The Dark Side of Doctoring • Hacker News Board

Re: The Dark Side of Doctoring

#151

Post by whitenoice » Tue, May 16, 2017, 4:36 AM UTC

riahi wrote: post #74

killjoywashere wrote: post #35

Earlier quoted context omitted.

There are ~30,000 PGY-1 spots and only about 18,000 allopathic medical school graduates. (1) All the native allopaths and all the osteopaths together can't fill all the residency spots. We inhale foreign medical graduates. (1) Pages v and 14: http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Re...

This is a bit more nuanced than this. There's 31,757 positions offered. However, if you are applying into a specialty, you apply simultaneously for a PGY1 and PGY2 position, so those people are being double counted. As a result, you need to subtract 2,677 advanced positions from the 31k positions, yielding 29,080 PGY1 + PGY2. There are 18,539 US MD applicants, but with the merger of the ACGME and COCA, DO applicants…

When it comes to the admission process aren't all IMG's considered the same irrespective of citizenship. So 5069 (citizens) + (x non-citizens) compete for the remaining seats (6951). Isn't that correct?

Re: The Dark Side of Doctoring

#152

Post by killjoywashere » Tue, May 16, 2017, 4:44 AM UTC

kyouens wrote: post #149

killjoywashere wrote: post #123

Earlier quoted context omitted.

Depends on who's complaining about a bottleneck. The AMA caters to a base that is not happy with the influx of IMGs and DOs. The AMA inflates their numbers by auto-enrolling every allopathic medical student. The AMA is equally unhappy that the government using large scale funding levers at the residency level to overwhelm their efforts to tighten supply. By using money and their exclusive access to legislate, the gov…

I'm also a physician. I am generally satisfied with my work, but I do feel distressed by what feels to me like erosion of the social contract between doctors and society that flourished during the second half of the twentieth century. It sounds like we agree that some of that erosion has occurred because of nakedly self-serving political action by medical professional societies. When I made the decision to become a p…

Don't get me wrong, we have a great gig. A fellowship director once expressed shock that I would advice my kids to go into medicine. I asked him "Have you looked for another job? I had a job before this, and had to look for another before I got an acceptance letter, married with two kids. Have you looked at the job market? What other job pays half as much, is half as satisfying, or gives you half as many further opportunities?" His reply: "Yeah, I mean, when you put it that way..."

Well, what other way are you going to put it?!

I'm all for organized medicine. But I favor PSR and MSF. They represent the ideals of the modern liberal social order. The AMA needs to be starved off the face of the earth.

Re: The Dark Side of Doctoring

#153

Post by kendallpark » Tue, May 16, 2017, 4:55 AM UTC

hbosch wrote: post #114

kendallpark wrote: post #81

This is a problem in medical school as well. I can't tell you how many anonymous posts have been popping up on r/medicalschool lately about being depressed, isolated, lonely, and/or suicidal. Missouri just passed the first bill of its kind to try and combat mental health issues in med school. http://krcgtv.com/news/local/medical-student-suicide-prompts... > The bill, also known as the Show-Me Compassionate Medical Ed…

I have a friend who is graduating from med school this week and starting residency. The stories of med school drama, gossip, backstabbing and cheating are insane - on par with anything on television drama. Moving into residency, they also feel alone, exhausted and anxious... I don't know how many people manage. I think knowing a doctor, or someone becoming a doctor, has changed my perception of doctors entirely.

I am fortunate that my school seems to vet the students well for character. Or perhaps it's self-selecting because we do PBL which requires collaboration. We don't have the issues with backstabbing and drama that I've heard from other schools. I think my classmates are perhaps my favorite part of the med school.

The scariest thing in med school is how vulnerable you are to someone with authority screwing over your entire future. Piss off an attending? Well, they could right a terrible letter for you that hurts your ability to match into the specialty you want. You could straight up witness mistreatment of a patient by a superior, report it, and have your entire future altered forever because of people above being petty or vindictive.

Re: The Dark Side of Doctoring

#154

Post by devdas » Tue, May 16, 2017, 4:56 AM UTC

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…

Regulations for pilots currently mean that any treatment for depression means the pilot will no longer have a valid license. https://www.faa.gov/about/office_org/headquarters_offices/av...

Re: The Dark Side of Doctoring

#155

Post by Herodotus38 » Tue, May 16, 2017, 5:32 AM UTC

pmiller2 wrote: post #132

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?

They are called scribes (or medical scribes if you want to google it and not get hits about ancient Sumer). It is a relatively new position, largely populated by people considering and applying for medical school.

Re: The Dark Side of Doctoring

#156

Post by ars » Tue, May 16, 2017, 5:32 AM UTC

pmiller2 wrote: post #132

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?

Nurse practitioner.

A tremendous amount of stuff that normally only doctors do can be done by a nurse practitioner, and since it's much easier to train them, (because they don't need as much schooling) there are far more of them.

Basically give them the "easy" stuff and reserve the harder stuff for the Dr. Or have a Dr. consulting for a team of nurse practitioners and they go to him with questions and summary.

Re: The Dark Side of Doctoring

#157

Post by stickfigure » Tue, May 16, 2017, 5:34 AM UTC

nathancahill wrote: post #115

nkurz wrote: post #63

Earlier quoted context omitted.

We have two family members in an assisted car facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay…

More book recommendations on HN should be a link to a good review like this, instead of just an Amazon link.

Sure - convince Scott Alexander to review more books? The problem is the supply of good reviews like this.

Re: The Dark Side of Doctoring

#158

Post by mowenz » Tue, May 16, 2017, 6:26 AM UTC

slackingoff2017 wrote: post #108

pixelmonkey wrote: post #18

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commoditi…

It's well known within the medical field that being a doctor is really really tough. It takes a lot of smarts and grueling years in residency before you officially become a doctor. However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. T…

They work very hard to provide a valuable service to people in need.

Contrast that with what exactly is provided by healthcare insurance executives, bankers, lawyers, lobbyists, and certain departments in government.

To be blunt: once you note the fact that other countries in the world can provide healthcare at fractions of the cost, it's obvious those insurance execs, politicians, and lobbyists are eating value, not creating it. The contrast is that Doctors actually produce something of value.

Re: The Dark Side of Doctoring

#159

Post by B1FF_PSUVM » Tue, May 16, 2017, 6:45 AM UTC

dikdik wrote: post #96

pc2g4d wrote: post #45

So... because the supply of doctors is restricted but demand for doctors grows proportionally to the population, the amount of work per doctor gradually increases and doctors, persuaded by their ethical obligation of care, put up with it as long as possible until they snap. Yeah? I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world. He was brilliant, a good docto…

A lot of physicians either push to restrict the supply of docs or look at this "issue" and do nothing about it. They do not want their wages to decrease by opening up the market (have had physician friends say this to me in words that make it sound less terrible). Cuba decided they wanted more physicians, so they invested in them to the point that they could use them as an export. If we have a shortage of doctors (wh…

Bingo. Medicine isn't inherently a particularly hard course of study, and in many countries is just a five or six year university degree similar to a master's level degree in engineering.

It is, however, subject to stricter licensing/certification constraints which are mostly in the hands of the existing body of practitioners ...

Re: The Dark Side of Doctoring

#160

Post by IIIIIIIIIIII » Tue, May 16, 2017, 7:15 AM UTC

trowawee wrote: post #48

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…

Every single study of the effects of fatigue on human cognitive ability that I am aware of indicate that A) fatigue can have massive deleterious effects on peoples' abilities to perform even simple tasks, and B) people are generally terrible at evaluating their own levels of fatigue. There's a good overview of a lot of this research here: https://hbr.org/2015/08/the-research-is-clear-long-hours-bac... . I don't know…

> The idea that doctors ... are somehow immune to those effects defies logic.

That claim was never made by OP. Can we have a discussion without attacking a straw man, please? You yourself acknowledge you only know one side of equation. If the other components are larger it would not matter that you have shown one aspect - that nobody disputes, incl. OP! - to be negative.

https://news.northwestern.edu/stories/2016/02/longer-shifts-...

> A new [...] study [...] showed allowing surgical residents the flexibility to work longer hours in order to stay with their patients through the end of an operation or stabilize them during a critical event did not pose a greater risk to patients.

> “It’s counterintuitive to think it’s better for doctors to work longer hours,” said principal investigator Dr. Karl Bilimoria [...]. “But when doctors have to hand off their patients to other doctors at dangerous, inopportune times, that creates vulnerability to the loss of critical information, a break in the doctor-patient relationship and unsafe care.”

I have no doubt that overall the long hours are bad, I only respond because you attack a position OP didn't take. Also, the long hours may still be a logical conclusion and even beneficial - within the twisted logic of dysfunction in the larger system: "For evil to triumph, all that is required is for good men to respond rationally to incentives."