survivable pancreatic cancers because he refused mainstream medicine). Outcomes in "healthstyle fad" type people tend to be incredibly bad, and then we see them avoidably dying in the hospital for no reasons with something preventable and demanding last second intervention.
- The medical industrial complex is a rapacious beast that will agressively steal anything of value from any form of medicine and put it to work (aspirin is basically repurposed willow bark). Sometimes if it can't be monetized you'll run into problems but these are generally edge cases and failing that someone will ruthlessly try and make a career out of it. It's hard to monetize Vitamin C but that doesn't change anything about the fact that we've had thirty years of people trying to make a career out of proving it's a sepsis intervention. If it worked they'd be able to prove it would be strongly incentivized to do so that they could get famous off of it.
Admittedly nutritional type interventions like OP's comment are a bit trickier because establishing evidence burden is hard, but that's not really what your link is getting at.
Throwaway05
1mo ago
Regrettably I don't think your interaction would have been any less unsatisfying if it was in the U.S unless you were seeing a concierge or something like that. While the social pressures at play are pretty different in Japan it's also possible that you were getting a "saying you should try a little iron but not too much" without saying it type interaction, as you might here but it would be more easy to understand.
The problem is that you are more likely to catch someone who demands some form of intervention, any intervention and does so incautiously and then injures themselves than someone who actually has a personal biochemistry that is somewhat atypical and would benefit. Not saying you are one of those, but the majority of the global population is total morons so the practice of medicine has to be optimized around that (and smart people can also be morons when it comes to medicine).
Hmm probably helps prevent fraud and such.
....Priapism from the Atomoxetine? Meds you would not expect can cause that.
It does sound like you did do some research but you should be looking things up, reading /r/psychiatry and /r/medicine - always be learning! (especially if you feel like you aren't getting enough at work). Be curious! Just the other day I was looking up the pharmacology of a med I use all the time (ODT Zofran) because I realized I had forgotten some details. Chasing stuff like that will make you a better doctor.
Scott is smart and is a good writer but he has a very idiosyncratic bent to his medical views that often doesn't match other clinicians. Beware. The Last Psychiatrist on the other hand is fucking incredible (and importantly - equally entertaining). I make everyone in every specialty I see who has deep questions about pharmacology of any kind read his receptor article.
In the U.S. Family Medicine, Sleep Medicine, Neurology, and Psychiatry all have different views on Trazodone (and everything else). For a long time lots of these were like "the evidence says it does jack shit" but some recent literature has some weird noodly explanation about why that's all wrong. It's hard to evaluate. Many docs go off anecdotes.
In the U.S. we do use Remeron but are often cautious because we have enough weight to go around... for the right patient it is great though.
Officially the answer is sleep hygiene and other lifestyle mods/therapy (and especially CBT-I first and foremost and all the time before using meds).
I mean if it works who cares, but if you end up needing something else going forward keep that in mind.
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