Throwaway05
29d ago
As is usual for us there's a whole bunch of different ways this happens. I'm going to simplify some of this for ease of reading.
Surgical rounding team (ex: post-op patients). A team of 4 residents manages 80 post-op patients they know nothing about. Some of them are very complicated, but they are complicated in a relatively small number of ways that can be picked up and put down as needed. Someone prints out a hand out from the computer that tells the residents everything they should need to know, which is generated automatically. Some particularly weird situations get handed off verbally. Nobody remembers what was said. Every X amount of hours the team changes over or new people come on and off. Shift times are generally vague, they exist on paper but emergencies are constantly happening and surgeries run long. One intern (first year resident) who doesn't really know anything about anything is hypothetically in charge of making sure floor patients don't die, while everyone else hides in the OR as much as possible. Handoff risk: low-to medium.
Radiology. You finish your worklist and everything is done. No handover. Ish. Handoff risk: low.
Medical floors. During the day 12 residents manage 120 patients. 2 them stay overnight or two fresh people going on to work 16 hour nights for a week straight. If something happens overnight you hope it's someone you know, otherwise you look at the chart, the notes are good because it's medicine, ideally if something complicated is expected to happen the day team told you about it. Sometimes they don't or it's a new problem. Fuck. Also the nurse will call you at 10pm asking for an update on the discharge plan because the family asked. You don't know because you've never met this patient before and never will. Handoff risk: normally low-to medium, but sometimes high.
Surgery. You don't hand off, you can't. Handoff risk: incredibly high, but because the docs stay until they are done, low. If the surgery has NPs/PAs involved (most typically Anesthesia). Can be hugely problematic since they don't have responsibility and try to stick with shift times.
Surgical/Medical ICU. Patients have failures of multiple organ systems. Documentation is good and on paper tells you what is up. In real life you lose track of how often fluid or blood products went in. Complicated stuff happens constantly. You takeover a patient and have to tell their kids and their mom is going to die. You've never meet the mom. Actually that was the other patient. This person is a dad and is fine. Fuck. Okay now someone else is dying. How many units did the first person get again? You've worked 90 hours a week for the last two weeks. Handoff risk: fuck my life.
Obviously I'm making this sound more ridiculous than it is for the most part, but in real life we do endeavor to write good documentation that supposedly allows an oncoming doctor to pick up the patient, we have handoff reports with automatically summarized information, and a verbal signout (or written via computer for like a weekend daytime doc on a psych unit) happens. But the reality and complexity of the situation often gets in the way.
Lots of research has been done to get this as safe as possible, and it works to some extent, but you can't substitute for actually knowing the patient and being the one who did the surgery or admitted them last week.
Throwaway05
29d ago
No no, it's not simple like that. For one, patient handoffs are so dangerous that one of the reasons we work stupidly long shifts is because someone so sleep deprived they are drunk is safer than having someone else come in for a complicated patient.
For another, we've been part of a multi-decade long project to remove the "guild" and reduce training requirements to bring in replacements. When I first started complaining about this the jury was still out, it's back - and it doesn't work. NPs and PAs have much less exhaustive training requirements and have been in place and growing for years. They suck. They don't save any money because increased testing costs money (it's just a transfer from the doctor to the hospital) and the increased testing and consults create burdens any everyone else. NPs and PAs just consult everything, overloading the sub-specialists even more. Radiology is near breaking from unnecessary testing.
Train more doctors you say. Sure, fine. Except that that takes a long time, requires professors and other resources (we don't have enough cadavers for anatomy lab already) and things like surgery specialties don't have enough procedures to adequately train in a timely fashion. You need to see a variety of cases and patients and advancements in medical care have made this harder (which is mostly good but not for this specific issue).
Import foreign doctors you say. Okay better. Yes most foreign doctors are very much not as good. They are also mostly good enough, especially after retraining. But then you are stealing doctors from other countries, which you know, need them. You are also stealing jobs and wealth from Americans, which is sometimes justified but most of the people making this complaint don't like it when it happens to them or people they like.
In the longer term you'd kill Americans going into medicine, and Americans going into medicine and our absurd wealth is responsible for a huge amount of medical advancement.
Even if you fix the hours worked issue (which for most specialties is a problem during training more than anything), you won't remove the other major causes of burnout which include administrative burden, malpractice, American patients, fucking dealing with dying people, and so on.
Throwaway05
29d ago
Here's one ~ someone else wrote when we were still on Reddit a few years ago.
The following is loosely based on true events:
Imagine you are a trauma surgeon.
You work in a small trauma center; you show up to your shift. There’s more shouting than normal in the ED, so you head to the trauma bay first.
24 hours to go.
The first thing you see is a headless body in one of the bays. “What the fuck is that Jim” you say to your colleague, who is currently administering chest compressions to a clearly very temporarily alive patient, and only such because someone is basically rhythmically punching her in the heart.
“Oh yeah, EMS didn’t want to call it so they left that there. Paperwork, you know? No idea where the head is.” He pauses. “Car accident, we think, didn’t get a great report before they ran off.” He then grunts and someone else takes over chest compressions, he walks over to lab print outs and stares at some numbers, willing them to change. They don’t. The patient gurgles for a second, everyone’s breath pauses as they hope, but then nothing else happens. You look back at the patient being coded, her chest looks like it has the consistency of spaghetti and meatballs.
You take in the scene and then ask the dreaded question “how long?” “we don’t know, she was down in the field and we’ve been doing compressions for…30 minutes?” One of the nurses’ interrupts “43.” You stare. He stares back. He then points to the pediatric trauma bay. The curtain is closed. “I didn’t want all three, you know?” You nod, then walk over to the headless body. “Time of death, whenever the fuck now is. I’ll chart later.” Someone reads off the time, someone else writes it on a post it note and puts the name of the patient on it, and then slaps it to the computer you usually use.
You briefly consider how aggravated this would make the hospital legal team when a nurse walks in from the main ED, exposing the headless body to a bunch of civilians waiting for treatment of their mild respiratory infections. She says “umm doctor, the one patient wanted to talk to you about their pain medicine. Thanks!” She then runs away before you can ask follow up questions, and you hear her saying to another nurse “OMG it’s just sitting their headless.” A patient looks ill hearing this.
“Fucking nurses” you say. “Fucking nurses” the nurses in the trauma bay reply back.
Anesthesia sighs.
The phone rings, you pick it up. It’s the OR. “Dr. Fuckmylife, how can I help you?” “We’ve got a hot gallbladder down here, and then you have emergency cases for the next 12 hours. Jim’s got the bay, can you come scrub?
You sigh.
23 hours and 45 minutes to go.
Early training is not going to help with the above shitshow.
Throwaway05
29d ago
As is usual when this kinda thing comes up, time for me to jump in and defend the field.
Doing medicine isn't what people expect.
For most specialties the hard part isn't knowing what to do for any specific patient (outside of fields with technical skills like surgery, or fuzzier guidelines with broader knowledge bases like Psychiatry), it's balancing all of the tensions of medicine. Some things are complicated. Radiology needs to know everyone else's shit. Neurology involves tough, at times technically challenging physical exams that are actually meaningful for diagnosis.
However most patients really only interact with primary care or basic bitch outpatient medicine, and then they go "I can toss this shit into google and get myself the diagnosis and the management." Yeah you can, we get paid for knowing the situations where the first hit on google is wrong, but that doesn't seem to excite people so let's talk about the other shit.
The hard parts of medicine include the long training period, brutal hours even as an attending physician, working nights, weekends, holidays, and 24+ hours in a row. Managing multiple types of intensely dysfunctional bureaucracy (the government, insurance, the hospital system, medical records), dealing with constant death and bad outcomes, writing notes that need to be clear for whoever is coming on to replace you and will protect you from getting sued if you fuck up, or if you don't, and doing all of this an environment where people are screaming, constantly trying to get your attention, and with a chair and keyboard that a homeless shelter would reject for being too gross.
It's the summation of requirements, including empathy and related fatigue and burnout, and also the necessary customer service/patient interaction skills, and the need to be doing stuff other than your work constantly like basic research and the need to continue to study continuously every year for the rest of your career...
Most doctors are teachers, researchers, and all kinds of other shit in addition to the doctor.
Balancing all this stuff without becoming an alcoholic or killing is absolutely a challenge and well, we see high rates of both of those things in the MD population.
I can't really think of many jobs that combine reasonably high intelligence, massively high work ethic, significant administrative burden, massive hours, catastrophically poor resources and equally disruptive customer service needs.
Takes a lot to balance.
To put some context in, most jobs involve things like lunch breaks and misc. downtime during the day where you can shoot the shit, unwind, and refocus. It's extremely common for a physician to work 16+ hours with barely enough downtime to piss and shove a flaccid banana down your throat like a two dollar hooker.
That's absolutely foreign to most sectors of the economy (including nursing).
Throwaway05
1mo ago
While players tear their ligaments all the time, and Watson was getting beat up by every pass rush he faced, the timing lines up a liiiiitle too conveniently.
It was non contact though right?
The mysterious extra law suit though...
Throwaway05
1mo ago
The niners have had the even year injury curse forever.
Throwaway05
1mo ago
Wasn't one of these types of doctors killed recently because he was holding one of the hostages and was killed in the retrieval? Could be misremembering, but I suspect that's what we are working with. And I say that as an ardent doctor defender.
Throwaway05
1mo ago
I mean there's an entire type of therapy focused around the idea of managing seemingly opposite impulses, but nothing so fancy need be used here, I just think there's an element of "what do you actually want here" that needs to be assessed first.
Throwaway05
1mo ago
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Based off of Dean's posting history and areas of knowledge he does have potentially relevant domain specific knowledge.
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Other indicators (financial markets, lack of U.S. ramp up, etc.) indicate no reason to be worried as of yet.
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Good news: China is a more competent adversary and isn't going to light the world (and themselves) on fire. Well bad news but good news here.
Throwaway05
1mo ago
I mean this is a personal question that OP needs to answer, come to terms with the answer, and then act accordingly.
Both options are fine as long as the outcome isn't paramount, but if the plan is somewhat ego dystonic you get this angst.
Throwaway05
1mo ago
What is a meetup exactly?
But whenever you have a hang up with someone ask yourself why. Often the answer is pride, so the follow-up question is - what is more important, getting the thing done or getting it done your way?
Throwaway05
1mo ago
Flash flooding happens when water rapidly appears from somewhere else. This generally requires a ton of water moving into a small area. Imagine you opened a dam into a giant plain. It fills with water but the water is spread the fuck out. Imagine you opened the same amount of water into a valley....it's going to be a valley with a big ass river covering the ground real fast.
Because Florida is wide and flat it fills, but evenly and over a period of time. Valley towns in a mountain though.....
Throwaway05
1mo ago
Counter Argument: Full Metal Alchemist: Brotherhood
Edit: I see someone else has already made this claim.
Throwaway05
1mo ago
Hospitals aren't really run by doctors anymore, this is partly by law and partly by incentive (other types of staff, like nurses can increase income by moving into admin but doctors in the U.S. usually make less). Physicians can't own hospitals, and a lot of places will have an on paper doctor who is in charge of something as a medical director or whatever but doesn't actually run anything and exists mostly as a liability sponge.
Public health stuff is its own specialty and you can cast them into the fire. There are a few exceptions like Fauci but as is usual with a lot of doctor stuff we aren't really responsible for most problems.
Throwaway05
1mo ago
The people in charge of the healthcare system are not politicians, they are the administrative state, both within medicine but also just the dems and their media apparatus etc.
Individual doctors were not in charge and just got their marching orders and beliefs via download as per usual.
Healthcare is rotted just like everything else but those tendrils are from elsewhere.
Throwaway05
1mo ago
more memorable elements.
Exactly five of them.
I remember lots of language about flatten the curve until genetic drift, vaccines, and herd immunity kicked in. By the time vaccines rolled out to gen pop it was effectively over, now politicians and public health officials not reopening in a timely fashion is a problem, but it has little to do with the actual medicine and is mostly purity spirals etc.
Throwaway05
1mo ago
No idea who Tommy Lister is
Dawg have you not seen The Fifth Element?
Herman Cain was a presidential candidate in the Obama era but Canadian is a good excuse.
re: lethality keep in mind that it's part of the expected course of a disease to eventually become less lethal as it mutates rolling through the population, which was observed with the various covid strains (not to mention the vaccines and immunity slowly building up). Importantly if you look closely a lot of people were pre-registering this so it's not a mere post-hoc justification.
Throwaway05
1mo ago
Maybe next time the doctors won't be so chickenshit and will stand up for the right thing.
Thus my constant banging of the drum here about political capture and political content in medicine. The right thing is now the left wing horseshit and brainlessness, but again the kernel was there.
I guess it's possible that my intuitions are wrong about viral inoculation, my conceptualization is that low enough inoculation and your immune system clears it before replication time gives you a full illness.
When it comes to celebrities they seem to have mostly hidden in beach houses and such. Colin Powell, Herman Cain, Tommy Lister ...shit why do I only remember intimidating black men.
Throwaway05
1mo ago
You can say haha fuck you doctors lose your careers but you do run the risk of having people die unnecessarily which is my worry (and did happen, but mostly in unsexy ways like missing cancer screenings and dying 5 years later, or being lost to psychiatric follow-up and dying of a heart attack in 15 years that would have been avoided with better medication management).
I think it makes sense for a higher initial inoculation (like being trapped in a train or city bus with a sick person) to result in more severe illness than walking past someone on the way into a grocery store and catching a whiff.
Throwaway05
1mo ago
experiences are just not consistent with a generational plague
It doesn't need to be a generational plague to overload the medical system, which it did to some extent. If we ever get a generational plague again we are absolutely fucked.
Rural probably does it though, most of the people who had a bad experience were in the city - likely due to close proximity etc, which probably also is why it's way more of a blue tribe concern.
Throwaway05
1mo ago
Huh.
Do you live somewhere very rural or like Florida or something? (can decline to answer b/c opsec).
I'm kind of shocked you haven't run into more.
Throwaway05
1mo ago
You mentioned this isn't the U.S. so I can't help you toooooo much it's probably mostly boilerplate language that isn't intended to actually be used.
Exceptions may be something like withholding test results until they can call you or tell you to come in. You are supposed to find out you have cancer in the office with the doctor so they can calm you down, tell you the plan, and help you make decisions. Not because some automated portal suddenly interuptYOUAREGOING TO DIE DIE DIEDIEDIE.
It's jarring and not good for patient mental health.
The other example that sometimes comes up in the U.S. with our equivalent legislation is blocking mental health adjacent notes. You have patients who you will documented "patient threatened to murder this writer, and then said 'if you write that down I'll kill you.'" You'd document this and then block the note so the patient can't see it, to protect you, and to protect the patient from doing something to you and harming themselves in the process.
Some theoretical discussion exists about things like blocking notes that call patients obese because they don't like it, but it isn't really legal.
Throwaway05
1mo ago
Union still have a positive role, it's just a union by union basis. For instance Resident Physicians are starting to unionize at various places, they do this because health systems will blatantly violate legal requirements and their contracts with the residents, because the residents can't leave.
If given the ability to do so most employers will misbehave ASAP. Beware of that possibility, even with shitty unions like this one.
The average patient's average interaction with a doctor is not complicated. What patient's don't generally realize is that is a small fraction of the overall work done by doctors. This is true both because more complicated patient's and problems take up more time but also because they have more interactions, and more kinds of interactions. Family Medicine is bread and butter outpatient appointments, but nobody else is. Every single interaction Emergency Medicine starts complicated or can go from simple to complicated at the drop of a hat, and needs to be treated as complicated for that reason and for others like defensive medicine. Entire specialties like Radiology and Pathology never see a single patient or outpatient appointment, and complex surgical specialties will see someone for five minutes in the clinic but only after all the work is done. Even when the thinking part is simple other parts of the workflow or not. An anxious 20 year old comes in with chest pain. It's MSK or anxiety, not a heart attack. But if you have to rule out the heart attack just in case. Remembering to do that is not hard. Triaging when to do it when you are balancing everything else, knowing what level of intervention (EKG? Sure. Echo? Absolutely no. Trop? Maybe, but if we do serial trop the patient might leave) is hard, and communicating this to a stressed patient again while balancing all the other tensions in your job is hard. Non medical people, and even medical people underestimate the level of intellectual challenge in medicine, and yes it doesn't require as much horsepower as being NYC PE person, but it's not a small amount....but it's only one slice of the job.
NPs/PAs are important because society decided that you are right, and they came up with this plan. And it sucked. It was decided to be the best plan, and it made everything worse. Other solutions will have similar problems, otherwise we'd have done them.
All the billionaires get together and decide to donate a 100 billion dollars to improving U.S. medical education to increase supply of doctors. Some things can be fixed. Some things can't, even with infinite financial support. One of the biggest problems is that doctors want to go where the people and society are because they have to give up years of their lives in training and don't want to live in upstate NY or Arkansas. Fine. 100 billion. Offer them 3 million a year and they'll go to the places that need doctors. You can fix that problem with infinite money but we don't have infinite money and its extremely unpopular to raise doctor salaries so even if you increase the supply all you'll be doing is improving supply in a few geographic areas and depressing salaries in them. Not helpful.
Some things just can't be trained. Surgeons require a certain number of procedures to be proficient. If we don't do them often enough because we don't need to then you can't train them. Plenty of programs cannot handle more residents because not enough stuff is happening to adequately train more than we have. You can increase the numbers mildly in most specialties but somethings it just won't work. With 100 billion you could bribe people to get extra, unnecessary surgeries or to use outdated modalities that you only do in emergencies, but that would be grossly unethical.
Year after year going into medicine becomes less popular. People quite and burn out and it's not because of the hours its because of other stuff like lawsuits, lack of respect, administrative burden. None of what you are talking about addresses any of those. Cut salaries by further increasing supply and you'll get less Americans in it.
Foreign doctors aren't free and without issues. Patients complain about accented doctors all the time. Training is inferior in most countries. This is a real problem. Stealing them from other countries is an honest to god additional ethical issue you can't ignore. Often (like with other forms of importing) they become trapped and subjected to poor working conditions.
What's your job? If you are posting here, probably tech? How do you feel about outsourcing? Americans are losing job, the product is terrible quality, most workers hate it and most employers hate it because it sucks, but go with it because cheaper is king. I don't want your job to go away, and you don't either. That applies here also.
The typical model of rent seeking is something like NYC taxi cab medallions. You can more or less costly increase the supply with maybe some mild increase in traffic and a significant decrease in salaries. Again that is not the case here. Importing foreign doctors is vaguely possible if you are okay with decreasing the value of American healthcare (which is a massive segment of the economy) and reducing quality of care (which you don't believe is important) and reducing salaries (which you don't care about at all) but you can't do a lot to increase the total number of American medical grads because their isn't enough work to properly educate them.
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