Throwaway05
3hr 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
3hr 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
5hr ago
Yeah the Meddit thread goes into some of this and that's a very sympathetic audience going.....oh my.
Throwaway05
5hr ago
Die
Very funny Worf, eat any good books lately?
Throwaway05
6hr 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
8hr 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
8hr 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
10hr 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
10hr 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
10hr 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
10hr 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
11hr 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
11hr 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.
Throwaway05
12hr ago
I'd love to see your critique of my rant!
Throwaway05
13hr ago
The following is an abbreviated version of the talk I give students on this topic.
For a resource that is reasonably easy to parse (and free) you can check out this link. It has a chart at the end that is very helpful.
https://www.aafp.org/pubs/afp/issues/2017/0701/p29.html
TLDR: Pharmacologic intervention is not first line. Proper assessment, lifestyle modification, therapy, and treatment of underlying conditions are first line treatment. Neglecting this can render medications ineffective or outright dangerous. Talk to a doctor.
Okay so occasionally a student comes up to me and goes: "Um, what do we do for patient's with insomnia? It seems to have a ton of different causes and the AAFP, ABPN, and AASM all have different guidelines.
And then I go "GLAD YOU ASKED!!!! If you look closely the guidelines are actually quite similar, but now that you have activated my trap card (students are starting to no longer get this reference sadly) you have to listen to me ramble for an hour instead of going to get lunch.
I will organize this into clinical pearls since it is in written format.
-
A very large amount of insomnia is not primary insomnia. In essence that means that most insomnia has a cause that should be targeted as your first goal. If you have sleep apnea... medication will not help you. Your problem is that you are not breathing while you are asleep and your body is very concerned. Medication can be counterproductive or dangerous. Treat the sleep apnea and magically you will sleep much better. Americans are fat, it is common and people do not want to treat it. If I had a dollar for every family member or coworker who had sleep apnea and knew about it and didn't treat it I would retire. Other medical problems can also cause insomnia. Nearly every psychiatric condition has insomnia as a symptom. People who might not otherwise notice they are depressed will notice sleep quality changes.
-
Patient's feel very strongly about insomnia (as they should! That shit is miserable). Therefore is a lot of lore and STRONG OPINION some of which has insufficient high quality evidence. Some of which is clearly bullshit but you will never convince people. For the former - one of the best evidence based physicians I know uses magnesium and is insistent it helps. Whether it shows up on treatment algorithms is a bit complicated but it certainly seems to do something helpful for some people. Many, many people use Weed and Alcohol. They will swear by them. Don't.
-
What type of insomnia you have is very important. Different treatment interventions (including lifestyle but also meds) will vary depending on what type of insomnia you have.
-
Meds don't work part 1: they don't work.
-
Lifestyle change and therapy work. CBT-I is one of the most effective treatment modalities in medicine. People hate the sleep restriction portion but that shit works. However it's kinda similar to recommending exercise to a pre diabetic. Will it fix the problem? Sure! Will they do it? No.
-
Some of the CBT-I components actually work great and are easy to do (like sleep hygiene). It can sounds stupid but screen time changes, reading war and peace, and so on are actually extremely effective when you can implement them. Google sleep hygiene for more or talk to a competent physician.
-
Meds don't work part 2: Patients want meds instead of treating underlying conditions. If you are anxious that is the problem and you need to fix it. If you have OSA meds won't work.
-
Meds don't work part 3: Okay meds do work. The situations in which they do work are complicated and beyond the scope of this lecture. Snowing someone with Seroquel to help them sleep because they are manic is not unreasonable. Same thing with aggressive grandma who is awake at night and hitting the nurses (or wait - no, you aren't supposed to do that, except sometimes you are...complicated).
-
Okay, the effect sizes of meds are pretty small. Some seem to work better but are more expensive. Some are extremely dangerous for one reason or another. BZDs cause dementia, IQ loss and all cause death. Ambien causes sleep driving. If you are actually sleeping on these is a complicated question.
-
Getting treatment for insomnia is super fucking important, so we will prescribe and recommend even when on paper things don't work or are dangerous or otherwise problematic. Often this is harm reduction. Patient won't get a CPAP but at least they will sleep this way...
-
Because of all the above it is EXTREMELY easy to get VERY poor quality care for insomnia. Insomnia is miserable, patients have preconceptions about works, they are very demanding. Even if YOU aren't very demanding many doctors will be like "fine, whatever" because they don't want to have "one of those" conversations. Be careful.
Sorry. I know this is not what people want to hear.
Throwaway05
16hr ago
"Our protestors don't get charged with anything and your protestors are the recipients of an unprecedented manhunt" IS abuse of the court system. Who to charge and over charge is weaponization of the legal system.
The law fare against the NRA and Trump and so on is abuse of the court system.
The ignoring of SC rulings on gun control is abuse of the court system.
It is not the EXACT SAME abuse of the court system but demanding it be is missing the point.
Throwaway05
1d ago
terrifying precedent
I was terrified when the democrats stopped listening to the court system (ex: gun control), ignored violent protests (BLM) and engaged in unprecedented law fare against individual politicians and an entire voting block (ex: anti-BLM, J6).
This is just more of the same or better than all that.
Throwaway05
3d ago
Every kernel of medicine has room for controversy, as Nybbler points out below. Where to prioritize resources, how research works (what do you do about males disproportionately signing up to be test dummies? ....a million other things. Some of it is certainly the "social" end of medicine like how to train and teach (is advocacy required?) but the hard science parts of it have plenty of dimensions.
Ethics are also fundamental to medicine and fundamentally on the spectrum of controversy.
Throwaway05
4d ago
I mean Medicine for instance is an example of a STEM field which can't function with the level of ideological mono polarity currently present in it - anything remotely politically controversial is super unreliable.
Throwaway05
4d ago
You feel really, really sad about that and want to undergo surgery to make them larger. Is that mental illness?
No real dog in the rest of this fight but I should point out that some of the plastic surgeons I've met believe that ANY desire for their services is fundamentally body dysmorphia (and therefore mental illness).
Even things as simple as nose jobs.
Throwaway05
5d ago
Holy shit. In the U.S? I know of a few but very very few at this point.
Even the VA figured this shit out.
Throwaway05
5d ago
Please do!
Throwaway05
5d ago
That may or may not be already starting to happen.
I hope so!
In any case what I wanted to make clear is that the experience some people have had with academia is so terrible that no level of alarmism is an exaggeration. Your corner (and in fact many or most corners) may be reasonable but a large enough chunk of it is not reasonable that it causes real problems and for those of us who have seen it - .....well burning everything to the ground doesn't sound terribly unreasonable.
Throwaway05
5d ago
I mean, quite a few of the authors are doctors, and I presume they'd also have a stake in us being gainfully employed.
Nah most of us Get Too Excited About Making A Difference.
Sidebar- I was watching "In Good Company" at lunch today (podcast in which the manager of Norway's sovereign wealth fund interview the most successful people in the world) and the CEO of Goldman asked Nicolai about the best features in leaders - empathy was one of them! And this was noted in the context of LLMs taking over other parts of the job for many things!
Empathy and leadership are core to being a physician (at least in the U.S.) and if two of the world's most successful people are going to emphasize the importance of that I'm going to imagine we will be well positioned lol.
I'm not sure what you mean.
More options
Context Copy link