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The Dark Side of Doctoring

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Re: The Dark Side of Doctoring

#131

Post by killjoywashere »

vacri wrote: post #124
markroseman wrote: post #67

Earlier quoted context omitted.

I'll just pick up on one piece of what you said, "meds from a psychologist." While I don't disagree that greed may be a part of it, unless that person's extra training involved a medical degree... that's truly been a crazy idea given the things that can go wrong even with "simple" medications, even when you know what questions to ask about other preexisting conditions and how to interpret the answers. The other thing…

I co-majored in a psychology and neurophysiology degree - psychologists should absolutely and totally be excused from meds prescribing. They do zero serious biochemistry, and often not even token biochemistry. Meds may need to be allowed to be prescribed by other professionals, but whoever it is should need to do some serious biochem training in some manner.

> biochem training

and pharmacology, and physiology, and several years on the wards watching the meds go in, watching the pee go out (or not), seeing what happens to the patient, sorting through laundry lists of meds at admission and discharge, losing arguments with pharmacy about why that max-concentrate K-Phos is a bad idea considering the patient's CCr was 1.1 yesterday and now it's 1.4, etc, etc.

Re: The Dark Side of Doctoring

#132

Post by pmiller2 »

joshuaheard wrote: post #95

I am a lawyer, and if this was a lawyer's story, this would be my advice for the firm. First, they need to hire more lawyers. This guy is way too busy and will make a mistake. Second, he needs a receptionist, secretary, and paralegal to support him. It is wasteful to pay him a doctor's salary to answer phones. Third, they need to streamline their record keeping so he doesn't spend so much time filling out paperwork.

What's the medical equivalent of a paralegal? A good nurse?

Re: The Dark Side of Doctoring

#133

Post by killjoywashere »

ploxiln wrote: post #57
hammerzeit wrote: post #32

Earlier quoted context omitted.

My spouse is a doctor as well, and I've also observed the issues the author discusses. I don't think your read of the causes here is correct. It's worth reading more about the history of medicine to truly understand what's going on here -- the culture of abusive overwork in American medicine goes at the very least back to Osler and the invention of the modern residency program, and has as much to do with cocaine than…

Maybe patient handoffs are so dangerous because of the dysfunction everywhere else in the system. Maybe patient current-state summary and recent-changes log could be much better maintained, if doctors had a bit more time and the forms/systems for it were refactored a bit. Doesn't it sound like medicine is like a web service infrastructure where everything is on fire, and there's just no time to really fix the root ca…

> patient handoffs are so dangerous because of the dysfunction everywhere else in the system

Anyone who has participated in a root cause analysis at a hospital knows that.

Re: The Dark Side of Doctoring

#134

Post by vacri »

wighty wrote: post #93
macrael wrote: post #13

Earlier quoted context omitted.

There is a tradeoff that is used to justify the long hours. On the one hand, having a well rested doctor is obviously good for them to be making good decisions. But on the other hand, patient handoffs are dangerous. The more times you change the person responsible for a patient, the longer the game of telephone you are playing with their care. This has been measured as being bad for patient outcomes. Now, that doesn'…

> patient handoffs are dangerous. I hate when this gets brought up, because it inherently implies that we can't improve them. Everyone talks about increases in handoffs causing increases in medical errors. I think handoffs have a long way to go, and we need to better utilize technology to help in this (ie make better EMRs). The overworked doctor is just as bad IMO. I've been there on solo 28 hour calls going on my 11…

I had a friend who was a QA process engineer at a regional hospital. He identified a significant source of errors - every morning there was a 'double-handoff' as the doctors handed off to nurses, who ended their shift and handed off to the next shift. The problem would be solved by moving hand-off time by a mere 15 minutes, but neither the doctors' group nor the nurses' group would budge on the matter.

I've heard a few other similar stories from him as well. Doctors have immense political power; if hospitals are grinding them to dust, it's because doctors as a group are letting them (the good old 'seniors don't care that juniors are getting crushed' problem). From my own limited experience working with them as a neuro tech, doctors will close ranks quickly against outside forces, but plenty will sell each other out within the profession. For every haggard ED doctor, there's a specialist somewhere making cushy deals with the administration.

Re: The Dark Side of Doctoring

#135

Post by killjoywashere »

pdelbarba wrote: post #16
macrael wrote: post #13

Earlier quoted context omitted.

There is a tradeoff that is used to justify the long hours. On the one hand, having a well rested doctor is obviously good for them to be making good decisions. But on the other hand, patient handoffs are dangerous. The more times you change the person responsible for a patient, the longer the game of telephone you are playing with their care. This has been measured as being bad for patient outcomes. Now, that doesn'…

Maybe OT, but pilots have a lot of time off between shifts and it's starting to come to light that their depression rates are much higher than anyone is comfortable admitting. This may from a different source though, since flying is very much about precise repetition and less about complex decision making (ADM is hard, but not the same level of mental stress that doctors endure), you eventually realize that you're a…

Pilots have more incentive to manage their fatigue: if they screw up, they die.

Re: The Dark Side of Doctoring

#136

Post by bobbington »

Us government ruining everything. GET OUT OF MY LIFE GOVERNMENT. The government should have no say in who can practice medicine. Currently it's a criminal racket as far as I'm concerned. It requires like 15 years of higher education to be able to be a doctor!! That's so stupid, especially with google. And once they graduate, it leads to a false sense that they know it all.

Government prohibiting the practice of medicine is the cause of so much ill in this country it is ridiculous. It stifles innovation. The official doctors have been known to ridicule things that were proven critical to success. For example now we know that germs cause disease. Well back in the day, they ridiculed people for belicjnf that microscopic bacteria could kill people. As a. Result doctors killed. A lot of people through their terrible practices. It still happens today.

Re: The Dark Side of Doctoring

#137

Post by killjoywashere »

jakewins wrote: post #43
qudat wrote: post #38

Earlier quoted context omitted.

tl;dr Federal health spending is the limiting factor. Question: Why do we need the government to fund residents? The fact that every single going-to-be physician must do so through government funding boggles my mind. On top of that, depending on the number of hours worked, many residents barely make minimum wage.

It's needed because the private sector isn't paying for it. There's no law that says private hospitals can't fund residency slots - in fact they fund many of them - but, as the source you're commenting on says; "[medicare is] the principal source of residency funding".

And the "private sector" is the existing physicians. Every dollar they pay a resident can't be used to buy their spouse more Prada or new tires for the Porsche. But the AMA had kept the valve throttled so long, society was desperate. Seeing a bunch of short-term greedy louts who apparently didn't study much math (don't get me started), the government seized the opportunity to pay for residencies, which created a Venturi effect where they can suck up not just the MDs, but added the flow from two other pipelines: the DOs and IMGs. And the flow has been so vigorous and steady that additional medical schools have opened outside the US borders (the Caribbean, Middle East, etc) to support the flow.

Re: The Dark Side of Doctoring

#138

Post by pdonis »

pixelmonkey wrote: post #77
kem wrote: post #66

Earlier quoted context omitted.

There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someon…

I think the credentialing in medical practice has more to do with the stakes involved than in some salary-padding or labor-control scheme. Patients want to be able to enter a hospital and have confidence that, when push comes to shove, even the worst MD on call is a better option than a "no-op" treatment. Also, exorbinant salaries and good hours are not to be found in the hospital system. Yes, specialist doctors get…

You are blaming the failings of the US healthcare system on "the market", but the market in health care in the US is not anywhere close to a free market. Some key reasons why not:

(1) The supply of doctors (and other health professionals) is restricted by licensing, not driven by the demand for their services.

(2) The price of health care is not determined by supply and demand, but by various regulatory arrangements and bulk agreements which often do not involve either the producers (doctors, hospitals, etc.) or the consumers (patients) of the services. So the parties who are determining the prices are the ones with the least possible stake in the outcome.

(3) The consumers of health care, patients, are almost always unaware of the cost of the services they are getting, so they have no way of knowing whether those services are worth more than they cost, and hence no way of signaling where health care is being inefficiently provided.

(4) What the US healthcare system calls "health insurance" is actually a combination of insurance and prepaid health care. Insurance is supposed to be for unforeseen costly events, but most health care does not consist of unforeseen costly events but of predictable expenses (annual physicals, shots) and unforeseen not very costly events (you go to the doctor with the flu, get an exam, and are told to rest and drink lots of fluids).

(5) Prescription drugs are regulated by a regime (the FDA) that is heavily penalized if an approved drug has any bad effects whatsoever, but suffers no penalty whatsoever for keeping helpful drugs off the market for years while they undergo "testing" and hence depriving large numbers of people of their benefits.

I'm sure there are more, but those are just the ones I came up with off the top of my head.

Re: The Dark Side of Doctoring

#139

Post by vacri »

epmatsw wrote: post #83
markroseman wrote: post #17

Earlier quoted context omitted.

Absolutely it's about the administrative end and not patient care. We've got a situation in our regional health authority (Vancouver Island, BC, Canada) where they're trying to roll out a significant update/expansion to their EMR (Cerner-based) in the hospital in Nanaimo. Despite immense pressure, some docs have been now suspended for refusing to use it and switching back to paper, despite the massive increase in tim…

This is a pretty shocking opinion to see expressed. Like, you may as well have said "A bunch of developers at decided to go back to C89 because writing code in Rust was too slow, plus did you see the bugs in its borrow checker?" . Do you really believe that paper is a safer alternative?

A better analogy would be ticketing in Jira versus ticketing with Post-It Notes. The main job of the professional (medicine/programming) is not what's at stake here. We're talking about documentation. Jira is a heavyweight ticketing system that is okay, but a lot of people are really slowed down by it, and if there are problems with the network, no-one gets much effective work done. Post-its are less visible to all stakeholders, but they let the worker get on with their primary job with less interference.

Keep in mind that medical software isn't written with the latest and greatest frameworks and UX designers.

Re: The Dark Side of Doctoring

#140

Post by pdonis »

467568985476 wrote: post #70
kem wrote: post #66

Earlier quoted context omitted.

There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someon…

I have a hard time believing that the "free market" can solve healthcare given that the demand for it is more inelastic than pretty much any other product.

The demand for food is also pretty inelastic, yet the free market seems to handle that fine.
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