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Culture War Roundup for the week of May 20, 2024

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Revealed preferences in the real world: black doctors.

I wonder if anyone has studied this? What is going to happen to all the black doctors who are being admitted to med school with inferior credentials and who will likely be socially promoted through residency/licensing as well.

I'm sure a large degree of affirmative action has already affected the supply of doctors, but the post-Great Awokening world seems to have taken that to a new level. Apparently rates of test-failing have increased by nearly 10x in some subjects at UCLA's medical school post 2020.

https://x.com/aaronsibarium/status/1793657774767022569

This is obviously forbidden information. I wonder how many schools will simply cover it up and graduate people as normal despite failures.

I hate to say it, but if I or a loved one was seriously ill, I would try my best to get a non-black doctor. If I wanted the best, I'd probably follow Peter Griffin's advice. I imagine others have similar revealed preferences that we would never admit in public. In the future, will black doctors magically have tons of open appointments while the cue to see Dr. Rosenblatt grows ever longer? I think probably.

There is a widespread conspiracy theory that black women are dying in great numbers during childbirth due to a lack of black doctors. Study after study claims that "black women more likely to survive childbirth with black doctors" and it's become a major talking point on the importance of things like affirmative action. Now it's the only way to save expectant black mothers. I don't think most people have thought about by what mechanism white doctors are supposedly killing black mothers, but it's enough to perpetually fuel the DEI push.

Last I heard, it was because black women chose black obstetricians, and being in a situation where you give birth with a doctor other than your first choice indicated some sort of problem (usually, complications that required a non-racially-filtered specialist).

It's also why home births are so safe in some studies: if they become dangerous, they become hospital births.

Most doctors are overqualified for the routine medicine that they often do. I'd expect that less competent doctors would just be given the routine cases like "man who needs his blood pressure medication prescription renewed" or "girl who's boyfriend got syphilis wants antibiotics".

A less competent doctor might be more willing to accept my "I need Adderall to get more done at work" line of thought.

Do people who just want prescriptions not just visit medical marijuana doctors these days? Are they not happy to prescribe adderall?

I'm in Canada so that's not an option. Weed is just legal.

If I wanted to put in the effort my best bet would probably be one of the "anti aging" clinics that does treatments like HRT that aren't covered provincially. They can charge for appointments so there's more revenue generated by having me as a patient.

Academic standards vanished with the Covid response - at least in the US - and have not recovered since. If I have to be treated by an otherwise unknown doctor, a top criterion would be completion of medical training by 2019. I suspect that this outweighs the racial preferences given, though the effect is probably cumulative.

The Ivies really need to set mandatory GPA’s at the class level. UC mandates every class has a B+ average.

Sometimes I take fitness classes. My body gets tired out. But there is someone in charge and other people in the room. The teacher is sort of yelling at me. I have peer pressure to get the reps in because someone will see me not doing the work and being a failure and I would feel ashamed by quitting. If I did the exact same workout in my living room I would tap out earlier. Grades serve the same purpose. If you just give everyone an A in every class then the natural human competition doesn’t show up.

Either that or Harvard just wants to be a school for socialization. You get better results when you force people to compete and it adds to their internal motivation.

The other side of the argument is that a grade should be based on what students actually know, not who they're (un)fortunate enough to study with. When I taught at a university, there were rigorous standards for what a 1 / 2.1 / 2.2 / 3 level essay should look like. You write First level essays, you get a First. End of. Of course, inflation is a thing. Especially since anything below 2.1 is now a death knell careerwise.

But I dislike the idea of grading on a curve. It seems to me that it encourages cheating, backbiting, competitive revision and resentment of other students. Too much competition can be as toxic as too little.

That’s a great way to get staff cowed into making their courses less rigorous.

How so? If you mandate B+ average. It doesn’t matter how hard the course is. If one person gets an A another person has to get a B-.

Ah, I think I misunderstood you.

The use of the word class probably confused. I was referring to a particular course not class in the sense of the class of 2027.

No, from a hard major perspective, a B+ average sounds like severe grade inflation rather than the reverse.

If I had to choose in the liberal parts of the US in a cold call situation - probably my gradation would be - East Asian, White, South Asian/Latino, black. Of course the best would be to actually have detailed professional history to make a judgement per individual. But that is not an option because of reasons.

In my neck of the woods, black doctors, especially those who've come onto the scene recently enough for this to potentially matter, are almost invariably relative newcomers from Nigeria (and often Irish-trained). They seem as competent as anyone - in any case I've been quite happy with mine.

They're thus unlikely to be affected much by lowered standards, actual or perceived, in the North American continent. Now you have me wondering if this might also be part of the answer to your question - clinics consciously avoiding potentially less qualified candidates from nearer to home, in a way that still makes them look "diverse".

Now you have me wondering if this might also be part of the answer to your question - clinics consciously avoiding potentially less qualified candidates from nearer to home, in a way that still makes them look "diverse".

This is the Harvard method. Supposedly, Harvard is like 20% black. The bad news is these are all rich international students, children of recent immigrants, and people with heavy European admixture.

It's been speculated that there are actually no Harvard students who have 4 ADS (American descendants of slaves) grandparents.

Hey, Google actually found it. https://www.thecrimson.com/article/2020/10/15/gaasa-scrut/

Within Harvard’s GAA population today, O’Sullivan has noticed a seemingly large percentage of biracial students and students who come from socioeconomically-privileged backgrounds. “If we were to count the number of GAA students at Harvard who were descended from enslaved people, came from low income backgrounds, first generation, four grandparents descended from enslaved people, I feel like that number would be so low — like, maybe one person. It’s just so, so, so low,” she says.

Harvard is completely shutting out disadvantaged black people in America. Instead, Harvard pads its stats with people whose only connection with ADS people is the same skin color (and sometimes barely even that).

Ultimately, Harvard and the KKK share the same belief about race: That the color of your skin matters more than the content of your character.

I mean, if the steelman position for AA is that black unequal outcomes could at least to some extent be due to lack of ingroup role models (the "studying = acting white" thing) and therefore black role models should be created even if they are promoted above their station - making this generation fake it so the next can make it, so to speak - then it doesn't really matter if the Nigerians that Harvard fills its quotas with are disadvantaged, or have or want anything to do with African-Americans at all, as long as African-Americans unilaterally believe that the Nigerians are just like them and therefore are valid role models to follow. The last part at least seems plausible - X-Americans imagining that they are actually X even as real X laugh at them is a recurrent trope even for instances of X like Asian or Norwegian.

The TV show "The Wire" had two black kids in what one black parent referred to as the "pediatric neurosurgeon phase", where a young black kid, who hadn't been ground down yet, picked as a role model one of the most intelligent and successful black men in the area. Apparently this was a real thing, at least in Baltimore, and it was due to Ben Carson being the director of pediatric neurosurgery at the Johns Hopkins Children's Center (in Baltimore).

https://en.wikipedia.org/wiki/Ben_Carson

But ‘I went to Harvard because my daddy took advantage of corruption in Nigerian oil production’ is not actually a good example of upward mobility for American blacks(or anyone else except a small number of nigerians). Most people have normal workaday lives doing normal workaday jobs and went to not-that-prestigious schools to train for them.

Hispanics seem to have achieved substantially upward mobility by acknowledging that lots of them are going to have job titles like ‘Secretary’ and ‘accountant’ and go to schools like podunk state, bumfuck nowhere campus.

This is a really interesting thought experiment: if the African AA do turn out to be stellar examples of pure black competence and the reputation of blacks as an aggregate increases on means and medians, yet 4ADS-grandparented blacks remain a perenniel underclass, will AA cease their bitching? Off the top of my head my own experiences suggest a strong no, given what my african compatriots tell me about dealing with blacks, as well as seeing how the extremely few 4ADS largely treated Africans in college. US afronationalists use Wakandanized pre-white africa as a tale of white perfidy, not African solidarity. Blacks are perfectly capable of immense in-group strife now without introducing nigerian, rwandan, kenyan or botswanan ultrachads, there is no reason they will cease their bitching. The question remains whether the white DEI champions will not play with blacks anymore if they are too successful. Perhaps the natives will FINALLY be the chosen pets for whites eager to show their good hearts.

Is this a fairly recent thing with Harvard? And is there a big gap between Harvard and 10-20 ranked American schools? I can’t think of people I know who went to the second tier of schools and one who went to Stanford who were ADOS. This article sounds like there are basically none. I think they said perhaps 17.

I think it is fair to say if ADOS at Harvard basically do not exists then all of DEI is just a grift. If your concern is structural racism then Harvard shouldn’t just be recruiting in Nigeria if they are extremely concerned about structural racism. If you believe the issue is structural racism as oppose to lack of ability admitting a ton of ADOS would be an obvious solution and something Harvard has the ability to fix (training plus credentialing) a ton of Nigerians and no ADOS would be a refusal to do the hard thing for laziness or tacit admission that ADOS are just too dumb to be at Harvard.

Also there is a big difference between padding the stats and the article sounding like there are a dozen or two ADOS at Harvard.

Is this a fairly recent thing with Harvard?

No, Harvard has been shutting out ADOS students for at least 20 years.

https://www.nytimes.com/2004/06/24/us/top-colleges-take-more-blacks-but-which-ones.html

While about 8 percent, or about 530, of Harvard's undergraduates were black, Lani Guinier, a Harvard law professor, and Henry Louis Gates Jr., the chairman of Harvard's African and African-American studies department, pointed out that the majority of them -- perhaps as many as two-thirds -- were West Indian and African immigrants or their children, or to a lesser extent, children of biracial couples.

were West Indian

This really boggles the mind. They are as much DOS as ADOS are, the vast majority of them were worked to death so the survivors weren't chosen for their working ethic or intelligence, why aren't they as dysfunctional as ADOS?

  • It can't be their genes, unless you subscribe to the idea that it's the white trash admixture that is responsible for low ADOS performance
  • It can't be their socioeconomic circumstances, Jamaican GDP PPP per capita is $13543, according to IMF, while Mississippi's is $49911

Selective immigration, probably. We're not getting random Jamaicans.

The English-speaking Caribbean is roughly as messed-up as black America. Jamaica is by far the largest country, and has the highest murder rate in the world at 53/100k (vs about 21 for black Americans). Trinidad (40), the Bahamas (31) and Belize (28) are all worse as well and Barbados (15) is not much better. I think this is the best indicator because most other indicators of ADOS dysfunction are improved by fiscal transfers from white Americans. The islands which remain colonies seem to be better off.

Windrush-era immigration from the British Caribbean to the UK was not selective, and British Jamaicans are the most dysfunctional subgroup in the UK that is large enough to have good statistics. (Gypsies are probably worse). But the DOS crime problem is eminently fixable with competent policing - the black British murder rate is about the same as the white American murder rate at 4.

Jamaica is by far the largest country, and has the highest murder rate in the world at 53/100k

Holy shit. That really is higher than even Haiti and that place is as failed state as they come.

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But if America is getting the right tail of the West Indies DOS, shouldn't there also be a corresponding right tail for native ADOS? ADOS are about 42m as of 2020, while Wikipedia says that the entire West Indies is 44m, and a quarter of that is Cuba, and that's the entire population including whites and all other races.

I mean, unless AADOS culture is so uniquely shitty(plausible; I don't think it's quite as bad as gypsies, but it's pretty bad) that it prevents the right tail from making anything of itself.

I think we have evidence of AADOS culture being pretty bad and maladaptive in any circumstance, far more constraining than HBD. I don't know if it's 'literally no right tail, it's that bad' tier.

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The corresponding right tail for ADOS presents identically to the black families of progressive dreams. Suburban 2 parented households with no crime. These blacks just refuse to identify with their failed brethren, like how suburban whites do not identify with kensington fent zombies.

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Every field has bad apples, the way medical education is structured it is very hard to get through without a certain floor level of competence.

When I think about "bad" doctors the ones I run into are generally lazy/burnt out types, or outright malicious/unethical types. Traditional incompetence is rare, because those people get kicked out of medical school or residency....unless they are a favored minority group.

In my career I've run into a handful of white/Asian doctors who are truly incompetent, while I've run into plenty of great URM (underrepresented in medicine) doctors, a noticeable percentage of URMs should never have been advanced through training. It's not a lot, but it's way way way more than the near zero for other demographics, and all of the absolutely catastrophic idiots have been URMs.

From asking it around it seems like the attitude is that it's easier for a programs reputation to advance an incompetent URM student than deal with the flack from trying to put the person through remediation and/or termination (in part because medical education now includes a lot of mandatory education in toolkits these students can use to complain).

When I think about "bad" doctors the ones I run into are generally lazy/burnt out types, or outright malicious/unethical types. Traditional incompetence is rare,

This is my impression as well, although I attribute it to gatekeeping effects (entry into American medical schools is traditionally so hard as to exclude truly incompetent candidates, and entry to practice in America from foreign training has similar gatekeeping).

By the way, I've always found it interesting that Scott, who seems like a brilliant and caring, almost ideal physician, attended medical school in Ireland - was that personal preference, or could he not get admitted in the U.S.? I remember him mentioning that he had a very difficult time achieving placement into a U.S. residency afterwards.

Traditional incompetence [among American physicians] is rare, because those people get kicked out of medical school or residency

I thought the stats showed that the overwhelming majority of individuals entering American medical schools are promoted to full privileges? Like, well over 95%. And presumably, a non-trivial part of those who don't get promoted aren't "kicked out" of medical school / residency for lack of competence, but rather leave due to other factors (medical problems, voluntary career change, etc.).

I'm sympathetic to the arguments that American medical school screening processes (appropriately) exclude candidates that lack the skills necessary to be successful as physicians. But alarm bells start ringing in my mind when I hear one set of people saying "admissions standards aren't necessary in the current system because we have such exacting training standards," while the other set of people is saying, "serious training standards aren't necessary in the current system, because we have such exacting admissions standards."

95% and other similar stats are for U.S. MD programs specifically (as opposed to DOs, FMGs, and IMGs), however U.S. MD is probably what is in your mind when you think medical school. And yes medical schools are so exacting about taking applicants because they want to take someone who is certain to make it through the process. Figuring out the cause of dropping out is hard because people lie for ego defense reasons which complicates matters, I do know people who have claimed some other kind of hardship but it was academics. A big piece of medical school is filtering people down to less competitive specialties and programs, but if someone falls below the competence floor they absolutely do get kicked out, it happens, but schools invest a huge amount of research into never admitting these people in the first place.

The exception of course, is minority applicants. An MCAT score that would result in a white person having a 50% chance of getting in and an Asian person a 10% chance is a 95 percent change for a black applicant. It's really really rough.

I'm not sure what happened with Scott but my guess is that he was the kinda person who didn't take undergrad that seriously which limits medical school options (and you gotta like, have at least a 3.8 with no blemishes for most white students) and that he's not very much of a doctor type person (but very much a psychiatrist) which may have made most of medical education very painful.

Figuring out the cause of dropping out is hard because people lie for ego defense reasons which complicates matters, I do know people who have claimed some other kind of hardship but it was academics.

I mean, sure, if someone leaves an academic program, then on some level it's related to academics. But even in cases where someone's involuntarily separated from their program due to bad grades, those bad grades don't necessarily indicate a failure of earlier-stage preparation or a deficit of natural ability. Often, bad grades are downstream from emotional problems, or from a general ambivalence about the training. I speak from some personal experience here, albeit outside of medicine (I don't think this is simply "ego defense").

I don't want to get too distracted from my main point, which is that, based on data and personal observation, I'm skeptical that American physician training requires as much intellectual horse power (or even hard work) as American physicians maintain it does. I do think it requires a high level of conscientiousness, which is surely related, but also different.

Something I don't mention enough that might help contextualize the difficulty is this - one patient is not hard in most specialities. If you are a hospitalist caring for one admission that's pretty easy. I'd even hazard that a bright person with some epistemic humility, ChatGPT, UpToDate, and a low-moderate complexity patient could manage it.

You don't have one patient.

You might have 20. You might have 30. Two of them are actively dying on you. You have to juggle those responsibilities while trying to discharge five people on your census who are supposed to go home and 5 new admits you know nothing about. All while nursing, case management, utilization, and the billing department are trying to call you. Every day. Maybe it's a weekend and you've worked 14 days in a row. Maybe it's hour 28 of what's supposed to be a 24 hour shift. And you still have to write all your notes from yesterday.

Yeah being really smart will help you save one of your dying patients by coming up with something clever, help you diagnosis something incidental in one of your random patients, and help you spot that your healthy seeming afib patient is a bomb waiting to go off....but more importantly it gives you the intellectual reserve to handle the volume without letting things slide.

That's the biggest difference I see between the smarter and dumber doctors. Dr. House isn't required, but having the reserve to not be overwhelmed is.

I'm ever more grateful thay a quick poke with haloperidol and lorazepam solves most of my "emergencies".

Ah, truly the specialty for me.

Unsolicited teaching time!!!!!!

I know your comment is meant somewhat facetiously but it's important to establish good PRN habits early, especially as you move to a higher resource community.

Some pearls.

  1. Haldol/Ativan/Benadryl (B-52! If you've never heard the term) works well and is popular for a damn good reason. It's fine as a default.

  2. Other PRNs exist however and you should be familiar with them and try and think about when to use them. Droperidol is big in the ED in the U.S. Thorazine is more popular as a pediatric PRN because it's thought to be more sedating.

  3. If the patient is on something that seems to be working (like say Zyprexa) you can consider using more of that for breakthrough agitation. Do not mix IM Zyprexa with benzos however.

  4. If you ever work in a consult setting or otherwise with medically ill patients you'll want to have a few tricks. QT related concerns are big in the U.S. even if they are questionably real so you have a lot of elderly dementia/delirium patients who need clever agitation management - low dose depakote can work for this.

  5. Know what's happening with the patient. Patient like the above will generate requests from idiotic physicians for benzodiazepines recs. Obviously that makes delirium worse. I believe all doctors who deal with agitated patients (read: basically all doctors) need a full length version of this rant for that reason. Less common problem (especially outside your field) are pure "behavioral" patients. If the agitation is all volitional antipsychotics aren't going to do shit.....choose more sedating regimens (but be aware of the risks of such).

  6. Unrelated question to check reading comprehension (this is a joke). Do they use hospital prescribed alcohol to manage withdrawal in India? It's so stupidly effective and simple and I don't know why we don't do it more anymore.

  7. Go assess the patient (skip if the bandwidth isn't there, admittedly). Nursing and ancillary staff are seldom reliable narrators for if a patient needs meds. Bonus points if you can learn which staff and teams are reliable for this. Sometimes you can save everyone trouble by throwing a pissed off person a sandwich. Also be aware of the risks of sedating someone you need to interview or examine later, can easily cause downstream workflow problems especially if it's a hospital setting and you are pulling in consultants.

I'm not that lazy so I asked GPT-4:

A senior doctor likely provided this advice based on several important considerations regarding the safety and effectiveness of treating acute agitation in patients with psychosis:

  1. Effectiveness of Current Medication:

    • If a patient is already on a medication that is working well (like olanzapine, which is Zyprexa), it often makes sense to increase the dose of that medication for breakthrough agitation. This approach minimizes the introduction of new medications and potential drug interactions.
  2. Drug Interactions:

    • Mixing intramuscular (IM) olanzapine with benzodiazepines can pose significant risks. One of the main concerns is the potential for additive central nervous system (CNS) depression, leading to profound sedation, respiratory depression, and potentially life-threatening consequences.
  3. Safety Concerns with IM Administration:

    • IM olanzapine and benzodiazepines, when used together, have been associated with severe adverse effects, including respiratory depression and cardiovascular instability. This combination can lead to excessive sedation, increasing the risk of aspiration, and can complicate the clinical management of the patient.
  4. Clinical Guidelines and Best Practices:

    • Many clinical guidelines and pharmaceutical recommendations explicitly advise against the concurrent use of IM olanzapine and IM benzodiazepines due to these safety risks. These guidelines are based on evidence and case reports of adverse outcomes.
  5. Minimizing Polypharmacy:

    • Increasing the dose of an already effective medication helps avoid polypharmacy, which can complicate treatment plans, increase the risk of drug interactions, and make it harder to determine which medication is responsible for any side effects.

In summary, the senior doctor's advice is grounded in clinical safety, evidence-based practice, and the principle of minimizing harm while effectively managing acute agitation. By using more of a medication that is already working, like Zyprexa (olanzapine), and avoiding the combination of IM olanzapine with benzodiazepines, the approach aims to optimize patient outcomes while reducing the risk of serious adverse effects.

I suppose that's the gist of it?

It's a good thing I took my Ritalin and have a psych textbook open, or I'd have permabanned for the aggressive attack with education at a vulnerable juncture /s

Thank you, while you Americans have an abominable addiction to brand names, I can understand that those are principles that'll come in handy.

Do not mix IM Zyprexa with benzos however.

I can Google that, but you're in a teaching mood, so might I know why from the horse's mouth?

Unrelated question to check reading comprehension (this is a joke). Do they use hospital prescribed alcohol to manage withdrawal in India? It's so stupidly effective and simple and I don't know why we don't do it more anymore.

Never seen it happen, and I've been here longer than I'd like. It's the usual benzos to cover the acute withdrawal, and it matches up with NICE guidance to boot.

Go assess the patient (skip if the bandwidth isn't there, admittedly). Nursing and ancillary staff are seldom reliable narrators for if a patient needs meds. Bonus points if you can learn which staff and teams are reliable for this. Sometimes you can save everyone trouble by throwing a pissed off person a sandwich. Also be aware of the risks of sedating someone you need to interview or examine later, can easily cause downstream workflow problems especially if it's a hospital setting and you are pulling in consultants.

Good stuff. I'm taking notes, albeit with the cafeteria being the way it is in the NHS, I might be tempted to steal the sandwich. Certainly not paying for one out of pocket, do I look like I make US money haha. I do prefer practical and common sense interventions where possible, Scott's story about the lady with OCD and hairdryer stuck with me.

Haldol/Ativan/Benadryl (B-52! If you've never heard the term) works well and is popular for a damn good reason. It's fine as a default.

More from hanging out in /r/drugs to watch in sheer awe at the people who choose to abuse deliriants, in the case of Benadryl, but Haldol? That's good old haloperidol and I love it like me mum.

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This seems kinda backwards from an organizational perspective. Being a doctor requires that you be really smart because they're all really busy because there aren't enough doctors, so we can only admit really smart candidates to medical school.

Wouldn't lowering standards and increasing the number of doctors improve things significantly if that's the argument?

I've argued in the past that it's helpful for doctors to be intelligent and here I present an example that comes from a little bit of a different direction than usual, but most of the selection criteria are more about diligence, toughness, and hard work, all of which is best preserved.

However, even if you take case numbers down to say 15 inpatients for a hospitalist you still need a lot of those skills if you get a couple of rough admits at once.

You'll find most doctors (myself included) want more doctors, but the tone of this discussion online is always "wow doctors are useless and overpaid, let's just create more from the aether and dump their salaries which will solve healthcare costs" which is not how any of this works.

I rarely see people online weighing in who actually understand healthcare economics or seem to understand and respect what doctors actually do.

Wouldn't lowering standards and increasing the number of doctors improve things significantly if that's the argument?

Yes! Except people always want the best doctors, so you need a way to gatekeep access to the top of the crop, either by making them more expensive to the consumer or by mandating you have to see Dr. Washington or Dr. Lopez before you're allowed to see Dr. Swami or Dr. Smith before you are allowed to see Dr. Wang or Dr. Leibowitz.

The problem is about to get much worse.

If professors were afraid to fail an underperforming URM in 2010, imagine how much more afraid they'd be in 2020. Once the new crop of doctors hits the market, it's going to start looking pretty bad.

The problem is about to get much worse [due to preferential treatment of URMs].

Separately, I'm concerned about the effectiveness of medical (and pre-medical) training performed remotely during the pandemic. I also think the integrity of admissions / promotion standards are potentially compromised by pandemic-era shifts, particularly rampant cheating and grade inflation.

A friend of mine recently went to a specialty conference, she described a lecture she saw that was talking about the difficulty in giving feedback to students these days, a student at the end asked "wait is that why all of my friends and I are told we are doing great the whole rotation and then get a 3/5 on our evaluation at the end?" Everyone just nodded.

Good teaching requires being able to safely give feedback and that just isn't possible anymore. The problem isn't limited to minority students.

Okay fine this a bit of an exaggeration but still.

The profession has a deliberately bottlenecked profession that makes it unnecessarily selective. Even if the average black doctor has lower MCATs than other doctors, they're still going to be plenty good to do basic medical procedures. I suppose part of the reason that I think this is that I generally think big chunks of medicine are significantly overrated, with only a few classes of medicine being consistently effective, and those not generally be all that hard to do. Antibiotics and vaccines work great, but they don't really take a genius to prescribe. Trauma surgery is very effective, but you're probably not going to have much time to pick who you want to fix your shattered body when you're brought in from a car accident. Without considering race, I just generally don't think I'm going to get much out of a physician with a higher MCAT.

There are a couple areas where I would want to get the absolute best. If I had cancer, I would want top-notch pathologists and oncologists working on the problem and would seek out an elite hospital. I probably wouldn't care about race in that context because the bar for being specialists working on bone marrow transplants at MD Anderson is pretty damned high. On the opposite end, if I had something that required sports medicine, I would be insistent on people that are actually knowledgeable int he field, but on this one, the intellect level shouldn't be much of a barrier.

Relatedly, I can't believe how many people that have nothing wrong with them just go to the doctor all the time for checkups, as though a physical is going to provide you any useful information about yourself. What a silly, shamanistic ritual. I'm especially amazed that people who pretty obviously don't care much about their health go through the debasement of being told annually that yep, you're still fat and should lose weight.

I'm especially amazed that people who pretty obviously don't care much about their health go through the debasement of being told annually that yep, you're still fat and should lose weight.

Health insurance wants you to.

Even if the average black doctor has lower MCATs than other doctors, they're still going to be plenty good to do basic medical procedures.

From the article

One professor said that a student in the operating room could not identify a major artery when asked, then berated the professor for putting her on the spot.

She knows literally less than a decent butcher.

From the article

One professor said that a student in the operating room could not identify a major artery when asked, then berated the professor for putting her on the spot.

She knows literally less than a decent butcher.

The qualifier major is carrying a lot of weight here. There are thousands of named arteries in the human body, ranging from the aorta (which every medical student in clinical rotations really should be able to recognize, at least when it's exposed to plain view) to tiny branches that exhibit tremendous variation across individuals, and which even the absolute best students (and expert physicians) won't be able to reliably identify in cadaveric dissection (never mind in the operating theater). Viewing angle, anatomical posture, and similar (physical) factors can also make it much easier or harder to identify individual vessels.

So, even if we take this anonymous source's claim at face value (i.e., we assume that some incident occurred in which a medical trainee failed to identify a "major" artery on request, and then reacted badly), how should we understand the term "major," and why do we assume that there was a clear presentation? (And of course, one case, however egregious, doesn't establish a trend.)

Yeah as someone who agrees that AA has gone too far I don't think this anecdote proves anything. Surgeons are notorious for interrogating stressed out, sleep deprived residents and med students and then asking them questions until they get something wrong.

You can ask this question in a way which every last med student in the country should get the right answer, and you can ask it in a way that someone who goes to the anatomy lab for fun is going to fuck it up.

Do we need the physicians to know the Latin for every small part of the body?

Yes, physicians need to know what parts of the body are called. That these terms are usually Latin has no bearing on that.

More or less, yes. Despite my position above that I don't think of there being much of a crisis of competence in medicine, that's precisely because there are standards that everyone has to meet. Some professions are basically fake in terms of actual technical knowledge and people can get by with a combination of improvisation and charisma; my impression is that people in these jobs sometimes mistakenly believe that all jobs work that way, and it just ain't so. Things like medicine and engineering have irreducible complexity, where you actually have to know each part of it and be able to use that understanding in practice. Physicians require more actual knowledge than marketing executives.

We need physicians to know the proper technical term for each small part of the body so they can talk to other physicians about it quickly and precisely. "Fracture of the left thumb" is not acceptable medical writing because the orthopaedic surgeon who reads it now has to find the X-ray image to know which bone in the thumb is fractured.

You can argue that Latinate technical terms make medicine harder to learn than strictly necessary, but the alternative of using technical terms that sound like ordinary words is worse (I've taught physics, I have the scars). In any case, my experience of dealing with doctors is that the technical terms named after obscure 19th century surgeons are more confusing that the Latinate ones.

I kind of want to see Ander-Saxon for medicine.

This is liefsome, but how would we win over the leeches to eft learn all their leechcraft anew?

The latin is the proxy for competence. If the doctor can't keep up with their research and papers to know their specialized lingo then they're unlikely to understand the workings of their trade. When you're in a select high context community, language is the filter to weed out imposters.

I don't think this is really valid. Maybe the median black doctor is fine and knows your arm from your arse. But the people on the tails... Truly bad doctors don't just mess up, they can ruin lives and leave corpses. If that's even 5% of the total, it would be a catastrophe.

Yes. Medical mistakes kill around 440k Americans per year. It is a leading cause of death. A moderate increase in medical screw ups could be deadly on a societal level.

This seems obvious if you run some numbers. I am not going to look up what percentage of the population dies a year or total deaths in America but 1-1.5% sounds about right.

I would guess 4-5 million deaths per year and the 440k number would imply 1/10 of deaths are medical error.

Either the definition of error is very low - like a mistake costs a person 10 minutes of life or the number is wrong. When people say medical errors they would assume they died youngish because the doctor did something like gave them the wrong drug or cut an artery during surgery.

And in some cases 'the doctor was only able to ensure 5% QOL heartbeat continuation by 3 months instead of 3 years fighting to the end' isn't necessarily a bad thing.

Even decent doctors doing 'normal' stuff can have surprising gaps, if they're struggling with combinatorics or recall -- outside of test reqs, it's one of the big arguments against the residency-as-hazing, because being that tired makes you stupid. This seems like a joke, but it's also a joke that I know three people in meatspace with similar stories specific to Crohn's. I've personally been given a combination of prescriptions that, about six months earlier, had received a black-box label about risk of horrible wasting cancers in my demographics.

((That said, I'm skeptical on both the naive HBD take, and also on the data here being completely causative, though I expect the base problem of 'prioritizing everything over ability' is bad enough even in a perfectly blank slate world.))

The naive HBD take seems to be a complete distraction. They had a standard. They're massively lowering the standard. We can be fairly confident that this is going to go very badly, because we have prior examples of it going badly when standards were lowered at smaller scales.

This, in a situation that can already be fairly described as a shitshow. I've got a close acquaintance who had a tough pregnancy a couple years ago, and has since been having dizziness, shortness of breath, and other scary symptoms. For years, plural, since the delivery, she's been asking her doctor, only to be told that it was asthma, or leftover pregnancy hormones, or just her imagination. long story short, the pregnancy caused a degenerative heart condition, which her doctors had been studiously ignoring since her delivery. She's currently waiting to find out if the crash course of meds they've put her on can turn things around, or if she's going to need a prompt heart transplant. She isn't poor, both she and her husband have upper-middle-class jobs with excellent health coverage. Her doctor was just a waste of air. Most stories I hear from people about interactions with the medical system run along similar lines. The expense is absurd, and the results are depressing.

Honestly this pushes me the other way. I’ve found straightforward by-the-book medicine to be largely useless in resolving any of the health issues I’ve had (other than one infection, at which point the doctor was just a hoop to jump through to get the antibiotics I knew I needed.)

As such, whenever I’ve had a doctor actually solve my problem, it was less because they were a doctor and more because they were an extremely high-iq person with enough exposure to health problems to discern the zebra-problem from the hoofbeats.

I can go through the checklists and find the normal issues myself. Hell, I can set a bone, pick medications out of the available options, or look at my bloodwork myself too. It’s like changing your car oil, just a series of steps.

What I can’t do is realize that I have a 1/1000000 congenital heart issue because of a weird head feeling I get, or know what the proper course of action is after that. Luckily for me I found a doctor who could, and it only took going through a dozen doctors who were useless.

My experience with that last doctor was completely incomparable to any of the others, and I desperately wish there was a way to differentiate the two. Frankly, they don’t even seem like they should have the same job title any more than the attendant at a Jiffy Lube and a Lamborghini mechanic should both just be called “mechanics.”

other than one infection, at which point the doctor was just a hoop to jump through to get the antibiotics I knew I needed

Personally, I despise having these kind of gatekeepers. An MD is the magic licence which will let you get anything (aside from controlled substances) from a pharmacy with a minimum of paperwork. Anything less than that -- even having studied pharmacy -- will get you nothing over a random person in the street.

A better system would allow amateur level qualifications which allow you to get a larger selection of drugs (like anything you had been prescribed before for a chronic problem, like thyroxine) over the counter.

Or just allow anything (possibly excepting controlled substances) OTC, and let natural selection sort it out.

Naturally, antibiotics are a special case because humans pay a collective price for irresponsible individual use (multiresistant organisms), so it makes sense to regulate that. Perhaps give licensed amateurs the right to buy one treatment of a first level antibiotic treatment per three years, plus the right to buy an appropriate specific antibiotic after lab tests show it their bacteria will respond to that. (Of course, the last line of antibiotics should be administered in insulation wards where you will either leave negative or feet first (if the bacterium develops a resistance).)

A number of degrees and licenses have prescribing rights in the U.S. right now (including NPs and PAs in most states).

Keep in mind that an overwhelming fraction of the population will prescribe themselves into bad outcomes if given the ability to do so, and often demand that their providers do so (with variable success).

Antibiotics as you note, is the classic example. People will demand antibiotics for viral infections. They will demand antibiotics when they don't need them. They will demand stronger antibiotics. They'll blow up their tendons or give themselves C Diff or one of any other number of things.

People will take thyroid medication wrong, or even easy to avoid fucking up things like most blood pressure medication. They'll take two medications that are fine alone but will fuck up your kidneys together.

Patients are idiots. That includes high education, high intelligence patients because they have a lot of overconfidence (just as doctors have overconfidence in domains outside of medicines).

But most people aren't high education and high intelligence anyway and you'll get a ton of people killed and cause extremely expensive, avoidable morbidity if you take the guardrails away.

You can just order from Petmeds and sketchy foreign pharmacies, like the rest of us.

This generalizes for basically every profession and even moreso since the internet exists now.

That being said 50-80% of the population likely doesn’t have that IQ I need the relatively smart doctor who can do the read the internet for cure thing.

The profession has a deliberately bottlenecked profession that makes it unnecessarily selective. Even if the average black doctor has lower MCATs than other doctors, they're still going to be plenty good to do basic medical procedures.

That would be a reassurance if it were true.

Are you familiar with Killer King? The history there seems to me to be an irrefutable demonstration that Affirmative Action can in fact have devastating effects in the medical field, and how those effects can in fact be perpetuated indefinitely despite general knowledge of the problem.

Many such cases.

Leland Memorial Hospital in Prince George's County, MD had a similar reputation, though I have no idea if there was any affirmative action involved. It was lore around the University of Maryland that if you go to Leland, you die.

What's your epistemic certainty on this? Where is the bottle neck? What level of selection is necessary? Do you know the data on under trained providers vs traditionally trained ones? We have it.

What does a doctor actually do? I don't think you actually know, in all likelihood your primary interaction with medicine has been outpatient or maybe some emergency, where most of the work is in inpatient (and for academics, research) and necessarily invisible to patients since they aren't following us around. Most patients don't have any actual need to see the hard work but it's very much their and being done and intensely concentrated on things like the elderly, chronically ill, and people who randomly role through with a one time episode of something.

For instance proper antibiotic selection can be tremendously complicated, and we can see this by looking at things like stewardship rates between NPs -> Urgent Care -> Procedural -> Primary Care -> IM -> ID.

Doctors almost always insist that their friends and family see actual doctors instead of NPs and PAs for a reason, and that's because the job is complicated and the training is doing something useful.

What's your epistemic certainty on this?

Low, although I'll note that my exposure to the field is much more extensive than you're thinking (although I'm not inclined to provide details). I'd definitely be interested in the data you're referring to - do you have any summaries I can take a look at?

If you meant for educational quality:

We've already introduced "lower education" doctors in the U.S. for awhile now, they are called PAs and NPs. It's been researched. Tellingly, their best case (presented by the nursing lobby) is research that shows that NPs results in equal outcome with U.S. MDs without controlling for case complexity (basically the doctors got the complicated cases, the NPs get the easy cases, and they still ended up with similar outcomes).

More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).

Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy

If you meant for the bottle neck:

I'm asking you, as I generally find that posters with an opinion on this don't actually know where the bottleneck is.

More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).

Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy

It's worth noticing that this source is from the AMA, which is an American physicians' group that lobbies to protect American physicians' class interests, including preventing mid-level health care professionals (NPs, PAs, etc.) from encroaching on practice areas seen as reserved for physicans. The url itself identifies this article as part of an advocacy campaign. The article highlights:

The AMA is advocating for you [American physicians] The AMA has achieved recent wins in 5 critical areas for physicians.

That doesn't necessarily make anything it says wrong, of course. But I'd expect the article published by the corresponding NPs' association to emphasize different observations and to reach different conclusions.

It's fair to say that obviously the AMA has an agenda, but it's also pretty objective that midlevels don't save any money (and in some cases cost more), it's just also popular with hospitals because they have a tendency to cost more in ways that benefit the hospital (like unneeded testing) instead of professional fees.

It's also pretty objective to say that NPs have 500 hours of training and doctors have 10k-20k. That gap is enormous and even if each hour of training is mostly worthless....it's a lot.

It's also true that NPs after graduating from a program can practice in whatever specialty they want with no specific specialty training, and changes fields with no training. Doctors require 3-10 years of extra training and retraining if they switch fields. Those years are generally 60 hour weeks minimum if not closer to 80 or beyond.

Even if you hate doctors that's a lllootttt of extra education.

NPs have 500 hours of training and doctors have 10k-20k. That gap is enormous and even if each hour of training is mostly worthless....it's a lot.

This seems to refer to clinical hours. Per wikipedia: During their studies, nurse practitioners are required to receive a minimum of 500 hours of clinical training in addition to the clinical hours required to obtain their RN. Let's leave aside the RN component. If clinical hours are the focus, then a typical NP who's been practicing professionally for 10 years has more than a physician who's been practicing professionally for 5 years.

This conversation brings to mind Yud's Is That Your True Rejection. Doctors are better than NPs, they have more clinical experience. No? Well then doctors are better, they have better outcomes. No? Well then doctors are better, they cost the system less money. No? Well then, doctors are better, their training is more rigorous. No? Well then, doctors must be better for some other reason.

The NP model was designed around the idea that experienced nurses working with significant clinical background would go back to school to get some "finishing." This is not the case anymore, it's extremely common for nurses to go for NP immediately because bedside nursing sucks and the pay is higher for NPs. Online only programs also exist now. I've seen an NP student exactly once in my entire career, she was shadowing in a family practice office doing nothing while the med students saw patients (she wanted to be an NP so she could be a medical director at a spa).

Claws out? NPs absolutely fucking suck and I see outright malpractice on a regular basis. And you can't even sue them for their idiocy.

Physician vs. Nursing training isn't apples to oranges, it's apples to wrenches. Physicians spend years being abused and called idiots in order to develop caution, intellectual humility, and limitation awareness, only when mastery has finally started to arrive does the confidence get papered over that fear. The nursing model is centered around establishing early excess confidence (so you can speak up if you feel the doctor is off base) and the what, never the why. And nursing tasks, which are incredibly important but learning how to make an IV tower stop beeping has precisely zero to do with with "this patient isn't having a neurological emergency you just got Albuterol in their eye."

If I had a dollar for every time I saw an NP managing someone in the ICU nearly kill a patient because they did the thing they always did (not realizing that with the specific patients comorbidity it'd be fatal) I'd fucking retire.

Urgent Care and Emergency Medicine (well, with the way most patients use this service) are extremely algorithmic and that gives people (both patients and yes also nurses and other healthcare workers) a false confidence in the simplicity in the provision of medical care but shit is fucking complicated and nursing training doesn't teach you jack shit, no matter how much of it you have. 30 years working in construction doing labor is nothing like going to architecture school.

A good NP can operate on the level of an Intern (first year resident) a great one can operate at the level of a second year resident. I've never, ever seen an NP operate at the level of a more senior resident or attending.

And oh god psychiatric NPs. Again if I had a dollar for every time I saw a patient managed by a psych NP who was on Benzos for their anxiety caused by excess Adderall I'd retire.

Nurses have better PR and everyone likes to hate on the doctor because we don't have time to talk to the patients, make a bunch of money (not really true anymore) and COVID etc. but the midlevel lobby is an absolute racket that is accelerating the death of the system through an excess of unnecessary consults, poor patient management, and a lack of easier breather cases for physicians.

Every physician I know who doesn't have a financial stake in midlevels (and isn't in admin) tells their friends and family to only see doctors whenever possible. That's for a reason.

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Yeah, that's what I was asking. Thanks for the link.

With regard to bottleneck, residency. Schools can't plausibly increase the number of students because they won't be able to place them.

My grumpy self has to say good, because that's more knowledge than I normally see, or perhaps Ive been ranting about this here for enough years.

We have an excess supply of med students (mostly provided by the Caribbean and outside the U.S., and therefore of much lower quality but still an excess).

However it's not as simple to increase the number of residency slots as you may think. You probably know that most residency funding comes from the federal government (and good luck getting them to fund more) but some states fund slots, as do some private hospitals (most notoriously HCA), as residents are a revenue positive thing (although hospitals will claim otherwise).

In the case of HCA the residents from those programs have been notoriously underprepared and unemployable outside the HCA ecosystem, not because the candidates are bad but because the education is bad. Robust medical education is very hard and expensive and complicated and in some cases like surgery you can't create more of it no matter how much money you spend (due to case requirements).

So increasing spots varies from "eh it's doable" in some specialties to very hard to impossible in others.

A related problematic trend is that people find primary care (biggest specialty shortage) and working outside big cities undesirable. Nobody wants to increase doctor salaries so it's incredibly hard to motivate people to go into primary care (it pays half as much and has more un-fun burdens like excess charting requirements) and nobody is ever going to convince a large number of people who had to skip their 20s to move to rural Iowa as soon as they have freedom without a massive pay bump.

But yes the problem is mostly allocation as opposed to shortage.

Residency is irrelevant. Even if you make the argument that US medical training and residency is vastly superior to Canada/UK/Germany/Australia etc, the US can and should simply skim off the top 20% of those countries’ trained doctors (who are surely at or above the American standard). They don’t because of the AMA cartel.

Let's just say for a moment that we want to take the 20% of all of the countries with good educations doctors. And that they want to come.

Is that remotely ethical? All practical and cost saving measures aside it seems kinda horrifying to just steal something so important to society like that.

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I'm with you in general. Americans overconsume health care to a ridiculous degree. I pretty much never see the doctor, just as I don't take my car into the dealership for a "routine checkup".

The reasons for the increase in life expectancy from 1900–present have little to do with doctors, and everything to do with public sanitation and vaccines.

But still, when I do access medical care, I can pretty easily tell the difference between the doctors who are quite intelligent and the midwits who also populate the field. The bar to cross is not THAT high, and medical errors kill untold numbers each year. Diagnosis in particular is not always easy and I don't think there's a skill ceiling. A higher IQ is always going to be better.

Americans have a lower life expanctancy than Costa Ricans, Thai people and Chileans. The US and China have roughly the same life expectancy. There are two scenarios: Americans live incredibly unhealthy lives and require 17% of GDP to be spent on health care to keep a decent middle income life expectancy or Americans live some worse than other countries and have somewhat better medical care yet get minimal bang for the buck.

We do. We’re rapidly approaching 50% obesity. We eat like crap and don’t exercise and that by itself I think lowers life expectancy by at least a decade. Add in stress and it’s like nobody should be shocked by the American life expectancy. It’s like asking why the car where you never change the oil needs more repairs than the one that gets regular maintenance.

The question should be if Costa Rican, Thai, and Chilean gringos have lower life expectancies than Costa Ricans, Thais, and Chileans.

Globally, the US has unimpressive average scores (surprisingly so, for non-Noticers) on standardized tests like the PISA for… socioeconomic reasons. Yet, after a simple control, the US comes out looking solid.

Americans have a lower life expanctancy than Costa Ricans, Thai people and Chileans. The US and China have roughly the same life expectancy.

Yep.

Most medical interventions don't matter that much for people without lifestyle disorders. Skin cancer, for example, collectively only takes 9 days off U.S. life expectancy. So if we CURED skin cancer it doesn't move the needle. Rinse and repeat with a bunch of other diseases.

On the other hand, the existence of diabetes likely lowers U.S. life expectancy by years, and that's with all the treatment. Did you know that 1% of the U.S. budget is spent on dialysis and the average 40 year dialysis patient only lives 8 years?

All in all, we spend like $5 trillion a year just to undo all the damage from our lifestyle diseases. It's pretty sick.

The crazy pill is that most medical interventions don't matter that much for lifestyle disorders, either, because for the most part, they can't undo the damage from our lifestyle diseases. I was just listening to this podcast with a couple MDs, and he was talking about chronic conditions generally, and a bit about obesity, specifically:

We don't really have the infrastructure to help with prevention, so you talked about how in medical school, we didn't have a single course on dying. We also didn't have a single course on nutrition or exercise or stress management or the psychology of eating and our relationship to food and how you can help patients make better choices with nutrition and things like that, so I don't buy the narrative that we have an obesity crisis just because people are fat, dumb, and lazy. I think that we live in a toxic food environment, and we don't have a healthcare system that's really geared to help people out of it, because frankly, physicians aren't compensated to do that. You just don't have the billable structure in which you can do these things, so instead, I think we focus on where our tools are, and our tools are drugs. Drugs become a good tool to use in a chronic condition setting.

Moreover, they often have patients who don't want to change their disordered lifestyle and wouldn't carry through with doing it even if the doctor had training and a billable way of doing it. So, they sort of default to, "When the chickens come home to roost, I guess we'll give you a drug to help manage your symptoms somewhat."

It's irrelevant because no one actually cares about their doctor's academic credentials. Maybe fail rates are higher at UCLA but UCLA is hard to get into to begin with, so I imagine the coursework is harder than at a place like NEOMED. And there are already schools of osteopathy that seem to attract people who couldn't get into MD programs. I'd be willing to bet that if I were to take a random poll few people would be able to tell me where their doctor even went to med school let alone how highly that school is regarded or what their grades were. Like almost everything else, once you get your first job your education is pretty much irrelevant.

You'd be surprised how much academic pedigree "matters," plenty of people don't care but you'll find soccer moms, educated people, the neurotic and all kinds of others very insistent on a "good doctor from a good school with good reviews on google," despite how often many of those disconnect from reality. For us it can matter because certain of jobs (like being a program director) may be essentially closed off to you without training at a "good" institution. Now, again this isn't necessarily reality based but it matters to a lot of people.

What you might find more interesting is that programs don't really work like undergrad or other fields. The preclinical half of med school is essentially the same country wide, in a large part because students have settled on a half dozen ultra high quality learning resources and ignore whatever the hell their school is trying to do. Pass rates for the exams (which can be using standardized exams but don't need to be) and boards (standardized) are higher at higher tier schools because the students are better. Therefore fail rates jumping is a huge huge black mark.

The other half of medical school is clinicals which uses standardized exams and evaluations from preceptors to determine your grade. The evaluations can get more program dependent and may actually have deflation, but this is also where variation in educational quality comes in since most schools pre-clinicals are basically the same* these days.

This is a gross simplification but for the purposes of this discussion should do.

Therefore fail rates jumping is a huge huge black mark.

So to speak

It's irrelevant because no one actually cares about their doctor's academic credentials.

That's the old way of thinking under how things used to be. They are no longer that way, and how people think about it will change.

no one actually cares about their doctor's academic credentials

Maybe not for their general practitioner or dermatologist or whatever. But if you get cancer or need brain surgery or something, then people care about the credentials of their oncologist or surgeon.

I'm not elite enough in any respect to really merit an elite doctor. I go to the doctors' office nearest my house. My doctor is a nice Indian lady. Maybe she's good, maybe she's not, who knows.

My doctor is an African immigrant. Which as HBD enjoyers have informed me means he is probably an unusually high IQ individual.

Subjectively he seems competent enough to me. And by importing an African some American medical program got to juice their diversity stats. Win, win.

I encourage this attitude, it's extremely hard to know if your doctor is good or not because the things that are available for a patient to know are generally customer service things that are often extremely uncoupled from actual medical knowledge and practice ability. Very common for people with good customer service skills to be bad doctors.

I would wager that all things equal the more acerbic personality will have higher skills (otherwise how to compete?)

It does, it's very common for patients to ask for things they don't need or for things that may be bad for them (classic examples are controlled substances and antibiotics). People don't like being told things like "just wait out the infection, it is viral" or "well I know you are in pain, but actually the narcotics are bad for you." People who just prescribe like crazy get better reviews.

Inpatient things can be a bit more different, but those encounters don't generally result in reviews.

And that's not counting things like psychiatry where a good psychiatrist is always going to get angry reviews from certain classes of patients.

People don't like being told things like...

The classic example that comes to mind here is "Have you tried eating healthier, getting more exercise, and losing weight?"

"Your diabetes is so advanced your limbs are falling off." "Stop fat shaming me."

You are taking that cartoon out of context. It isn't saying that the patrient's arm fell off because of diabetes. It's showing the patient complaining about one thing, and the doctor telling him routine boilerplate about losing weight that has nothing whatsoever to do with the patient's problem. The patient is not ignoring the doctor's advice about weight, the doctor is ignoring the patient's complaint by mentioning weight.

Note that the cartoon nowhere says "diabetes" or "fat shaming".

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"I came for my Vicodin for my joint pain, not to be fat-shamed, you sexist pig!"

I saw something about black surgeons having poorer performance by some metrics. Trying to find it now Google is disregarding my search terms and instead showing irrelevant articles about how we need more black surgeons and how black patients may be receiving worse medical care. Thanks for nothing, Google.

Welcome to epistemological hell.

When LLMs become the default store of knowledge, forbidden information will become even more difficult to find than it is now.

Not only did Jeroboam post it, you are replying to a reply to that post.

The curse of directly replying from the comments feed

Try Yandex?

This has been huge, students used to spend 2+ years studying to get the highest possible score on an exam they get to take one time so you had to be sure. Now they just try to pass. Now a lot of that exam was stuff that "doesn't really matter" (ex: biochem pathways) but the incentive shift was absolutely massive.

You get shit on so much in medical education that I find most people forget what the exams are for and minimize their value. A good chunk of preclinical learning is laying the ground work for later knowledge growth (Step 1, the relevant exam, included). We also need something that isn't pure pedigree or totally luck of the draw and subjective evaluations to provide candidate discrimination. It also needs to happen early enough for people to filter themselves to specialties that will be actually realistic for them.

Basically Step 1 + Clinical Evaluations (but not preclinical grades) and the usual Letters of Rec/Research/EC.....that shit worked great.

However Step 1 was enormously stressful and got harder to write questions for due to exam prep resource inflation. Someone uncharitable may also note that minorities tended to underperform. So they made it pass/fail.

This killed student motivation in preclinicals (which is again, supposed to be foundational knowledge) and was a huge win for premier med schools (and loss for lower tier ones).

If I had to change one thing I'd increase the weight behind Letters of Rec - they are unpopular these days and admittedly make things harder for those without a medical family (and I was one of those) but done responsibly they can do a lot to recognize good and well trained candidates.

Returning to Step 1 - people get upset because a big chunk of the exam is "low yield" but that's because everyone successfully learns the basic stuff. And they need to. And the old exam format forced them to. The low yield stuff is also things that doctors should be vaguely aware of because you'll see individual rare cases all the time, just not a specific rare case.

Yeah most of the research industrial complex is bullshit, fair enough.....but the rest of it makes sense.

Medical exams are hard (and not like most exams you see), someone who was in the top 5% of their class at a respectable undergrad institution can spend two years studying for Step 1 and still barely pass it. Shit is hard. Part of this is driven by how modern test questions are designed. Little of it is fact recall and questions are mostly second or third order. Some have multiple correct answers and you are supposedly to be figuring out what's most likely and even sometimes essentially from first principles (especially in Step 3). Step 1 is a bit hard to do this in because the material is more basic and it's (well, was) our primary "you get to go somewhere nice after graduation" exam because it happens earlier. Thus the vaguer content, but it does serve a purpose and every question ends up having clinical utility for someone, even if it's just a medical geneticist.

A good chunk of volunteering is bullshit but this requirement (absent the social justice end of things) is meant to establish life experience which you otherwise would not have because career changers are still pretty rare and medical education is all encompassing.

Letters for admission to med school are often the way you describe but letters for residency absolutely should involve someone who knows you well and has seen you work, if that doesn't apply for a student they were doing it wrong.

Medical exams are hard (and not like most exams you see), someone who was in the top 5% of their class at a respectable undergrad institution can spend two years studying for Step 1 and still barely pass it.

In 2021, before USMLE Step 1 moved to pass-fail, 98% of 1st-time takers from MD programs passed per here. By comparison, the first-time pass rate for the California bar exam (to practice law in the state) is roughly 45% per here.

I mean what I say quite literally, you can be a top of your class science student at a reasonably good institution, study for two years specifically for the test (including a multi-month "dedicated" period where your only job is to study for this test), spend thousands of dollars on incredibly well designed test prep material and that still might not be enough.* Keep in mind that this is after multiple filtration points designed to weed out people who aren't good at hard work and studying.

The bar is designed to be acceptable to fail multiple times, law school is not set up exclusively around passing the bar, and while admissions can be rigorous at top institutions it's got nothing on the adderall snorting madness which is med school.

*and while the fail rate is low, failing it fucks you over incredibly, and getting an average score looks you out of entire specialities and regions for residency.

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“We need affirmative action to normalize black doctors and make people less racist and lessen stereotype threat when comes to grades and MCAT scores” -> Black doctors less in human capital -> Patients reluctant to go to black doctors -> “This is all just further proof that we need even more affirmative action to normalize black doctors and make people less racist and lessen stereotype threat when comes to grades and MCAT scores”

I hate to say it, but if I or a loved one was seriously ill, I would try my best to get a non-black doctor. If I wanted the best, I'd probably follow Peter Griffin's advice.

Why should you hate to say it? There should be no shame in applying a little Bayes to keep yourself and your loved ones healthy. However, beware of imposters and their stolen valor.

In the future, will black doctors magically have tons of open appointments while the cue to see Dr. Rosenblatt grows ever longer?

And there's the argument for a socialized/centralized healthcare system.

I'm looking at the data in the linked article and having some difficulty squaring the two images with each other, and with the thesis more broadly. The second chart, which has data from 20-21, 21-22, and 22-23 does show a substantial rise in fail rates on various exams. However the first chart, which has 22-23 and 23-24 data seems to show an increase in pass rates, in some cases quite a large one (Pediatrics 1A block goes from a > 50% fail rate to around 20%). The data also seems inconsistent between the two charts for the one year (22-23) on which they overlap. For example, the Pediatrics Block 1A failure rate in the first chart seems to be in excess of 50%, but the Pediatrics 1A block in the second chart seems to be < 20%. Similarly the failure rate for Family Medicine block 1B is in excess of 50% for the 22-23 year in the first chart, but is less than 30% for the same year and block in the second chart. Which number is correct?

I look at the charts and see a gigantic increase in fail rates from 2020 to 2023, followed by what appears to be a decrease in fail rate in 2024 (but still massively above the previous baseline).

In honesty, we can never know what these tests look like year to year. Perhaps they gave everyone an A during the Covid years. Perhaps they dumbed down the test in 2024 so more people would pass.

We'll never have the objective data we need, and the powers that be want it that way. I agree that surreptiously-taken screenshots is no proof, but it's not like UCLA is going to publish data that shows they are graduating incompetents.

Who knows, maybe despite lower MCAT scores black doctors are just as good because they compensate in other ways. Are you willing to bet your life on it?

Haven’t we already done this experiment and it failed miserably. Killer King hospital did exists and people tried not to go there.

Wow, I did not know about that. Yikes. Poor Martin Luther King getting all the worst stuff named after him.

So basically, those who supported the practice of associating his name with the bad part of town might as well have been the, er, MLKKK.

Activist goals (the stated ones, anyway) would have been better served by just trying to get more high-human-capital into medicine. But that’s a bridge too far.

Sure, it definitely seems like there's been an increase in failure rates, but why are the charts inconsistent about failure rates in the same year? It also seems weird to blame black doctors specifically. According to the chart on racial admission data in the article black enrollment over the 2019-2022 time period (the article doesn't have 2023 or 2024) was essentially flat (2212% to 2413%). Unless there is some huge un-shown spike in black enrollment in the last two years it seems hard to see how having a more-black student body is responsible for the increase in failure rates.

ETA:

After reading the article a bit more closely I realized I was interpreting the demographic change chart incorrectly in the context of the tests. Medical school takes four years and the shelf exam test scores in the charts are coming in the third of that four years. So the 22-23 class that has the horrible scores is actually the 2021 demographics and the 23-24 class with the improved scores is the 2022 demographics. We don't have test scores for the last two bars on the demographic chart because they haven't taken the tests in question yet. So the improved 23-24 test scores were achieved with a demographic makeup that is less Asian and more black than the worse 22-23 test scores.

ETA 2:

As Joyful points out below they removed a year of coursework, so this is happening in their second year, so the 2022 demographics are the 2023-2024 test year.

ETA 3:

Confusing numbers for percentages. Updated.

Most likely UCLA is experiencing much more trouble attracting the limited pool of black students with good test scores now that every other school in the country is aggressively poaching them.

Morehouse college has the same problem despite going from 100% black to 100% Black

The immediately visible effects of AA first show up at the lowest ranked schools and work their way up. When Harvard takes the 1050 SAT guy who would have gone to Evergreen State, Evergreen has to settle for the guy who learned to write his name in his juvie GED program.

Combined with the rise of Grade-Inflation Studies degrees and endless free money, it's the perfect cover for everyone who matters choosing to ignore the consequences.

As a matter of simple mathematics, assuming the first chart with the > 50% fail rates is correct, this cannot be the whole story. In the Family Medicine category failure rates go from around 10% in 21-22 to around 50% in 22-23%. Even if no black students had been failing in 21-22 and every black student failed in 22-23 that would not be enough of a change to explain this difference, unless the fraction of students who are black also doubled.

nd 2+ years studying to get the highest possible score on an exam they get to take one time so you had to be sure. Now they just try to pass. Now a lot of that exam was stuff that "doesn't really matter" (ex: biochem pathways) but the incentive shift was absolutely massive.

The article mentions that they also changed the curriculum from two years of coursework to one.

Not sure what they are talking about specifically (the linked data was for clinical "shelf" exams and the course length change is preclinical) but a number of higher tier schools started to condense the traditionally two year preclinical curriculum into a year and a half or so (the spared time was used elsewhere).

This transition predates making Step-1 P/F, COVID, and recent social justice advances, but not every school is picking it up at the same time. They may also start to roll it back because it can be very rough on students.

A number of massive changes have hit medical education all at once, some of which are quality suppressing some are not.

Wait, 24% of UCLA med school admittees are black !?

Blacks are 14% of the national population, and like 6% of California's population. What is going here? Those numbers can't be right, can they?

Those aren't percentages; they're numbers.

Appreciate the correction, updated my post with the correct numbers.

Welcome to why Affirmative Action makes Asians and Whites furious

If you read the article linked in the Twitter post, you'd see that Asian enrollment dropped by about 1/3 and Hispanic enrollment went up about 50%. Black enrollment seems to have mostly held steady.

How many legions hath the Supreme Court? The answer, alas, is "not enough". The race-pushers know they can just ignore the decisions and the worst thing that happens is someone tells them not to do that again.

If this isn't your wake up call to get healthy now, nothing is. Best way to never have to see a fake doctor is to never get sick. Eat right, exercise, hope you don't have any genetic predispositions towards chronic conditions. Do it now, because it's way harder to unfuck your health than it is to maintain it in the first place. Once you see your GP and they are axing you about your medical history before you ask about this pain in your gut that hasn't gone away for three weeks, it's over for you.

Eat right

Easier said than done, given how everyone and his brother has an opinion on The One True Right Way To Eat, and all these opinions contradict each other.

It's easier than you think. Avoid processed foods and refined sugar and you are 75% of the way there. Yeah, it involves picking up lots of meats, vegetables and grains and cooking them yourself. Sometimes even those are still adulterated, but it's still gonna be better than boxed slop.

Sure, everyone swears by a one true right way to eat that is better than all other ways. But that doesn't mean give up, especially when there are so many pretty obvious, and pretty universally agreed upon things you could do to move the needle in the right direction.

Processed foods are a meme. Washing and cutting up counts as processing for the FDA. It’s a ridiculous standard.

https://yuka.io/en/

This is the app I use, it scans barcodes and tells you how healthy the food is.

We're not cavemen, we have technology.

Well shit, then I guess learned helplessness is the only possible answer. Not using the eyes in your skull to perceive that the veggie tray is categorically different from the canned "Hearty Vegetable Stew" with 30 added grams of sugar, along with more unrecognizable ingredients than not. It's all processed! Nothing to be done about it.

That’s not the point. The point is that ‘processed’ is a bullshit designation that doesn’t mean anything and has no information about the health impact of a foodstuff.

Pop tarts aren’t unhealthy because they’re “processed food”. One could likely have an entirely healthy diet consisting of processed food. The term is irrelevant.

There was a bit I read once, possibly even on Slate Star Codex, that went a bit like this:

Person A: I don't want to eat (food item), it has too many chemicals in it.

Person B: I don't understand what you mean. Everything we eat is composed of chemicals - even water is a chemical!

Commentary from blogger: But, of course, B is being deliberately pedantic, and knows perfectly well that A is objecting to ingredients with complicated names that nobody uses in home cooking and most people don't even know what they are, e.g. sodium benzoate.

It seems like you're being Person B here? Yes, "chemicals" and "processed" are technically overbroad, but they work pretty well for normies to communicate concepts like, "this category of food tends to be low in fiber, high in added sugar and salt, and has good odds of being designed by food scientists to be as tasty and un-satiating as possible so you'll eat more of it per sitting and thus spend more money buying more of it".

B knows what A is gesturing at, but doesn't know what A means because A doesn't either, and that's the point of the objection.

Scott's covered two hypotheses for what the issue with "processed food" is:

  1. it has more degrees of freedom, and food producers' incentives are to trick you into eating 500kg of their food and becoming a balloon so more degrees of freedom for the producers are bad for you,
  2. it's invariably full of vegetable oil, which "normal" food is not.

Yes, many definitions exist which do not correspond one-to-one with a reasonable hypothesis such as these, and to the extent they do not they will be less effective than they could be, but the basic idea of categorising things this way is not insane.

I’d hazard a guess that regardless of definition, processed food will have a strong correlation with unhealthyness.

Listening to the FDA here won't work well. But somehow I doubt that "I look at the food and decide whether it counts as processed" will work well either.

There are dozens of "this is the real diet that works that Big Food doesn't want you to know about" diets which have worked for large numbers of people including smart people. The only thing they seem to have in common is severely restricting refined sugar.

I don't see how you can live well as a normie in a country where the bread is sweetened by default.

Mostly the one weird trick stuff works on two pillars. One, it requires you to pay attention to what you eat. If you’re doing Paleo, you can’t just go buy something that sounds good, you need to read the label and evaluate the ingredients. That alone is a huge help. Second, because the market hasn’t yet caught onto the trend, there aren’t boxed versions of that diet’s foods available. If you were doing Paleo or Keto or Gluten Free when it first became a thing, you had to get the foods and cook them yourself. That eliminates most processed foods from your diet. In early Keto, before the food manufacturers started making hungry man keto foods, you had to get real fresh chicken or steak, real vegetables from the grocery store, and cook them yourself. So you’d end up making marginally better choices even if the new fad diet was based on unicorn farts.

even if the new fad diet was based on unicorn farts

Oh, fasting, I've done that. :-)

I don't see how you can live well as a normie in a country where the bread is sweetened by default.

Buy a bread maker?

Healthier people tend to receive more medical care throughout their lives because they live into old age, when things start to slowly fail. Fat people, alcoholics, etc., tend to drop dead quickly and receive less medical care during their lifetimes.

I'd still rather live to a ripe old age and drop dead of medical malpractice in an "equitable" healthcare system than wreck my body young. Current statistics about amount of medical care used mean nothing in the face of how "equity" is cannibalizing all other concerns going into the future.