Throwaway05
7d ago
Rideshare apps completely slaughtered traditional cabs and cabbies, especially the racket of medallions. Sucks to be some poor cabbie who saved up for years to get his own medallion only to have his entire investment torpedoed.
It's worth noting that one of the main reasons for this transition is the sheer depth of poor quality service and outright fraud associated with the old yellow cab model. It truly was unbelievably brazen and hard to convey if you didn't live through it.
Now back to my regularly scheduled defense of doctorhood.
- We don't have a MD stranglehold in the US anymore.
There's a range, everything from pretty much parity (MD, DO, MBBS) to obviously inferior but often not in a way that patients notice (NP, PA, Psychology Prescribing), to actually quite dangerous (Chiropractors, Naturopaths, Alternative Medicine providers - some of these have full or mostly full rights in some settings/states).
You see all kinds of tensions associated with these options and I know plenty of doctors who have lost out on jobs to one of the others, but in terms of improving care well... we have evidence it makes it worse, and we have evidence that it saves no money or even costs money (example: unnecessary testing).
Many of physician job responsibilities extend outside of direct clinical work and you can't replace them adequately with the others (they make better administrators, managers, and executives). Others also can't fulfill the educator roles or research roles.
Most doctors do some form of teaching and research and essentially all of them have done both at some points in their career.
That kinda stuff doesn't track well on research into these matters but is important. Likewise physicians pick up the slack in the way the the others (especially nurses) do not.
We've been running a natural experiment for awhile now and having growing evidence of that gap.
- Again, physicians do more than you think. Carpal tunnel doctor actually needs to be able to know the physiology medications, and so on. Emergency overnight staff like a surgeon or surgical resident need to be able to cover part of the work of others otherwise you'll need full time overnight staff that you might not otherwise....a million things like this means the training is relevant and necessary.
You also have to consider that if you box someone into say total knees from the beginning then they have to do that 100% of the time they can't switch to another specialty to avoid burnout or other things like that. It's very common for surgeons to switch around and extend the longevity of their careers by doing that sort of stuff.
Throwaway05
7d ago
I think this is easy to say in principle but if you look at how successful identity politics were at taking over such a large part of the public discourse and intellectual framework...well we don't need to speculate what happens in practice, which is that some people figure it out (cough cough looks around) but most don't and it isn't enough.
Moral panics and crowd hysteria and Hersey have always been part of human culture. Expecting that to not be the case is foolhardy, even if we can feel comfortable tossing out labels about lack of ethics or whatever.
Throwaway05
7d ago
I think the flip side of this is important to hold onto when it comes to why so many people hate medicine.
For most people, the most important things that happen in their lives (aka life and death and the prevention of the latter) involve interaction with medicine.
When it goes poorly, that sticks and it hurts. If your mother passed away as a complication from a clot treatment (assuming ischemic stroke) you'd hate that intervention, and maybe even your doctor and healthcare. Maybe you have the wherewithal to know that's an emotional response - but it would still hurt and feel that way.
One invalidating interaction, one missed diagnosis or bad outcome...and suddenly the emotional connection to the idea that the system is useless and needs to be burned down is established. It's really hard to avoid and generates a lot of the ill feeling.
The opposite happens too! But you only have to get it wrong once and that's not avoidable.
Throwaway05
7d ago
EDIT: It's true that Trump also genuinely has a habit of saying stuff he doesn't mean seriously, like locking up Hillary Clinton.
I suspect you was serious about that but that he actually listened when people tossed out the arguments against it (like "we dont do that so they don't do it to you").
Now it seems like they defected anyway... but I do believe in his original intent on that one.
Throwaway05
7d ago
I think the decline of Musk illustrates what makes Trump so impressive.
It is is nearly impossible to function at a high level if everyone fucking hates you, even if you have unlimited money. Musk is not handling it well, the fact that Trump has done so well for so long is amazing!
Throwaway05
7d ago
Absolutely, a lot of businesses are just waiting for someone who isn't a corrupt asshole to show up. Uber so massively trounced cabbies because cabbies absolutely fucking sucked.
General trade and contracting work, lots of things to do with cars.... you could make a killing by getting into these things and not being corrupt assholes.
Throwaway05
7d ago
On a related note (in case you didn't know), the Pulse Nightclub shooter was not motivated by targeting homosexuals - that was by accident. This kinda misattribution is common.
Throwaway05
7d ago
On a practical level I think that sort of thinking is gone from almost all modern education - we don't really focus on critical thinking any more and much of the university experience in America is essentially just a fancy trade school.
In medicine in particular you have to get phenomenally good at box checking and thinking too much is going to get you in serious trouble and unable to advance. This is magnified by downstream pressures - people who are republican or unable to hide being republican don't get admitted to medical school, people who aren't willing to engage in games about social signaling don't end up at good programs for residency, teachers who don't engage with wokeness either get fired or pushed into non-teaching roles and so on.
Outside of medicine most disciplines in school don't really select for or allow much in terms flexibility on this front.
Some people do still have those chops but you have to be very good at turning them off and not saying shit to succeed.
Basically blame the framework for brain washing people, not the people who got brainwashed.
If your job requires you to not notice - at every level, for years, with tremendous pressure to do so....it's hard to keep noticing.
And while the impacts of not noticing from medicine are higher, I'm not sure we should be held to a higher standard than anyone else - all the other disciplines are having this problem and medical professionals are already held to a higher standard in so many different ways that put much of the community on the knife's edge of burnout, suicide, substance abuse, and exit. Don't add more.
Throwaway05
7d ago
Black physicians deal with healthier babies including healthier black babies. The sick black babies go to white physicians. Therefore black physicians have better outcomes for black babies than white physicians do.
They focused specifically on what happened to black babies for the paper.
Throwaway05
7d ago
I'm sorry you still aren't being clear.
Throwaway05
7d ago
I'm not sure what you mean.
Throwaway05
7d ago
I really don't think that is true. People in medicine are there because they are willing to suffer to help people. They are getting it wrong because of propaganda efforts by the university administrations and journalist classes.
They are just as fooled as everyone else, even the bad actors in this case think they are helping and doing the right thing because "these things are true, if the data doesn't match we must have done something wrong!" after years of being brainwashed.
Throwaway05
7d ago
but I am glad to know you can see it now too
Nah this problem is why I first started posting way back in the days where some of our most reasonable contributors didn't see that the news and "science" was biased. I think pretty much everyone still here gets that at this point, so I've spent more time arguing about overreaction lately, but my views haven't changed.
This is a particularly good example for everyone to toss into their brain for later though.
Throwaway05
7d ago
Yeah the Meddit thread goes into some of this and that's a very sympathetic audience going.....oh my.
Throwaway05
7d ago
Die
Very funny Worf, eat any good books lately?
Throwaway05
7d ago
They just thought it was worth the risk.
No, most people were fooled just as much as anyone else was. Everyone in medicine is in the academia basically, and most of the academy are true believers.
Throwaway05
7d ago
While this is good care, I rarely see this implemented in practice. GPs handle the brunt of insomnia, though of course it's a perennial concern in psych. I've never seen my bosses actually order formal assessments for sleep apnea, not that we have the equipment to do PSG in a psychiatric hospital.
In a medical setting you should always be thinking this way - just because a patient has a psychiatric complaint doesn't mean your brain should turn off. You'll miss autoimmune encephalitis this way. Also I'm looking at you 95% of emergency medicine physicians.
In psych you should be considering sleep study in a residential or outpatient setting but for crisis or inpatient I get it, other things need to be dealt with first.
Throwaway05
7d ago
Yeah we have a bunch of national and state level regulators and things. It. Is. A. Nightmare.
Also great! (but often for bad actors)
Throwaway05
8d ago
I've asked before, as an example, some well-credentialed liberals I knew if they would accept universal health care funded and run by the government, with the constraint that it would be entirely run and maintained by experts from the Communist party of China, with their own internal methods for determining who was an expert. And (it should go without saying), I have not got any takers
That's a wonderful hypothetical.
Throwaway05
8d ago
So that was totally a senior trap but good job in your response haha.
Some thoughts:
-Sleep isn't just for Shrinks. In the U.S. it's bread and butter for Psychiatry and Sleep Medicine (duh) but also Family Medicine. And......everyone needs to know it. What impact do you think insomnia has on surgical wound healing times? Behavioral regulation and thus overall care while admitted under care of a hospitalist? Knowing this well is important and it's a great thing you can use to help out other specialties.
-Remember OSA cause psychiatric disturbance. The DSM emphasizes that psychiatric problems are not otherwise caused by a substance or medical problem. Consider this with respect to correlation and causation. A strict doctor will not diagnose someone with depression with untreated OSA for the same reason you won't diagnosis someone with mania if they are high on meth.
-There are more CPAP and other OSA treatment options than you can imagine. Obviously the UK probably has some limitations on this front but you'd surprised where you can go with this. Don't give up (for yourself OR the patients)!
-Meds do work sometimes. Knowing when they are likely to work is why we get paid. Controlled situational depression in a high functioning patient (during for instance...residency) is a good example.
-Bitch I will use whichever is easier to spell or say. And yes don't use Seroquel for sleep (usually- general and psycho-geriatrics will use it in certain populations and that's actually the right move, also can be used in certain acute settings with care and deliberation), but you'd be shocked at how often it's used when it shouldn't be. Especially cough cough NPs.
-Do not give granny Ativan. It worsens delirium. If consulted tell medicine to fuck off and prescribe it on their own recognize and copy paste whatever your delirium protocol is into the consult note. ...and then rec Ativan anyway because your attending long ago gave up.
-You are correct! I always overstate Benzo risk with patient facing communication and writing because what we are certain on is quite bad enough and it's probably better to emphasize what we may later find to be true. AND...in the best case the Benzo is impairing establishment of more definitive care anyway. I find most patients and clinical staff underestimate just how addictive Benzos are.
-Check out the AAFP and other more updated guidelines, you'll benefit from them and they lay out the thinking and some include the evidence base for the new agents. The sleep medicine ones also.
-Put rule out other processes including OSA much higher up in algo.
-Work on your lifestyle mod, you can get some common sense sleep hygiene done usually.
-CBT-I is magic if you can get them to do it. IF but it is magic.
Throwaway05
8d ago
The problem is that I saw plenty of doctors uncritically citing this, using it to mentally update, and using it define future research and goals.
Much of medicine is social science or even just art (they call it the art and science of healthcare for a reason!) often this is because patient interaction and buy in and convincing is most of the job and ethics impairs how much hard science we actually have.
Throwaway05
8d ago
but if any of the authors are doctors, the AMA should throw their license in a bin and light it on fire.
-They weren't doctors IIRC.
-Lol don't listen to the anti-AMA nonsense, they aren't that influential.
Throwaway05
8d ago
I wouldn't call this an update/change haha. Because of how far people go in the other direction here I'm often defending the academy but not always, and out in the real world I'm almost always complaining about it. I do however this example is particularly egregious and because it's a multi-year follow-up too many people will miss it.
Throwaway05
8d ago
So, I can often be found posting on here complaining about bias in medicine (although I disagree about some of the kinds of bias with quite a few posters here).
We do have something of an update to a long running story that’s worth sharing.
Meddit link for more discussion and detail: https://old.reddit.com/r/medicine/comments/1jotpzz/follow_up_on_the_study_showing_discrepancies_in/
Basically, awhile back there was a headline about how black babies received worse outcomes when care for by white doctors. Apparently, this went so far as to get cited in the supreme court.
Sometime later someone on Meddit (which is still quite pro-woke) noticed that they forgot to control for birth weight, which would likely completely kill the effect size (explanation: white physicians have more training and take care of sicker babies who have worse outcomes). At the time there was a significant amount of speculation essentially going “how do you miss this? That would be the first you would control for.”
Well, it turns out that someone filed a FOIA request and well, to quote Reddit:
“A reporter filed a FOIA request for correspondence between authors and reviewers of the article and found that the study did see a survival benefit with racial concordance between physician and patient, however it was only with white infants and physicians. They removed lines in the paper *stating that it does not fit the narrative that they sought to publish with the study.” *
While I often criticize medicine for being political, I’m often found here telling people to trust the experts when it comes to (certain aspects) of COVID or whatever, and well this kinda stuff makes it very very hard.
The initial findings were passed around very uncritically and sent up all the way to the supreme court.
How can people trust with this level of malfeasance? How do we get the trust back? How do we stop people from doing this kind of thing? I just don’t know.
The Great Books program is specifically supposed to be a replacement for a traditional college curriculum in which you learn things from primary sources in and see Western Civilization being shown off.
Much of what you ask for is contra to the mission - if you made the changes you are suggesting it would be something else.
It's like getting annoyed at Western Canon lists for not having Eastern material.
More options
Context Copy link