71–80 of 387 posts
Elephant in the room, related to the article's first point: We have to tackle ageing. Many of the other diseases (cancer, heart conditions etc) and causes of mortality are highly correlated with it.
I don't have much personal experience with hospitals, but there's a trend I've noticed across several articles now where the medical system is characterized by an unpredictable and frequent alternation between extreme competence and extreme incompetence. The author's dad was being seen by a variety of highly trained specialists all working to treat him, but "people need to sleep" seems to be a recent discovery in the…
I don’t think the problem is cost cutting. I think the problem is just the same problem that every human enterprise has. Most people just don’t give a shit outside thier immediate responsibility. Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task. Many people who do give a shit get this crushed out of them early in their career by the negativ…
A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!
> 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…
The main thing that House MD has, that no other doctor in the world has, is not so much his superior intellect. It's that he and five other doctors spend 100% of their time on a single case, and can sit around all day discussing it, trying different things. If real world doctors had even a fraction of that luxury, you would see a lot more of what you describe.
Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".
It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.
Also I'm not kidding but I would LOVE such a show.
I noticed that the incessant beeping all night has decreased quite a bit, of late (at least in my local hospital, St. Francis Heart Center)
These threads always have lots of people jumping on doctors and their decisions/callousness/lack-of-reason/etc.etc.etc. My wife is a physician (OBGYN) at a major city hospital that primarily serves a very poor population. I'd like to share her schedule, and see if you think what kind of care you could perform under these circumstances: Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to start rounding on…
That sounds illegal.
But this was Kaiser. Other hospitals may indeed be a shit show.
I've spent a fair bit of time in ICU's on both sides. I think the observations and conclusions show misunderstandings. Generally, opinions are not ignored, nurses don't go wild, the patient population makes sense for an ICU, the institutional memory is actually fantastic, etc.
And most importantly: "There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though" This is complete and utter hogwash, borne of a difficult experience.
They key idea is this: in complex cases, doctors have to identify the condition that matters most, and prioritize that. Collaboration is necessary to get the picture and give care, and perhaps to consider alternatives, but it's not how you make decisions.
It's hard to see symptoms ignored or under-treated. But it's very likely that delusions do not make a difference in the patient's recovery, but something like lung surfactant matters most. So everything from fluid intake to drug dosage and activity are direct accordingly. Unless they're symptoms of the main issue, discomforts can be prioritized later after the main issue resolves.
"Identifying the main condition" means understanding the actual insult and the healing process for this patient; understanding how symptoms, labs, and imaging reflect all the conditions i.e., how it presents (and skews labs or self-perception); and understanding how all the interventions may interact with the disease/disability states, from drug interactions to liver and immune-system complications, etc.
It's not uncommon for other doctors and nurses and patient advocates to have some slice of this complex picture, but it's the attending who has it all, and the experience of other cases and knowledge of the underlying conditions and interventions.
And, for the most part, the attending is not responsible for explaining their understanding or reasoning to anyone. They do offer reasons and make records, but there's no place or time or even audience for comprehensive account of why other alternatives weren't considered or followed.
Science, and medical trials, try to isolate single factors to get reproducible outcomes. Medicine in the ICU has to accommodate multiple factors, by focusing on the main disease/healing process and optimizing for that.
As for value to society: good ICU attendings are key to good outcomes for patients and their families. It takes decades to get good. They produce far, far more value than they're paid, largely because they do it as a mission. If they see people, particularly those who enjoyed the benefit of their dedication and service, disrespecting and misunderstanding them, it's likely to dissuade them from continuing or dissuade others from their difficulties.
So complain all you want about digital advertising and go full-disruptive to fossil fuels, but please be very, very careful when attacking health care. Otherwise we'll end up with Russian hospitals where you bring your own materials and pay your friends of friends for side work.
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…
Had a cousin and a friend (both I would characterize as smart and hard working) take several years after undergrad and eventually “settle” for physicians assistant schools.