Throwaway05
16m ago
For anyone wondering
Laparoscopic surgery is the other main issue on this front, but you'll have more of that available in Africa.
Throwaway05
2hr ago
Sounds like a design problem.
It's designed well, people just refuse to use it correctly and we can't force them. No amount of civil engineering is going to make up for disaffected young males who insist on driving around at 40 miles over the speed limit.
Society has mostly decided we can't force patients to use the systems correctly or take care of themselves. And I'm okay with that. Although this was a big part of what the ACA was about - health insurance only really works if everyone has it so you needed to force people to get.
I'm not saying all the regulations are good, many are emphatically not - physician salaries have been dropping for forever, so what's causing increased costs? Well a bunch of it is admin and other horseshit like that.
Think about how complex some of this system is, a huge percentage of costs, maybe even worth as much of 50% of doctors salaries, is healthcare workers and systems protecting themselves from getting sued. You want to drop healthcare costs and make access easier? Great make it so we can't get sued. I promise you that you will mostly get better quality care faster and for cheaper. But no, people don't want that, they want to be able to sue.
So healthcare is more expensive.
So much of what goes on is like that.
Throwaway05
4hr ago
PCPs have sick visits, you establish with a PCP and they'll schedule you urgently if something needs to be managed urgently, if you have an established relationship with a PCP they'll know how reliably you are and will do somethings over the phone. This is how it is supposed to work, Urgent Cares exist because people these days refuse to use the system how its designed (and it's because of incentives, I get it and have committed this crime also) but they aren't really designed for the care people ask of them.
Additionally, physician pay has decreased year after year for longer than the majority of the people in this forum have been alive. This has a number of important effects one of which is: most of the shit that annoys you most about doctors is not their fault, they are required to do it because they aren't in charge anymore (most people in most specialties are employed now and not in independent private practice).
-Can't do something simple over the phone has to be an appointment? It's because that doctor's employer requires it so they can bill.
-Appointment short and unrewarding? It's because that is how the employer wants appointments scheduled.
-Doctor pays mostly attention to the computer? It's because there is no admin time and if he wants to go home before 8pm he's gotta start charting in the room.
-Doctor asks you annoying repetitive questions? Someone has mandated they ask them in order to bill or satisfy regulatory requirements or some other annoying thing. Or some incompetent front desk staff person said you were a smoker or a drinker or are missing your appendix and it requires forms in triplicate to remove from your chart.
Doctors no longer work for themselves and are now required by law and by their employer to do things that annoy the hell out of patients and we hate it but its not our fault please dont blame us thank you.
Throwaway05
5hr ago
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.
Throwaway05
5hr 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
14hr 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
16hr 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
16hr 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
16hr 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
17hr 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
2d ago
Heard chief.
Throwaway05
2d 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
2d 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
2d 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
2d 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.
It's called the art and science of medicine for a reason, in psych it can be pretty evident to the lay man, in other specialties it's less but still present. This means experience, heuristics, gestalts, they lead doctors astray yes, but for a lot of things we don't have good guidelines or understanding.
Importantly, doctors can be sued - this causes all kinds of problems but it does serve as a feedback mechanism that assess for problems and gives patients recourse.
Let me give a specific example of how this happens, sticking with psych because it's more interesting than me mumbling about open vs lap vs conservative appendix management.
Most people are aware of Bipolar disorder, at least superficially. Lots of people say "I have mood swings" and tell that to healthcare workers with less training, these people dutifully write down Bipolar in the chart. Or they say "you ever like have mood swings and be unable to sleep?" Gets the diagnosis. Someone who actually has Bipolar 1 with a manic episode barely sleeps for a week of more, does illegal things, or spends ALL of their money in the bank account and all kinds of other stuff. The diagnosis is serious and life limiting without treatment. The medications are also serious - most patients get antipsychotics these days which increase all cause mortality. They are worth it if you actually have the disease. Put undertrained staff give the dx to people who don't have it and then suddenly...
NPs also do things like mix benzos and stimulants, put people with depression or anxiety on antipsychotics which will result in an early death....just all kinds of ridiculous stuff.
The skill ceiling in psych (and medicine) is very high, but if you don't work in healthcare you'll (hopefully) never see it come into play. Most medical work isn't your quick annual physical with your doctor but for many patients (especially young ones) that's all you see.
As for the second point, no the issue is that physician salaries are less than 10 percent of healthcare spending, and it's been decreasing every year. Cutting doctor salaries does not solve the problem and introduces all kinds of new problems.
Likewise NPs don't save money because they do more unnecessary testing and over consult, which drains the specialists and slows down care.
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