Throwaway05
28m ago
In order to learn the U.S. standard of care you must learn with a U.S. level of resources and training. Much of Europe can meet that standard but the third world cannot. This is magnified by the fact that the U.S. population is more challenging due to obesity and other factors.
Putting aside that general point, with surgery in specific we are talking about modern surgical modalities - I don't know how many da Vinci's are in the entire continent on Africa but I doubt it's more than a handful.
Throwaway05
9hr ago
I mean a physical therapist is the appropriate medical professional for the issue you had. You went to the "am I dying" doctor and they said "shit I don't know, you aren't dying," if you were dying they would be able to help you. They have limited training in diagnosing MSK issues because that's not what they are for.
Routine issues and urgent care level emergencies are supposed to be managed through your primary care doctor who would say "this seems like an MSK problem, here's as prescription to go see a PT for that, as they are the experts in this area and can spend an hour with you twice a week and I can't do that without it being cost prohibitive."
We see this all the time, people go to the ED for non-emergent issues and get frustrated when they get what seems like poor quality care and it takes forever.
Furthermore patients don't like hearing this so you get some half-assed attempts at managing these issues in those settings instead of the correct response which is "no go see your PCP."
Ultimately if you say, go to your lawyer and ask for accounting help, they may charge you for it and try and help but they aren't an accountant.
Throwaway05
11hr ago
I mean we (being doctors) mostly hate NPs and PAs unless we are benefiting from them financially.
They have very limited training (in the case of NPs excruciatingly limited) and yet think they have the same level of knowledge and expertise.
All of us have lost patients are seen catastrophic avoidable outcomes.
And they can't be sued in the way we can.
Throwaway05
11hr ago
Ugh I bring this up every time and it gets ignored every time by people with axes to grind.
To further explain - common surgeries still happen (duh) but you have things like:
-Needing to experience complications, which happen less because we are better at stuff now.
-Stuff that used to be always or often a surgery being managed more conservatively leading to less cases.
-Changes to how surgeries work to be less invasive but more complicated to learn. Might take 100 open cases to be proficient and a 1000 robot cases or whatever.
-Duty hour restrictions. We used to work 100% of the fucking time. Now we get to sleep, but that means stuff happens without us.
This is pretty surgery specific but a number of other types of specialities have similar issues where you can't maintain training quality with increased residents.
Throwaway05
11hr ago
I know this is an immensely frustrating experience as a patient but it is important to understand that this is not what urgent care is for.
If you saw a physiatrist (which is the specialty that handles this kind of problem) and they get it wrong....that person's license should maybe go away. A good PCP should get this right but these days we don't do nearly as much MSK work and hospital demands mean we aren't as good at this kind of thing as we used to, you may have PT be the replacement for managing it since it isn't really a medication issue.
But it's effectively out of scope of practice for Urgent Care and ED.
Patients go to UC and ED because it's more convenient than getting a PCP, but ED physicians don't handle these kinds of issues, their job is to triage and manage emergencies, which would likely involving turfing this back to a PCP or PM&R doctor for outpatient management.
There's all kinds of reasons why patients use UC and I get it, but ultimately it results in a lot of disastifiaction because it's generally not the right doctor for the problem.
Throwaway05
12hr ago
preferably actual studies
This is an area of ongoing research, for a long time there was a bunch of non-inferiority type studies published by the nursing lobby which were apples to oranges comparison. Ex: NPs with simple cases and MDs with hard cases had similar outcomes.
Now that the NPs have made such a mess of things you have more research such as this: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs#:~:text=The%20study%20found%20the%20physician,complexity%20of%20the%20patient's%20condition.
It's important to keep in mind that NPs get effectively no training. Even if you think medicine is grossly simple (which....sigh), you should have some training.
I think people really struggle to understand how big the gap is no matter how often it's pointed out. You wouldn't trust Juan the day laborer working construction with designing a skyscraper, but that's a reasonably apt comparison in training differences and amounts.
NPs don't save the healthcare economy because while they do get paid less they do more unnecessary testing, it's just a wealth transfer from MDs to hospitals. They also stress the system more with unnecessary consults and admissions which only makes the doctor shortage issues worse.
Throwaway05
1d ago
Heard chief.
Throwaway05
1d ago
"Reasoning behind the existing state of affairs is understood."
The fence is not some abstract Platonic solid locked in time, it is a thought experiment to remind you to understand why the current state of affairs exists instead of some other possible state of affairs.
I have provided numerous questions whose answers may help explain the current states of affairs. You have quibbled over a fence like it is some sort of shamanic totem that if only you shake it in the right way argumentative success or understanding is reached.
This does nothing to address the issue at hand.
Throwaway05
1d ago
"(public policy) The principle that reforms should not be made until the reasoning behind the existing state of affairs is understood."
It is not literally a fence.
reasoning behind the existing state of affairs is understood
Throwaway05
1d ago
Great sure, some suggested avenues of exploration-
"How much has the number of drugs increased since then? How much has polypharmacy increased since then? How much has comorbidity increase since then? How much has personal behavior in response to healthcare changed since?"
Throwaway05
1d ago
You keep accusing me calling you stupid, I'm not. I'm saying you don't know what you are talking about...because you don't. These are not the same thing. Intelligence is not required to make a judgement on this, information is, and you haven't exhibited any evidence of training or knowledge that would address that absence.
Arguing in the way you are now may be evidence of lack of intelligence or character flaws...so don't do that.
Passion on a topic is not a substitute for information or understanding, I've given you a significant number of rabbit holes you could go down to educate yourself on considerations you seem unaware of, and you are resistant to doing that. I also simplified my argument to the bare bones premises and tellingly, you made no effort to engage with those.
Ultimately you've fallen into the same trap that the overwhelming majority of patients who bring up this kind of thing do you, you want to make your own decisions, damn the consequences, without awareness that consequences may even exist and when told "no, you must actually think about this" you become upset and sling mud.
It's fundamentally the same conversation I have every time a patient demands an antibiotic for a viral infection.
These conversations, for the record, are what establishes our stance - because most people become riotously upset when told they need to learn.
Throwaway05
2d ago
If you consider the answer to the questions I asked it will be clear.
Attempt to understand what you are advocating for.
Throwaway05
2d ago
I don't agree with your characterization of the fence, previous message describes why.
With respect to test, previously I said:
"Do patients ask for these? What's the ratio of people who actually need them versus just think they need them? Are their side effects? Are they bad? Are the risks something that someone can easily understand and make informed decisions based off of? Are patients willing to try safer and more effective interventions first? What's the evidence base and recommendations, how sure are we about them? Are their bad actors involved who are incentivizing certain behaviors? What is the level of excess supplementation that production can carry? How many of these questions can you answer?"
Given your lack of response and changing the subject I think I can safely assume you can answer none of these things.
--
-Benefits and risks of a given action exist, for oneself and for others.
-In order to determine the benefits and risks of this substance as a medication you need to know the answers to those questions, and others.
-You do not know the answers to these questions.
-Therefore you do not know the benefits and risks of testosterone.
-Other medications may or may not have similar risks and benefits.
-You do not know them.
-Therefore you do know if medications are safe, for the taker or for others.
-Expanding on that, you do not know the cost to the patient or others have a given medication.
-Decisions should be made with an awareness of the costs and benefits.
-You personally, and patients in general do not have the information to make these decisions.
-Therefore you shouldn't.
Smuggled in there is the premise that people should not be allowed to grossly harm themselves or others, if you are fine with that ....then sure, but if that's the case I'm not sure how you are going to argue against me putting one in the head when someone hurts others with their decisions.
You may say "well sure but they can harm themselves a little bit" but the same frame holds and you don't have the knowledge to know what actions will cause no, a little bit, or significant harm.
Throwaway05
2d ago
In order to have a conversation about increased patient autonomy you need to know the risks and benefits of increased autonomy. I'm not saying you are stupid, I'm saying you don't know anything about medicine or prescribing, which is the thing you are trying to alter. Demonstrating knowledge of the regulatory landscape is not the same as demonstrating the risks and benefits and you certainly have not intimated any knowledge of the many, many discussions about patient autonomy that have been going on for the last several hundred years.
You don't. And that's normal. If I was arguing for deregulation of nuclear energy and you told me you were an expert and that was insane and I blew you off by mumbling about something else, well...no bueno.
You are arguing that people have a right to walk along the train tracks without knowing about the existence of trains.
Since the 1938 date-
How much has the number of drugs increased since then? How much has polypharmacy increased since then? How much has comorbidity increase since then? How much has personal behavior in response to healthcare changed since?
Do you know to think about any of these things?
Sophistry is not a substitute for domain specific knowledge.
Throwaway05
2d ago
The point is Chesterton's Fence.
You know nothing about medicine or the risks and benefits of what you are proposing. Medicine is not auto repair.
That's kind of important.
Throwaway05
2d ago
Do patients ask for these? What's the ratio of people who actually need them versus just think they need them? Are their side effects? Are they bad? Are the risks something that someone can easily understand and make informed decisions based off of? Are patients willing to try safer and more effective interventions first?
What's the evidence base and recommendations, how sure are we about them? Are their bad actors involved who are incentivizing certain behaviors? What is the level of excess supplementation that production can carry?
How many of these questions can you answer?
Throwaway05
2d ago
Testosterone/Estrogen (for hormone replacement, not trans issues). Any scheduled or formerly scheduled substances. Any medication with significant CYP interactions or other related interactions. Any drug that requires lab work and/or monitoring. Any medication that can impact renal or hepatic function if used chronically or to excess acutely. Any drug that makes someone feel good in a non-addictive way but causes significant side effects like steroids.
And that's just taking 30 seconds. Do you know which drugs you'd want to prescribe yourself show up in which categories? Do you have any idea the number of ways you could kill yourself or cause yourself permanent harm?
No.
We had a guy on here a few weeks ago who describing Tylenol usage that could have easily gotten him killed in a slow and agonizingly painful way, and this forum is mostly stuffed with high intellect and education people. And Tylenol is over the counter...
You have no idea what you don't know.
I have seen plenty of patient mortality and morbidity associated with misuse of prescribed medications, bullying NPs into giving them non-indicated medication, or outright ordering meds from another country. And that's right now with the safeguards we have in place.
Throwaway05
2d ago
Metformin is seemingly more benign than statins (which have a bigger argument) but has a few significant drug interactions and a bunch of hypothetical (read: hotly debated) kidney and Lactic Acidosis issues.
Most otherwise safe medications have COVID vaccine problems - you give em to the entire population and weird shit starts happen. One in a million side effects happen hundreds of times.
Throwaway05
2d ago
You are advocating for people to do what they want and have others pay for their failure. People taking over their medical care without professional supervision directly hurts others and themselves, and society literally pays for it in terms of opportunity costs and DIRECT costs.
I haven't seen you engage with any of the examples I've given or actual content at play, just give a metaphor which is poor and repeatedly express your stance.
When given the ability to hang themselves in healthcare people do so. This is not a hypothetical. This is true right now and I gave examples, and that's for the simpler things.
If you want to continue this conversation please explain what antibiotic stewardship and why it's important, or argue why it isn't.
Throwaway05
2d ago
There's def reasons we don't give everyone Statins and Metformin, but everyone always forgets lol.
Throwaway05
2d ago
I actually know a physician who ended up with this:
https://en.wikipedia.org/wiki/Statin-associated_autoimmune_myopathy
Throwaway05
2d ago
If you are okay with putting a bullet in the head of anyone who uses medical care without expert opinion in any way that causes a societal cost then sure.
But we don't do that.
If you become disabled, or end up on dialysis, or increase the risk of a multi drug resistant organism other people subsidize you.
The cost with which we subsidize you is immense. Hundreds of thousands to millions of dollars per person. Society cannot afford to pay that more than necessary, and ethics prevent us from euthanizing people for their ineptitude.
Paternalism is good to some extent it's why we have building codes and financial regulations and you know....laws. Where you draw the line is a point of discussion but drug libertarians don't know anything about medicine and have zero idea what they don't know.
Throwaway05
2d ago
Antibiotic stewardship is something that impacts others, but the bigger problem is that people will ignore their own health as much as possible and then society pays the costs by caring for them after their mistakes. With obesity and some other lifestyle things accept this because you do need to limit how much you impact people's rights, but throttling of medical care is almost universally considered reasonable due the complexity in making informed decisions.
Throwaway05
2d ago
We require people to get car insurance because we know they will make the wrong decision (not getting insurance) if left to their own devices. Some people try this anyway.
We know that people will make the wrong decision with medicine also. Some of this is objective - people would prescribe themselves substances that are controlled (for a reason, for instance opiates), people will ask for treatments where the benefits are clearly outweighed by the risks. Consider all the people who use marijuana when they clearly are not supposed to,* or try and get Addy as a performance enhancing drug, or use illegal substances. What do you think would happen if you could just Dilaudid at the pharmacy? It would be a catastrophe.
The classic non drugs of abuse example is antibiotics. People will ask for antibiotics every time they get sick. Even when it's clearly viral and therefore the abx won't help. They will demand abx, they will write reviews complaining about it and bully the prescriber into giving them abx - even though they won't do anything helpful. Zero benefit.
And the costs can be high to the individual (side effects can be very bad), and to society (antibiotic resistance is increasing greatly). If someone becomes disabled because they took an abx of their own recognize society will pay the cost. This is not theoretical, people kill their kidneys with NSAIDs for example (that's OTC).
If left to their own devices patients will make objectively shitty decisions. The regulatory state exists to prevent this, you don't want people on the road without insurance.
When it comes to the more subjective stuff it does get a bit fuzzier but the fundamental problem remains, no layman has the knowledge and experience to make these judgements, just googling a pubmed article is not enough, smart and educated people think they can figure it out but this requires training and experience. The average person has no chance and society needs to be organized around protecting average and below average people.
The regulatory state has its problems but we require building codes because people will elect to live in a poorly built slum if given the choice because it's cheap. We have to protect people from themselves.
People will take a gamble on "it's fine I have a 1% change of a bad side effect from this antibiotic but society will pay the cost and even though this infection is viral maybe its not."
This is stupid.
People do not like being told what they can do and put in their bodies, but little in the world is as important to get correct as human lives. I remember what it was like before I was a doctor, I thought I knew what I was doing I did not.
*I'm not saying nobody is allowed marijuana, it's complicated.
I mean you are always going to run into study design limitations. In this case most of the money in medicine wants NPs to look good so there isn't good funding for this. The VA (generally) has pretty much the worst healthcare in the country and the quality of care in the ED is also pretty much the worst in the hospital (because of how it gets misused). This is likely to flatten the curve a little bit - good doctors almost never work at the VA.
Psychiatry is a better example - psychiatric interviews and pharmacology are the most complicated in medicine. Mental health care NPs are terrible at both of these things, give people unnecessary medications and incorrect diagnoses and are legible experienced as lower quality by patients and staff with some regularity. In general hospital medicine nurses line up each other and that includes NPs but in most mental health care settings nurses will say they think the NPs are shit.
However the bad outcomes are mostly increased lifetime mortality and risk of side effects 20 years down the line when the patient is seeing someone else. This becomes effectively impossible to study so we don't.
Now you could argue that you don't really care about those problems and if its not obvious their is a skill difference in outcomes lets save money, who cares if people have the wrong medication or diagnosis. But that goes back to the ED stuff - you have a difference in mortality and morbidity, it may be small but most Americans value "the best possible" not "good enough."
Also, since this is why people normally bring it up - if you magically paid all doctors NPs salaries and didn't really change anything else......healthcare costs wouldn't go down at all in any substantive way.
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