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Things I've noticed while visiting the ICU

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Re: Things I've noticed while visiting the ICU

#211

Post by db48x »

Blammar wrote: post #203
duffpkg wrote: post #124

Author of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc... One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry…

Can you explain why one ICU room costs millions, and why they cost 10k a day even if no one is in them? Neither makes sense to me. I can imagine say 100k in monitoring equipment in a room. Maybe it's the hospital inflation applied to equipment?

Most of the cost is people. It’s not much use calling it an ICU room unless there are doctors and nurses and anesthesiologists and other specialists on call to actually care for people intensively. Plus a janitor or two.

Re: Things I've noticed while visiting the ICU

#212

Post by fernly »

ericmcer wrote: post #142
fernly wrote: post #141

> 1. The ICU is filled with old people... Pretty much all these patients are on Medicare, which means your taxpayers dollars are making this happen. This ignores the (I think) very strong possibility that the old people are preferentially selected by the system because, thanks to Medicare, they can _afford_ the ICU. Many people aged less than 65 cannot. Consider the idea that if we had something like "Medicare for al…

Old people having more health issues is not really a crazy observation to make. I would be blown away if medical care needed was equal across all ages.

It wouldn't be. Clearly age brings medical problems. However, I'm saying that the cheap access to hospital care afforded by Medicare, could be skewing the distribution of ICU patients. If we had universal medical insurance comparable to Medicare, the ICU population might be closer to the demographic norm.

Re: Things I've noticed while visiting the ICU

#213

Post by derbOac »

I've worked in ICUs; this is mostly accurate except for a few things.

Older individuals do probably occupy most ICU beds but this really depends on the ICU. Some are dominated by acute traumatic injuries which can actually skew younger.

The observation about attendings is accurate, but as one of those psychiatry and neurology consults, the gripes can go both ways. ICU physicians have a reputation for ignoring long term consequences of decisions. So you end up with a lot of "can they go off a ventilator? then they're fine" stuff. This is reasonable in some ways but sometimes there are patients who will probably predictably be ok and attending more to consequences 10 years later makes a huge difference in the rest of the life of the patient.

Also, some ICUs are actually very neuro heavy depending on patient populations.

Re: Things I've noticed while visiting the ICU

#214

Post by dimal »

rscho wrote: post #88
warner25 wrote: post #37

> There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though. It’s all shooting in the dark, and most of the time I felt like I could have done just as good a job on these longterm issues... This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and…

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers. What you should want is curious and creative _researchers_, but precise and totally unimagi…

Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again.

Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.

I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.

Re: Things I've noticed while visiting the ICU

#215

Post by [deleted] »

jmcgough wrote: post #176
lofatdairy wrote: post #147

Earlier quoted context omitted.

I would argue that having onerous tests are not a great proxy. Not only do they not necessarily measure how good a physician a student would be, but it also encourages undergraduates to intentionally enter easier/less rigorous coursework to focus more on the exam aspect (though GPA plays a large role as well). I'm sure a psych major may make a fine physician, but I don't want doctors to only be educated in a rather d…

Everyone takes the same premed courses though, and you need to be able to teach yourself any MCAT content that wasn't covered by coursework. Sure people will game it, but it's your science GPA that counts, and having people from a diversity of backgrounds is a good thing.

[deleted]

Re: Things I've noticed while visiting the ICU

#216

Post by fernly »

ghufran_syed wrote: post #155
fernly wrote: post #141

> 1. The ICU is filled with old people... Pretty much all these patients are on Medicare, which means your taxpayers dollars are making this happen. This ignores the (I think) very strong possibility that the old people are preferentially selected by the system because, thanks to Medicare, they can _afford_ the ICU. Many people aged less than 65 cannot. Consider the idea that if we had something like "Medicare for al…

ability to afford the ICU is not relevant at all when the docs decide to put someone there or not, based on my 14 years practicing in the US. Do you have any experience to the contrary? I’m pretty sure that would be illegal in the US

A very quick DDG search turns up stories from reputable outlets:

"Americans dying because they can't afford medical care"[1],

"66% of Americans fear they won’t be able to afford health care this year"[2],

"Nearly 46m Americans would be unable to afford quality healthcare in an emergency"[3],

"Nearly 1 in 4 Americans are skipping medical care because of the cost"[4],

and more are easily found. If this doesn't reflect people avoiding hospitals, or leaving early AMA, and thus reducing the number of pre-Medicare patients by some amount, I'd be very surprised.

[1] https://www.theguardian.com/us-news/2020/jan/07/americans-he...

[2] https://www.cnbc.com/2021/01/05/americans-fear-they-wont-be-...

[3] https://www.theguardian.com/us-news/2021/mar/31/us-affordabl...

[4] https://www.cnbc.com/2020/03/11/nearly-1-in-4-americans-are-...

Re: Things I've noticed while visiting the ICU

#217

Post by anon291 »

ericmcer wrote: post #137

His observation that the ICU is full of the elderly reminded me of the Obamacare debates when I was younger. I always felt like I was taking crazy pills when I would leave my conservative elder parents who hated the idea of universal healthcare, and go to my younger liberal friends who were all for it. It was such a clear case of peoples ideology running directly against their self-interest. Young people being agains…

A lot of old people have made peace with death. Not all, but many

Re: Things I've noticed while visiting the ICU

#218

Post by opportune »

dimal wrote: post #214
rscho wrote: post #88

Earlier quoted context omitted.

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers. What you should want is curious and creative _researchers_, but precise and totally unimagi…

Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say t…

Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do

Re: Things I've noticed while visiting the ICU

#219

Post by toast0 »

chromatin wrote: post #154
maxerickson wrote: post #13

The solution to difficulty booking doctors isn't to pontificate on how to allocate their time, the solution to difficulty booking doctors is to make more doctors. There's lots of levers that could be pulled in the US. Cut down on undergraduate requirements, incentivize large health systems to fund more training (people like to complain that the federal government only funds a fixed number of residency slots, as if a…

Although I agree with you on a distaste for the foolishness of central planning, lLet me provide an alternative perspective. A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.

> Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.

The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.

Re: Things I've noticed while visiting the ICU

#220

Post by duffpkg »

Blammar wrote: post #203
duffpkg wrote: post #124

Author of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc... One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry…

Can you explain why one ICU room costs millions, and why they cost 10k a day even if no one is in them? Neither makes sense to me. I can imagine say 100k in monitoring equipment in a room. Maybe it's the hospital inflation applied to equipment?

An ICU unit isn't exactly a single room. There are different configurations but they typically involve some sort of centralized monitoring station and 5-20 ICU "beds". Total cost of that / number of beds. Everything in hospital construction is expensive, ICUs are at the extreme end of that. Huge power requirements, medical gas lines, fixturing and surfaces needs to be able to be disinfected, special air, special water, on and on. It has requirements very similar to an operating theatre.

The reason they cost so much even if no one is in them is because of what a "bed" means. It isn't the literal bed, it is a unit a treatable/treating capacity. Requiements vary somewhat by jurisdiction but it's going to mean 24/7/365 nursing and attending doctor staff. You can't just call them in when a patient shows up, they need to be scheduled and available. Then ICUs will also need a large cadre of oncall specialists, neurologists, cardiac, laboratory testing staff, and on an on to cover a huge range of possible patient needs. Stocked blood units, stocked medicine units. All those things have costs whether a patient in in the bed or not. Hospitals to a large extent spend an incredible amount of money on capacity. No wants wants to end up in a hospital to have them say, "oops, we didn't expect your spleen to rupture today, Dr. Bob won't be in till next tuesday so you are out of luck, sorry"

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