This one's not going to 1000 with that attitude, Wafer.
Sorry, I know I'm insufficiently committed to the cause. Still, I saw the original op-ed when it came out and thought it was so mind-bendingly stupid that my one-word reply seems more than generous. Anyway, I'm sure someone will be along shortly to troll this thread all the way into the thirties.*
* This sentence is not intended as an implicit or explicit criticism of this thread, its producer, or the blog on which it appears.
The original op-ed:
1. Here are some structural reasons that we have a shortage of doctors.
2. Despite #1, we can conclude that it is all the fault of the wimmenz!!!!!
Really, I would write more, but I took out a student loan while in graduate school, and though I've long since paid it off, I still feel as though the term of my indenture to the federal government is ongoing. I was considering having lunch later today, but I worry that the dip in my productivity would be unfair to my fellow tax-paying citizens.
so mind-bendingly stupid
Indeed. I happened to be talking to some doctors yesterday, and they said that all of their colleagues thought is was incredibly stupid as well.
They also mentioned that anesthesiologists have the highest rates among doctors of substance abuse and of suicide. (Unrelated to the op-ed.)
This thread probably won't go anywhere, since I can't imagine anyone will agree with the original op-ed. Maybe someone can disagree just to incite an argument? urple?
I think that bowling ball return machine repair people should all work parttime time since I've always been annoyed that I can't break 130 and because they aren't subsidized by tax payers since Obama hates loud noises and white people having non-ironic fun.
Doctors should work double-time! Doctors should not take time off for any reason whatsoever.
YOUR POOPING IS HURTING AMERICA, DOCTORS.
DOCTORS SHOULD WORK FULL TIME - AS AGRICULTURAL LABORERS!
Shit. I found these glasses on the street. They aren't mine.
Anyway, I thought we already enslaved all the doctors. What are they doing writing op-eds?!?
Doctors have erected a subsidized oligopoly that constrains supply and pumps up costs. Damn straight they shouldn't work part-time until they do something about the system they profit from. They're not helpless victims here.
America has bigger problems anyway. Like the apparent oncoming convergence of seriously-promoted pop music with the lyrical and musical standards of Rebecca Black's "Friday."
14: You could say pretty much the same thing about any First World citizen relative to the rest of the world. Or the UAW. The only concrete thing that ending part-time work for doctors would do it drastically cut the number of women in medicine.
15: The fact that Rebecca Black's video has become the subject of a copyright dispute proves that America is doomed.
16: Do you belong to a union that works to constrain the nationwide supply of entrants to your industry? Because I sure don't.
18.2: Pretty much any union that insists on any kind of seniority is restricting the supply of entrants into a job, if not the whole industry. Restricting supply, globally or locally, is pretty much the point of any union or professional organization. The doctors are better at it than most, because if they fuck-up, you die. But any profession with a test (lawyer, realtor, barber) is doing the same thing.
Unfortunately, 4 gets it right w/r/t the original piece. On the other hand, Walt is totally right about doctors in general, the degree of cartelization of the US medical profession is outrageous (way too few medical schools, residency matching, etc.).
19 -- Don't go all Matthew Yglesias with the generalizations. Sure, all professions have a degree of cartelization. On the other hand, you could probably open another 100 American medical schools that produced qualified doctors every year. You don't hear about an auto worker shortage or a lawyer shortage; the purported doctor shortage is 100% an artificial creation of the decision of US medical schools to severely cut down on the supply of doctors.
Says the man who has a job that requires you to take a test that over half of the people who take it fail and that has a fairly tenuous relationship to the work most of those who sit for it do.
You don't hear about a lawyer shortage because they can just the bar exam standards whenever they need a few more. The criteria is nearly completely artificial and unneeded.
You could not open another 100 American medical schools that produced qualifed doctors unless you either vastly improved U.S. undergrad science education or started handing out visa for it. Even then, you'd have trouble staffing them even if you spread it out over a dozen years.
There are efficient alternatives to licensing requirements:
http://en.wikipedia.org/wiki/H-1B_visa
The AMA is very effective at restricting supply, yes. However given the current economic structure of medical care in the US, there's a zero-sum game between medical providers and health insurance companies.
The editorial failed to mention nurse-practitioners, or other alternatives to having an expensively-trained MD stitch a minor wound or prescribe antibiotics for flu.
22: While that affects who becomes a lawyer, it doesn't seem to have been effective in cutting down the supply of lawyers. Isn't there a gigantic lawyer glut?
Oh, don't get me started on the stupidity of the bar exam or its needlessly restrictive nature. But the lawyers' cartel, whatever its faults, is way looser than the doctor's cartel, and the need for a fully-supplied world of lawyers is, shall we say, less urgent than the need to have more doctors out there.
26: Your argument is that people with jobs that aren't vital should be better able to protect artificially inflated salaries than people whose jobs are vital?
24: It did mention nurse practitioners.
No, it's that the medical cartel is more effective, and therefore more dangerous and socially costly, than the lawyer's cartel. Which is why we have a purported doctor shortage and not a lawyer one.
27: His argument is that having less lawyers is, in the words of economists, "welfare improving". If serial killers had a cartel that cut down on the supply of serial killers, that would be good too.
They could certainly expand the number of dermatologists so that the prices might go down. They all drop out of insurance to do Botox and nobody is available to treat skin disease.
But the dermatologists don't want to increase their numbers, and Medicare pays for their training, so.
We have a proported doctors shortage only at the GP level because they can't control their pay and work conditions nearly as well as specialists or doctors who move into research.
You could not open another 100 American medical schools that produced qualifed doctors unless you either vastly improved U.S. undergrad science education
Is that really true? When I was an undergrad, premeds I knew believed that any non-A, even in a non-science elective, was likely to torpedo any shot they had of going to med school. They were the drop-happiest students I ever knew. (I know at least one counterexample who got into med-school from an imperfect undergraduate background, but I think that's very rare.)
If that loosened up a bit, I bet you could fill a bunch more med schools without actually lowering standards in any meaningful sense.
24: Heaven help us when the medical professionals prescribe antibiotics for the flu (a viral infection).
I find it completely unexpected that this is one of the topics that causes Moby to break from his strict regimen of one-liners.
and Medicare pays for their training, so.
Does everybody who got a Pell grant or a federal student loan have to pick a job on social betterment grounds also?
You could not open another 100 American medical schools that produced qualifed doctors unless you either vastly improved U.S. undergrad science education or started handing out visa for it.
I would paraphrase this as "you could open another 100 American medical schools".
Not that you would need to - there is a whole wide world out there full of qualified doctors whose qualifications aren't recognised in America.
33: And I think that some of the better doctors are imperfect people who have some empathy and are able to listen and not just memorize things.
I have a great friend who has struggled a bit, because she had some serious illness issues, but she works incredibly hard and is devoted to research. She managed to match in hem/onc, but she couldn't do derm even though she wanted to skin oncology which is seriously underserved.
And her medical leave of absence really hurt her, because it was for psychiatric reasons and she didn't want to share that info. She's getting good treatment now and doing well, but it hardly seems to matter.
If the supply of lawyers increased, would it be easier for Poor Black Guy Facing Texas Jury to get a fair shake in the legal system?
I'm not very fond of the "import doctors" solution. Unlike, say, importing engineers or engineering students, it seems to remove trained people from situations where they can do the most good.
33: I had a student at your undergrad alma mater who was headed to med school and double majoring in biochem and classics. He had no real natural facility for the languages, his grades in that major were just ok, but he thought it was fun *and* thought it would set him apart from other med school applicants. He got in everywhere (all fancy) he applied.
36: Sorry, I wasn't clear. I just meant that Medicare which pays for a lot of post-grad education has a lot of power in determining the numbers in any given specialty.
Sometimes, they're slow to adjust.
33: The medical school with which I am associated has 600 students. I suppose it is larger than average, but I doubt there are 600,000 undergrads out there who would make good doctors, would want to be doctors, and aren't getting in to medical school now.
You could not open another 100 American medical schools that produced qualifed doctors unless you either vastly improved U.S. undergrad science education or started handing out visa for it.
This boils down to "everyone in the US who wants to, and who meets the desirable standard of academic achievement, is able to go to medical school" which is a surprising statement.
35: It's because I have more work today.
40: If they send cash back home, it can help. My dad came over to the States from India, and the money he sent back is why his home village has a water pump and an outhouse and electricity sometimes and why my uncle who worships Jesus alongside Hindu gods has a medicine wholesaling business.
It might even be the case that a village with a water pump, an outhouse and electricity but no doctor is healthier than one with a doctor but no water pump, no outhouse and no electricity. Prevention better than cure, etc.
If the supply of lawyers increased, would it be easier for Poor Black Guy Facing Texas Jury to get a fair shake in the legal system?
Possibly, only to the extent that un-/underemployed law grads might resort to public interest type jobs or volunteering as a desperate effort to have some sort of professional employment to fill the gaping hole on their resumes until firm hiring picks up again. But that client isn't being poorly served right now because of some shortage in the market but because getting legal services to clients who can't pay for those services is going to require some financial commitment from somewhere.
#43: factor of ten-fail, or am I missing something? 100 new medical schools x 600 per medical school = 60,000, which looks a lot more plausible that there would be that many OK doctors.
This is actually something I have been worrying about quite a bit. The marginal good I can do in a career with a guild-like or tournament structure is the difference between the impact of my work and the impact of the work of the person I displace. Plus (for money-generating professions) the difference between the impact of the money I give away and the money the person I displace would give.
In more open professions, I don't have to feel bad about displacing harder workers or something, but once I include my own opportunity cost of slacking off, I feel that my time does not quite belong to me.
I am not quite sure how to apply this. There are lots of things I think I could do quite a bit better than the worst person in the field right now.
The existence of reasonably efficient charities is also a complicating factor. To a first approximation it looks like I could do the most good by joining one of the money-getting evildoing professions doing less evil than the person I displace would have done, and giving away most of the extra cash I got.
But even so, doing evil would damage my soul, and I am selfish enough that I would be willing to save somewhat fewer lives in order to have a better chance at personal happiness.
49: Fortunately Moby's job doesn't involve working with numbers.
46, 47: I hadn't considered that even though I'm aware that there are countries that get a significant amount of their foreign capital this way. I can imagine that it improves welfare, but I still have a instinctual aversion to brain drain. It just feels sub-optimal.
The marginal good I can do has less to do with your will than you may think.
The best advice of sages concerned with moral development does not include making a difference in the world.
#53: I salvage a small amount of intellectual self-respect from a day which has seen me multiply instead of dividing when converting exchange rates on *five* separate occasions.
I'm trying to see how 60,000 fits within the number of U.S. college grads who could conceivably be medical students and I am failing completely and finding a nice table of B.S. graduates by major. The internet sucks sometimes in terms of raising expectations and then fucking them over.
Yes, everybody. Look at Moby's penis.
Where exactly did you just stick your face?
The museum here has a kiddie dino-dig where they have to wear goggles. When you turn in the goggles, they use UV to irradiate them into germlessness. I wonder if that isn't just for show.
50: The existence of reasonably efficient charities is also a complicating factor.
It probably shouldn't be. Private charities work okay for scattered, small-scale endeavors but can only hope to slightly ameliorate larger problems rather than really addressing them, on account of they have to work with the limited attention span of donors and an increasingly overcrowded market of nonprofits. Waves of charity periodically inundate disaster-struck places -- Haiti, Pakistan, Japan, Sri Lanka, Iraq, Afghanistan, various sub-Saharan countries -- without producing much in the way of long-term value. Same applies to the poor and/or homeless in North America (what was that crazy thing Ogged posted once about a charity that was trying to get the homeless into jogging?).
Giving money to charity is something rich people do to accumulate "social capital" (for themselves, ultimately), it's not about practical results. It's not entirely unlike the way medieval peerage used to build monasteries to pray for them while they went about the dirty work of maintaining and expanding their estates. If you're okay with that, then there you go.
(68.2: It's not purely "something rich people do," of course, I'm just talking about the primary reasons that seem to motivate corporations and philanthropists.)
Back in the day, and this didn't stop until the 60s where I am from, the local Catholic parish would publish how much every family contributed. Given social norms, this made giving effectively a tax for the middle class families, a status competition for the rich, and a source of shame for the poor.
I had trouble following the line of worries in 50, to be honest. This certainly seems defensible:
it looks like I could do the most good by joining one of the money-getting evildoing professions doing less evil than the person I displace would have done, and giving away most of the extra cash I got.
But if you feel the need to defend your choices (assuming they're wide open), you're already in trouble, no? This seems wisest:
But even so, doing evil would damage my soul, and I am selfish enough that I would be willing to save somewhat fewer lives in order to have a better chance at personal happiness.
This doesn't strike me as selfish. As long as you feel that the money-getting, evil-doing professions are just that, they are not so just to the extent that they affect you, but to the extent that they affect others.
71: I care about "being a good/virtuous person" and "helping others" as separate goals. That's not as much of a conflict if you limit your career choices to ones that create social value directly. And I'm far from decided that I can't do just that.
The problem is cases where there is a net reduction in harm, but one has to participate in inflicting some harm.
The linked articles suggest ways in which being a "do-gooder" can be a net harm if you displace someone who would have done more good. The mirror image of this is also possible. Here's an oversimplified example. Suppose you work for Pollution, Inc. and have the opportunity to profitably poison the water supply for 10,000 people, and earn a $5 bonus for making the company more money. Homo Economicus would say OK, I would say no, so there's a net reduction in harm if I replace Homo Economicus and decline to do evil where it doesn't cost me very much.
Evildoing can also amount to a net gain in welfare if you can give away enough money to more than offset the harm you do directly. (Few or no people in such careers actually do that, and of course I have to take into account the possibility that I will become more selfish if I start doing evil.)
There are also not-obviously-evil ways to accumulate lots of money (Zell Kravinsky is a good example of a guy seems to have at least *tried* to produce maximum good for others), but there is less of a standard career path there.
Of course I would *rather find an option that also makes me feel good, and I will probably end up doing that whether or not it is the "right thing" abstractly. And the more uncertain I am about my explicit reasoning, the more reasonable it is to do something that "feels right."
But if there's poor kids in Africa who would have been vaccinated if I made different choices, I don't think they'd consider my moral purity a good consolation prize.
And then there are also the Kantian reasons to refrain from evildoing, i.e. because even if my marginal impact considered alone might be 0, if everyone else likewise refrained, the world would be a better place.
Evildoing can also amount to a net gain in welfare if you can give away enough money to more than offset the harm you do directly.
Or so Big Carbon Offsets would have you believe.
75: Or if you think different harms are commensurable. For example, sending a planeload of medical supplies to a poor country is a net harm climate-wise, but may be a net gain human-welfare-wise.
76: Sorry for my over-earnest reply to your actually-quite funny joke.
Well, I agree you're asking the right questions, and I don't think there are easy answers. Though I suspect it's very easy to overestimate your chances for doing good, or less evil, from within Pollution Inc.; and it's almost impossible to avoid coming to see whatever nice people are doing around you as normal, over time.
I've heard the "I could make the world better off by making zillions working for Big Evil and sending large amounts of money to Oxfam than I could by working as a low-paid aid worker" a thousand times. I have also heard the "I'm working for change from within" a thousand times." It never, ever, ever works in practice.* You will pocket the cash and convince yourself that you're in fact doing good and that your poor employer has been misunderstood.
*I do think you can "work for change from within" in a fundamentally good but imperfect institution, like much of the government, but that's different than being the least evil person at, say, Massey Energy.
And Trapnel is exactly right that "it's almost impossible to avoid coming to see whatever nice people are doing around you as normal, over time." That's just a fundamental fact of human psychology.
Or even if Benquo can manage to keep his (?) eye on the ball and avoid or outwit this fundamental fact of human psychology, it is surely soul-killing and -exhausting after 10 or 15 or 20 years.
it's almost impossible to avoid coming to see whatever nice people are doing around you as normal, over time
You know, I bet even some of you commenting types are relatively normal.
If anyone would like to forestall this decision by joining (to the tune of $5/month) an incredibly effective organization that fights poverty in Los Angeles, at a time when they are gearing up to repel a suspected ACORN-style investigation, send me an email and I'll hit you back with the details. I grant indulgences same as any woods-shitting pope, and they roped me into a membership drive thingy. You don't have to live in LA to join, but if you do, there's a party, and it's actually been fun two years running.
[/least effective charitable appeal ever]
Okay, just got around to reading the linked articles in the OP, and I gotta say, damn, that first article is so full of shit its back teeth are floating. It's all about lying with statistics, and then backing up the lies with more "common sense" nonsense.
First of all "RNs and PAs can't take the place of doctors, because patients want doctors there when critical decisions are made". Fair enough, if I'm wondering whether I'm going to be alive tomorrow, then sure, I want to talk to an MD. If I've got some knee pain from shoveling too much snow? If I've got an ear infection and need a prescription for some antibiotics? If I've got sleep apnea and need a CPAP machine? Do I really need to see an MD in those cases? Probably not. Increasing the number of RNs and PAs would do a huge amount to lessen the strain on the medical system in general and doctors in particular. But the plutocrats who run the hospitals and HMOs and insurance vampires don't want that, 'cause it's a lot easier to convince an RN to join a union.
Second, "even if there were more medical school slots, there can't be more doctors because Congress won't allow more residency spots." This is about 3 different kinds of wrong on the face of it. First of all, residents work what, 60 hours a week, plus are on call for another 20 or 30? How about halving the number of hours and doubling the number of residents. Let them act like normal human beings a little bit during that time. Or, equally heretically, how about existing doctors lobby aggressively to up the number of residency berths. Yeah, like that's going to happen anytime soon. And God forbid that hospitals find other money to pay residents with! That's un-possible!
Then too, this idea that "it doesn't matter whether there are more or less [insert occupation] in society -- but fewer doctors can never happen!" Total bullshit. Cut the number of doctors by 20% and it would take most people years to notice (especially if you bumped up the number of RNs by a commensurate amount). Cut the number of garbage workers, brokerage sales assistants or hospital receptionists by 20% and there'd be anarchy in the streets. Maybe med school wouldn't be so expensive if they cut all the coursework on how to develop a God-complex, at least for the first-years.
I don't think I've seen an MD since I left my parents' Kaiser Permanente insurance plan.
Wait, maybe the OBGYN who patted my ass, told me I was too pretty to worry that my boyfriend was cheating on me (I was worried about what turned out to be a pimple--and more worried about my own sexual past than my boyfriend's!), and charged me $400 for a 1/2 hour visit. Out of pocket. I think he was an MD.
78: Yeah, one of the problems with that approach is that it's not exactly well documented how much evil is gratuitous and how much is highly profitable.
79: The best strategy I've heard is to precommit to a fixed percentage (say, 50-90% of everything over some number) and then stay in touch with a peer group who will disapprove if you don't follow through. But I don't know if that's actually been tried by enough people to yield useful data. We know enough to conclude that "I'll get around to it someday" does not work, and that the best way to commit to giving in the future is to give now.
81: Relatedly, I think I wouldn't be very good at a job I thought was really evil for very long. I would find it hard to stay interested.
85: It's weird how resentful people can be of doctors. There are bad doctors, and good doctors, doctors who do little to no good, and doctors who are on the case, man.
There are definitely good doctors, but doctors as a class have a lot to answer for.
The RNs I've seen for routine care have been great! And I'm sure that guy was an anomaly. He was, however, an expensive anomaly.
86.last: I think I wouldn't be very good at a job I thought was really evil for very long. I would find it hard to stay interested.
I've found that it's useful to ask yourself whether you feel one way or the other about the ultimate goal of the work: to make a profit? Or to serve clients? How is success measured?
I've worked in both sorts of organizations, and there's a distinctly different feel, in my experience, between them.
(Some organizations whose ultimate goal is to make money/profit may ostensibly measure their success in terms of numbers served, or how well they're served, but one wouldn't want to be fooled: there's a different feel (again, in my experience) to the organizational, erm, gestalt regardless.)
Sweet! 83 worked. Not saying who, but if you kick down, I'll ask them if I can tell you.
There are bad doctors, and good doctors, doctors who do little to no good, and doctors who are on the case, man.
True enough, and the same might be said of the members of any other profession or occupational group. But as a class/profession, doctors enjoy an enormous amount of status, wealth, and cultural authority, so the resentment doesn't seem so surprising to me.
Recommendation for those who need to pay out of pocket for check ups and other routine, non urgent medical care, and who also travel: get it done when you're abroad. So much cheaper (offer does not apply in Switzerland). When I did a full, I have not seen a doctor in ten years, check up in France, it plus a half dozen lab tests cost about 60 Euros.
An old high-school friend roomed with me the year after he had gotten rejected from umpteen medical schools. He was certainly not stellar academically, but I could honestly predict that he would make a very good pediatrician. And he did* after he got into precisely one (1) local med school that year. I like to fancy that my very persuasive recommendation letter that (in a potential lapse of judgment) he asked me to write helped (Shorter: "Candidate X will make ten times the doctor than the insufferable pre-med twits I knew in college and whom you would admit in a heartbeat.")
*Although his tendency towards conservatism ultimately blossomed in all the stereotypical AMAish ways. Somewhat as a result, we no longer keep in touch. Sadly.
"85: It's weird how resentful people can be of doctors. There are bad doctors, and good doctors, doctors who do little to no good, and doctors who are on the case, man."
well if you are going to try to be more arrogant than me, you should also know more the topic under discussion than me. getting your info from drug reps is not a wya to do that.
I think that an initial CPAP consultation would probably benefit from seeing a doctor.
I'm biased, because I haven't had good experiences with NPs. One of the one's I saw at the hospital-based practice I go to wasn't great. If I need to see one now, I'm going to see the ones she named that she works most closely with. One's only available in the summer, cause she works for a local college the rest of the year.
The big problem that I have is that I really need someone who keeps up on the research and can tell me what the published literature says. I haven't found a single NP who does that, but very few doctors do it either.
In psychiatry, i kind of wish that there were a middle-tier track. Like, you shouldn't have to go through a full medical school curriculum to become a psychiatrist but you do need to have some people who are more expert than a typical NP. I have not been impressed by the NPs that we hire in that area.
Having said all those negative things, there is a fabulous PA at a state clinic who has served one of my clients, and there's this horrible internist who is the PCP for about 20% of our clients who is lazy in a way that is really bad for people who can't advocate well for themselves. He said that the cause of my client's incontinence was "mental illness/mentalretardation" and couldn't be bothered to diagnose the problem or write the proper letter to get the prior authorization to cover the Depends type of pull-up garments as opposed to the diapers.
Eventually, I called the urology department directly, because he sucked so bad.
96: In my fantasy medical system, there are people who specialize in diagnosis and nothing else. Not bedside manner, not hectoring people to eat well and exercise, not even immunizations. Just diagnosis. They could do most of the work of keeping current with the literature.
People could specialize in medication and drug interactions, but probably that can be better automated.
Non-doctor medical professionals should be used more often for narrow, specific, straightforward problems/procedures. (e.g. I got a gash in my leg, someone needs to sanitize it, sew it up, that's it.) Granted specialization and assembly-line medicine will as always produce alienation but these procedural specialists would be cheaper and get much better at their specialties than doctors are now. This should especially be the case with dental hygienists vs. dentists. No reason every tooth cleaning should come with a dentist's inspection.
Yes this is Yglesiism, blah blah move with caution disclaimer blah blah...
And while I'm fantasizing, I might as well save a dance-a-thon.
Right now, we entrust our health to these bizarre philosopher-doctor jack-of-all-medicines types. Which is really awesome when your doctor is actually of epic hero caliber, but really sucks for people who don't have the time or money to find one of those, and get something materially worse than cookie-cutter care.
Shorter me: a system that relies on heroic efforts will work when and only when the people participating are hero-class.
97: I get dental cleanings 4 times a year because of periodontal disease. I wish that this was the standard for everyone, but the dentist only inspects my teeth twice a year.
97: Doesn't your version of Taylorisation require a division of diagnosis/treatment that doesn't map terribly well onto clinical reality though? As in, it works in simple cases ("patient has impetigo"/"Prescribe tetracycline"), but for most cases that reach a hospital, the diagnosis is going to be complicated enough ("Patient has a bacterial infection, with inflammation of the liver and fluid on the lungs") that the problem is in prioritising what's wrong with them, and the "diagnosis" is going to be indistinguishable from a treatment plan.
100: You'd need a diagnostician on-site in lots of different cases, and quite likely they'd need to be present for and sometimes make treatment decisions. But it's not obvious to me why the same person needs to be an expert in administering, e.g., surgical treatment. Probably there are lots of people with just one of the two skillsets (smart, caring people with shaky hands, steady-handed touch-oriented people with mediocre analytical skills or interest in keeping up with research).
Likewise probably the surgeon needs enough diagnostic understanding to notice when they find something funny that might be important. But even though at Toyota supposedly everyone on the line was "responsible" for safety and QC, that doesn't mean they didn't employ safety and QC specialists.
There's also a difference between urgent, in-the-thick-of-things diagnosis, triage diagnosis, and the kind of diagnosis the recognizes something important from a calm conversation about a set of initially mystifying symptoms. I was mostly thinking about the latter.
*the kind of diagnosis that recognizes
Also, the human body should be redesigned modularly so that we can just swap out defective components. They only brain medicine will remain complicated and expensive.
101: To a very large extent, that is what happens now except that they all have a common core background from college and three years of med school. You could streamline that much easier by reducing the undergrad general education requirements. You could shift a bit more to physician assistants and that is happening, depending on where you are.
Also, what Kobe said.
104: I know there's some segmentation by inclination to work with particular body parts, but I didn't know there was more division of labor than that. When I or someone I know has needed something involving surgery, the same person has provided the consultation and performed the surgery. Sometimes a generalist will make a preliminary diagnosis and refer the patient to a specialist, but the specialist (usually the surgeon) is also the person to make a definitive diagnosis and decide on a treatment.
Is that unusual?
My experience with the NHS has often involved escalating levels of specialisation.
i) GP
ii) hospital consultant in general area X
ii) specialist in sub-field Y of area X
iia) imaging/investigation
iii) surgery/treatment [often by someone other than ii]
Also, friends have reported difficulty getting information from doctors about the relative likelihood of different outcomes for different treatments. For example, a friend's wife's labor lasted unusually long, which apparently is an infection risk. The doc offered the choice of continuing as is w/ antibiotics or a caesarian, was willing to describe the possible complications in each case, but was completely unwilling to venture a guess as to whether the caesarian would reduce or increase the likelihood of a complication.
I don't know if that's because the doc simply didn't know (docs are busy and it seems plausible that they just don't have the time or mental space to remember the relevant stats for everything), or some weird liability thing, but it seems like it should be someone's job to figure out whether a proposed treatment will help or hurt.
106: I'd readily believe that the UK system is more industrialized in this regard than the US system.
107: And by "someone" I mean somone other than the patient.
It depends on the field, but there is a very big division between generalists and specialists that covers much of the ground you are talking about. Also, the distinction between doctors doing research and those who aren't. There is a similar division between surgeons and not surgeons. Often the surgeon makes the definative diagnosis the surgury is where you see whatever it is you need to see to make the diagnosis.
Certainly, in most cases a surgeon will do a consultation before hand. In my opinion, it would be inane for a variety of reasons (including legal liability, but much more) for the surgeon not to talk to any patient who is able to talk to him/her before surgery.
But, for many chronic diseases, the specialist doctor will do the diagnosis and supervise non-MD people going the disease management stuff.
110: OK, I guess my experience is slightly atypical, then.
107: That's probably not a very good example because infection isn't the biggest risk there (at least for most people). If the doctor asked, the doc has already decided that the biggest risks (e.g. mom bleeding to death, baby suffocating) are not a problem.
Also, I think you over estimate how precise the stats are for that kind of thing and how bad it would be to rely on a general stat when you have many more details because you are looking at an individual patient.
108 is probably right, but I don't know the British system that well.
111: I'm not saying that what you suggest isn't possible or pointing to a real problem. I'm arguing that it probably would be a marginal adjustment, and not a game changer, for those changes that are possible without a vast leap from current technology.
112: So instead of being annoyed at the doc for refusing to offer a statistic, they should have been annoyed at the doc for refusing to make a recommendation based on looking at the patient.
115: Yes, except that the OB could be (almost certainly is) under pressure to keep down C-sections. They usually won't actually recommend one until it becomes medically necessary. Like I said, it is a funny example.
114: That sounds right - a lot of the gains would be far down that road, after we'd tried some things and accumulated enough data to guess pretty well what things can be modularized with little harm, and what things really do require a generalist.
96: I think that an initial CPAP consultation would probably benefit from seeing a doctor.
Aha! Because of the things I mentioned, the CPAP was the only one where I didn't see a doctor (except to the extent that I went to my GP and said "I have symptoms of sleep apnea X, Y and Z, do you think I should consult with a sleep clinic?" and he said "Yup." And then I was able to go and talk to a PA, who, when he heard the symptoms, which were all of the classic ones for sleep apnea, also said "Yup", and authorized doing the sleep study, which was conducted by an RN. No actual MDs involved with the diagnosis or treatment, just for gatekeeping.
107: With childbirth in particular, I could imagine an alternate situation where the narrative goes that the woman had to fight to be able to keep laboring even though the doctor was pushing c-section, likely unnecessarily. People are invested in making their own decisions about childbirth in a way that is different from other medical situations. And when it really is unknown what would be better, I think it's absolutely the right thing for the doctor to have the patient make the decision.
Though we don't really want to face this, it can be impossible to tell "whether a proposed treatment will help or hurt." In some cases a doctor could probably make a better guess, but by no means all of them.
I'd readily believe that the UK system is more industrialized in this regard than the US system.
Our doctors are efficient but alienated.
Our doctors are efficient but alienated.
This is in fact true.
Maybe we could get the aliens to do colon screenings since that would have to be pretty efficient.
Unless the aliens started to bill for their transit costs.
Given that the aliens seem to wipe everybody's memory, I'm guessing that they won't bill for transit to avoid having their spouses ask questions.
But Moby, no one asked, how can there be enough aliens to screen everybody if the probing only happens to people on isolated dirt roads?
I think it is more likely that everybody is probed by aliens and that only the people on the isolated dirt roads remember it because that's who takes the most meth.
Then, all we need is to find an alien planet full of lipid fetishists to do my HDL/LDL scores.
I can't wait for robot doctors.
Along the lines of 97, I think the optimum situation is NPs whose training is in how to get people to accurately describe their symptoms and how to notice symptoms during examinations, who then put the symptoms into a computer which does the diagnosis. Based on the symptoms the computer will return followup questions for the nurse, or recommend further tests (some of which would be administered by doctors and some by nurses). Doctors who are at the front lines of research can work on improving the robots and on dealing with diagnosing new symptom patterns which appear in the data.
Also better robot toilets will be running tests on you all the time telling you if they notice something bothersome.
I do not think that doctors are currently very well-trained at getting people to accurately describe symptoms, and I don't think that the human brain is as good as expert systems at doing diagnosis.
119: It's extremely unlikely that the available evidence has the risk exactly balanced between the two outcomes. Of course in cases that aren't obvious the patient's desires are important, and of course the doc should communicate the very high level of uncertainty as to which option is better, but there is a difference between letting the patient decide, and providing no opinion when asked.
I agree that there are much worse possible outcomes that refusing to offer an opinion on ambiguous cases. Perhaps this doctor was overcorrecting for a tendency to be too pushy. And avoiding pressuring people into accepting procedures they don't want is probably worth the cost of annoying people like me. But that's another good reason to try to separate the informational, executive, and operational functions. If the information provided isn't the decider, they are at less risk of being too pushy.
How do you (or the OB) know what the risks to be balanced are? The risks of different actions are known, to a fair degree, but balancing risks requires being able to take the probabilities of various outcomes and match them with utilities for different outcomes. Plenty of things are so subjective that providing an external opinion is useless and the decision here would seem to rest mostly on how the woman feels about different types of pain and discomfort and granola-birthiness.
127: What you are describing are cyborg doctors, which are, if anything, more awesome.
What happened to the expert systems that were supposed to revolutionise medicine, anyway?
What happened to the expert systems that were supposed to revolutionise medicine, anyway?
To the (large) extent that diagnosis is already computer assisted, they did.
Benquo, I'm not saying that you don't have a point but that you are picking a very tough case on which to make that point.
I also had a situation (broken wrist) a few years back where the doctor was completely unwilling to give me anything even approaching a likelihood of the possible states/outcomes that interested me (continuing pain without surgery, continuing pain with surgery, loss of functioning due to surgery, etc.). I found it incredibly frustrating--I'm supposed to make this decision based on "well, this is a possibility, but so is this, and this, and I refuse to tell you anything about their magnitudes, relative or otherwise."
That was supposed to end with an indignant question mark.
But your wrist was in so much pain you couldn't type it?
I do not think that doctors are currently very well-trained at getting people to accurately describe symptoms
It can also be hard for patients even to know what a 'symptom' is, in some cases. Especially for people who aren't generally healthy, it can be hard to know what a 'normal' baseline is.
I also had a situation (broken wrist) a few years back where the doctor was completely unwilling to give me anything even approaching a likelihood of the possible states/outcomes that interested me
Louis CK has this covered.
http://www.youtube.com/watch?v=WzEhoyXpqzQ
http://www.youtube.com/watch?v=tvqrJpyAqYg
The horrible OB that I had with Hawaiian Punch would trot out Dead Baby threats any time you tried to get information out of him. No exaggeration - my friend who is a doula says that every time one of her clients is a patient of his, the client is terrified because they've been given that "Well, it's a possibility that it could kill the fetus" answer to every stupid question. I really loathe him.
130: Sure, that info probably would have been helpful too, had it been provided.
I was not there in person, and it's possible that my friend condensed his description, but it sounded like the doc didn't even want to say that much. I strongly suspect that if they'd been presented with that info, they would have told the doc, "we don't care about the granola stuff, painkillers are for pain, we just want the option with the lowest mortality risk." It's one thing to respect patients' different choices and preferences, it's another thing not to give them the info they need to decide based on those preferences.
139: "For the co-pay, do you accept American Express?"
My mom's OB was pretty cool, at least afterwards. She asked how warmly to dress me (it was winter in Boston), and he said, "Put on as many layers as you think will keep him warm enough, then take one off."
Louis CK has this covered.
The first one, at least, was really funny. And kind of connected to the other thread, what with the stretching.
So, for a half-hour a day, you should stretch your ankle.
Uh, ok--how long will that take to fix my ankle?
No, you just ... do that now. That's just a new thing you do, until you and your shitty ankle both die.
140: That's more on why I think this is a bad example. As soon as the difference between the mortality risks starts to get significant, you don't get a choice if you have a competent doctor.
Also, "painkillers are for pain" is beyond flippant. First, for healthy people in surgery in an actual passable hospital*, the anesthesia is the part where the mortality risk comes in. Second, pain killers aren't that effective, especially the kind that you can get if you are giving birth.
*I don't know about birth specifically.
144: Again, that's information they would have loved to have: "Option A is more painful than Option B, and the mortality risk is similar enough to be immaterial." Not saying anything feels very different to the patient from saying that based on the available evidence, there's no good reason to think one option is materially riskier than the other.
Maybe everyone else except me and my friends already knows this? That if a doctor offers you a choice, it's because the mortality risk of the different options is probably the same?
146, 147: I've been in that situation delivering my first kid, and while I assumed that the doctor wouldn't be leaving the option of what to do up to me if either option were significantly riskier than the other (at least not without explaining which one was the significantly riskier option and why), I was unhappy about having to deduce that rather than having the doctor say it explicitly.
The risks are not the same and may even have statistically significant differences for certain women (based on age, weight, whatever). But, in the U.S., there are only 13.3 materal deaths for 100,000 live births. Assuming mortality risk should be the deciding factor in the choices around delivery is making a very big assumption about priorities. If you are talking about the difference between .01% and .02%, maybe leaving the decision to the person bearing the pain/potential scars/task of raising the kid should just go with what she wants.
Anyway, it doesn't seem to me to be unreasonable for a doctor to say these are both plausible choices and you have to make the decision. Running the specific numbers is probably something that should have been done in the weeks before.
Somebody check my factors of ten, but I think I'm right.
149: When I said 'not significantly' different, I didn't mean 'not statistically significantly different' I meant 'not meaningfully different'. And it's not unreasonable for a doctor to say that the risks aren't different enough to worry about, and I should make the decision on different grounds, but when I was in that situation the doctor didn't actually say that -- he just left the decision up to me in a way that I assume he wouldn't have if there were a meaningful difference in risk -- and I wish that he'd made that explicit.
I understand, but most people really, deeply suck at statistical inference and just not mentioning shit is often the best way.
To be clear, I'm not arguing against the idea that doctors should communicate more clearly with patients. I'm arguing against the idea that it is somehow clear how they should do this communication and, even more directly, against the idea that more information is somehow better communication.
re: 134
Yeah. Doctors are bastards.* I'm getting better at the whole, 'Look, fuckbrains, here's the questions I want answered: 1, 2 and 3' thing, but it's still a drag and some doctors are cunning.
* not really a joke.
I'm arguing against the idea that it is somehow clear how they should do this communication
I think that it is clear that if a doctor offers you a choice between two courses of action and says it's up to you, that that offer should be accompanied by either: an estimate of the relative risks; a statement that the risks are close enough to be meaningfully equivalent; or a statement that the doctor doesn't have enough information to know what the relative risks are. Leaving decisionmaking up to the patient is a good thing, but it really should be accompanied by whatever information the doctor has about the risks of each choice.
155: Like the consent forms you have to sign before they put you under when there is no hurry?
I haven't been under general anesthesia since I was seven, so I don't know, but maybe? Depends on what they say?
A woman in my office sent a wonderful email to our bosses, asking about some stuff that never really gets resolved (since it is important but uninteresting stuff about internal process).
She closed her letter:
I count five questions, to which I expect at least four answers.
Then I told her again that she full of awesome.
I'LL ASK THE QUESTIONS AROUND HERE.
I've had a few really poor experiences with doctors over the past few years, so have reached the 'I'm fucked if I'm coddling you cunts' egos' stage. The next round of which is about to begin as I chase the fuck who promised me a surgical referral for a sports injury [which he singularly failed to treat *] and who seems to have completely forgotten about it.
* I told him stretching wouldn't cure it as I already stretch a lot and am pretty fucking flexible. I was right.
157: The last one I signed was for an upper GI endoscopy (not general anesthesia but that kind where you don't remember anything) and it said there was a risk of death at about 1 in 10,000. Which, if wasn't an over-wrought liability thing, would mean that I probably should not have had the procedure. Also, that the procedure shouldn't have been done in an outpatient clinic as it was.
A study being done by some guy who keeps parking my car underneath the tree where the birds are shitting has a base consent form that is ten pages of single-spaced 12 point type plus more forms for specific tests that are part of the study.
157: Being on top and in command all day at work, I prefer something different in the bedroom.
Oops, I didn't notice the "seven" part. That was either offensive and in poor taste, or unintentionally much more hilarious than intended. Or possible both.
Which, if wasn't an over-wrought liability thing, would mean that I probably should not have had the procedure.
Are you thinking that the form was wrong, or that the procedure was unjustifiably risky for the benefit? That is, I'm not sure what your point is -- that if we ask doctors to give out this sort of information, they'll be unable to give it even approximately accurately?
I'm thinking that having me sign that statement accomplished nothing but keeping the doctor's insurer happy.
Sure, but it didn't have the information I wanted on it -- if you have this, 1/10,000 chance of death on the table, versus if you don't have it, x/y chance of death from colon cancer. I'm not saying this has to be formal, but if a doctor is advising you to get a test, they should be clear in their own heads that the test is less likely to kill you than not knowing the answer is. If the doctor doesn't know that, something's wrong, and if they do know that, they should be able to tell it to you at some level of approximation.
they should be clear in their own heads that the test is less likely to kill you than not knowing the answer is
In my case, there was basically no chance that not knowing the answer to the test could kill me. However, I was in daily, intense pain and there was a very good chance that the test could help reduce that. (It didn't, but the chances were good.)
167: Sorry, I should have been more careful to include all possible reasons for getting medical care other than avoidance of death.
So in your case you'd want the doctor to at least have the thought "1/10,000 he dies on the table, against 3/5 we get a diagnosis and the pain goes away," at some level of precision which could be quite low, but the doctor should be evaluating that sort of thing somehow. And if they're going to leave the decision of whether or not to have the test to you, they should be communicating their estimates of the relative risks somehow, rather than not at all and leaving you to guess.
The doctor should and did communicate that stuff at the regular appointments during which it was decided which tests would be good to run. (Though somebody with shitty insurance might not have gotten those tests.) But that was communication was necessarily very vague on the pain part and much more general on the risks of the tests (i.e. these are safe for someone in your health).
even more directly, against the idea that more information is somehow better communication.
Moby, is your argument that most patients would just be confused by more information?
My argument is that too many people give me information and I wished they'd stop doing it. I assume that anybody who doesn't feel the same way has too much time on their hands or too much self-discipline.
In lieu of information, I'd like to go back to vague threats, grunts, and fondling.
I'm torn. On the one hand, fuck those god-complex know it all doctors. On the other hand, the whole reason why I see a doctor is that they know more about what to do than I do -- just pick a treatment! In conclusion, don't get sick.
In conclusion, don't get sick.
Best medical advice ever!
169, 174: I don't actually mind a doctor, if the issue's clear enough, just giving advice without an elaborate statement of relative risks -- this test is safe enough and will help you, this treatment is indicated, whatever. What I was bitching about was the situation Benquo and x.trapnel described, and that I've been in as well, where a doctor says "These are your options, you're the boss, make a choice," and doesn't give you their sense of what the probable outcomes are.
175: I've had two doctors tell me this quite seriously, as the conclusion to a long involved thing about how none of these tests are conclusive and we don't know what's wrong for sure but it's probably related to your immune system so if you get sick that will make everything worse, so try not to get sick.
Also, as I was being discharged from a 5-day hospitalization primarily due to not being able to balance well enough to walk, during which time I was not cured, I was told "try to be careful when you stand up".
Yea, you don't want to hear that. Hope you feel better.
I mean, when I got oral contraceptives, I had to do all the research on drug interactions.
My PCP spends most of her time doing research, but I just want someone who will tell me what the research says and if he's recommending something different, then tell me what makes my case different or why the methodology was weak. I don't need a researcher, just someone who spends 3-4 hours per week reading it.
Also drug interaction checkers are still fairly primitive and don't really provide explanations. The danger in my case was that fluctuating hormone levels would reduce the efficacy of another drug, so I went with one that only had a day or two without any estrogen. The computer wasn't sophisticated enough to pick that up. And the clinic specializes in women's health. The greatest hospital on earth does have a specialty clinic for women and mental health, but it seems silly to need a referral for a relatively common issue. I mean, we're not talking about sheperding someone with a history of psychosis through pregnancy.
I wrote the last comment hours ago, but my ipod lost its wifi signal right before it was supposed to post, and it just got in range of my home wifi and went up.
I think it was sort of on topic when I wrote it.
My experience is that GPs often don't know much about specific rare or non-serious conditions. If you are a fairly informed patient, you often know more. They have tons of experience in many areas, but no-one is a perfectly informed specialist in every area, and if you've something uncommon, or chronic, or not easily dealt with by standard antibiotics or anti-inflammatories, then you may well know more than they do.
174: I'm torn. On the one hand, fuck those god-complex know it all doctors. On the other hand, the whole reason why I see a doctor is that they know more about what to do than I do -- just pick a treatment!
I'm not exactly torn. I've been plugged into the medical system since I was 19 (chronic condition, controlled by medication), and over time I've developed a fairly thick skin, and a certain calm stubbornness that means that I ask a lot of questions or simply ignore certain things that come out of doctors' mouths: the result is that I think of doctors as collaborators in the determination of what should be done, but not necessarily the possessors of the last word except in emergency situations.
It means that I can't always work well with some doctors, but then I find another, and that works out okay.
The most interesting medical experience I had recently had my endocrinologist -- we're trying to diagnose some mysterious test results, chiefly chronic low sodium -- ordering another CT scan of my adrenal glands, and the radiology folks essentially said, "No." It would have been the third within 12 months (not advisable, radiation issues), and the radiologist sent me home while she yelled at conferred with the endocrinologist, then called me back to make it an MRI (safer, provides diagnostic imaging suitable to our needs). Thank you radiologist lady! I found this peek at the dialogue between doctors really interesting.
Anyway, I guess I've long stopped thinking of doctors as anything other than human. Specialists seem especially prone, perhaps not surprisingly, to having tunnel vision; it's for this reason I deeply value my GP. [An example of this: the endocrinologist recommended I start on calcium/vitamin D supplements; it was the GP who told me not to take these around the same time as my daily medication, as the calcium could interfere with absorption of the medication. Thanks, GP! I'd have liked it if the endocrinologist had thought about this, but that's why I talk to my GP, who coordinates care.]
I went to the dentist for a check-up today, having managed to miss going for over a year. The dentist wanted a new set of X-rays on everything and explained, "The new machine is digital. Only half the radiation compared to the old kind!"
That was not comforting information. Also, I kinda suspect they simply lost the last set of X-rays they took. Which is rather messed up.
I thought they took new xrays every year. Of course, my record is ten years without dental care. It cost me a root canal.
185: I was kind of expecting new X-rays. It's more troubling to me that the most recent X-ray he had was from 5+ years ago, when I started seeing him. I've definitely had X-rays there since then.
On the other hand: no additional charge for today! Presumably because I've finally started paying for dental coverage that's not abjectly awful. Stupid healthcare system.
having managed to miss going for over a year.
I don't think I've had more than one dental check up within a twelve month period since I was in high school. Just recently did ten years. Free (cousin dentist) and a notification that I've got the beginnings of a cavity that will need filling in five or ten years.
Just remember to floss and you may want to use less smokeless tobacco than I did.
It honestly makes me angry that Stanley, the twice a year dentist visitor and guy who wants to try out sympathetic sobriety with pregnant women, is a drummer. What the fuck happened to rock and roll in this country?
That should be "aspirational twice a year dentist visitor" and "potential trier out of sympathetic sobriety with pregnant women," in fairness. Still, Keith Moon died for nothing if this is the state of the rock drumming profession.
189-190: I'm also using paid time off to play a few upcoming tour dates (including NYC! and DC! maybe!), so as not to affect my full-time-employee status and attendant benefits. Put that in your bacon and smoke it, Caveman! Wooooo! Rock 'n' Roll!
Don't you understand that we're supposed to live vicariously through you? Whoever writes the "Hammer of the Gods" style biography for your band will have a very boring story to tell.
(you know I'm kidding, right? A very good friend just quit a job as a manager for well known but not quite huge act because the artist was just too much of a drug addict and it was unbearable. Still, I feel that the business lawyers of the world should not be going to the dentist more rarely than the rock drummers).
you know I'm kidding, right?
Yes. We are on the internet.
Also: doesn't everyone in LA have veneers anyway? You're probably slipping in your clients' eyes if you don't already have them.
How often do the business lawyers go to the rock drummers?
I 100% honestly do have veneers, actually.
193: Veneers are a popular choice, but the rustic charm of solid wood is coming back in a big way. Plus, that way you know that what you see is what you get.
195: That's at least mildly hilarious. And I appreciate your honesty.