Debugging the Doctor Brain: Who's teaching doctors how to think?(bessstillman.substack.com)
bessstillman.substack.com
Debugging the Doctor Brain: Who's teaching doctors how to think?
https://bessstillman.substack.com/p/debugging-the-doctor-brain
106 comments
In Canada, subjectively, it feels like the quality of newer doctors has gone up dramatically. The training must be a lot better these days. I’ve been impressed, especially when you go in to a clinic where they actively take in students for their practicums - the old doctors are often stepping up their game as well
There’s considerable research on the subject: https://www.mdlinx.com/article/are-older-doctors-wiser-not-n...
> https://www.mdlinx.com/article/are-older-doctors-wiser-not-n...
Link doesn't work in Europe, redirects to https://eu.m3.com/.
Link doesn't work in Europe, redirects to https://eu.m3.com/.
This freakonomics episode covers some of the research as well: https://freakonomics.com/podcast/how-can-you-choose-the-best...
From the transcript:
> But before you go looking for the oldest doctor you can find, you know, hold on for a second. Turns out that what David and his colleagues found in obstetrics may not apply to all fields of medicine. Let me give you an example. A few years ago, we looked at a similar question among internists who provide care to hospitalized patients. These doctors are called hospitalists and nowadays if you’re hospitalized with a general medical condition like pneumonia or heart failure, chances are you’ll be treated by one of these types of doctors. So, my colleagues and I looked at whether the age of a hospitalist physician was tied to outcomes among elderly patients. We looked at about 730,000 hospital admissions by nearly 19,000 physicians and we found that patients treated by older physicians had a higher rate of mortality within a month of their admission date — it’s called “30-day mortality” — compared to patients treated by younger physicians. More patients died under the watch of doctors who were age 60 or older. And interestingly, doctors who were just five years out from their training lost the fewest patients. That finding appears to contradict David’s data showing that obstetricians continued to improve even 30 years into their career.
From the transcript:
> But before you go looking for the oldest doctor you can find, you know, hold on for a second. Turns out that what David and his colleagues found in obstetrics may not apply to all fields of medicine. Let me give you an example. A few years ago, we looked at a similar question among internists who provide care to hospitalized patients. These doctors are called hospitalists and nowadays if you’re hospitalized with a general medical condition like pneumonia or heart failure, chances are you’ll be treated by one of these types of doctors. So, my colleagues and I looked at whether the age of a hospitalist physician was tied to outcomes among elderly patients. We looked at about 730,000 hospital admissions by nearly 19,000 physicians and we found that patients treated by older physicians had a higher rate of mortality within a month of their admission date — it’s called “30-day mortality” — compared to patients treated by younger physicians. More patients died under the watch of doctors who were age 60 or older. And interestingly, doctors who were just five years out from their training lost the fewest patients. That finding appears to contradict David’s data showing that obstetricians continued to improve even 30 years into their career.
There's an archive version https://archive.ph/fpyEG
At least in the US, the widespread use of Anki by medical students has actually impacted the way standardized testing are written/graded IIRC.
Wow, it's amazing to me how much anki eventually caught on with medical students. Back in 2008 I introduced my med school classmates to Anki via a web app front end that I scrapped together. Basically it allowed us to crowdsource a shared flashcard corpus but with individual accounts each with their own state for Anki's SRS, allowing us to practice from any web browser without having to have Anki installed locally. Though it had some success among some of my fellow students, the vast majority of the class did not want to engage with a web app for studying back then, so I'm surprised by how much penetration it has now.
It should be quite naturally so as a lot has happened in the field of medicine in the last 30-40 years. A 60 year old doctor who was trained 35 years ago uses old knowledge and techniques. Even though doctors get some updates via conferences and articles in journals and maybe some hand on course, they cannot absorb all that new knowledge in practice.
Physicians are required to complete a certain number of hours of continuing medical education every year. These are training courses (online or in person) which have to meet at least some minimal quality standards; it's not just showing up at a conference. But whether they actually keep their skills current or just check the boxes depends on the individual.
It's quite hard to learn something completely new by taking 1 or 2 week courses once a year.
I had a 55+ year old dentist who wanted to pull out my tooth and replace it with a bridge. The tooth was cracked and 1/3 of the tooth had fallen off. Luckily he worked only half time and was on vacation a lot so difficult to get an appointment so I got to see a young dentist who could fix the tooth by repairing it (building up the missing part). She said it could last a month or forever, but if not lasting then the next option would be a titanium implanted tooth. Making a bridge would have been considered malpractice nowadays she said. The old dentist was probably a master at putting in bridges, but if that method is bad and he never practiced the other technique, which you probably cannot learn in a 1 week yearly course, then tough luck.
Not the perfect example maybe, but imagine you have learnt assembler and C in school and programmed in that for 30 years doing say embedded applications. You maybe update yourself regularly in that very field of assembler and C. Then one day you are asked to program a web app using HTML, javascript and CSS and complete it in the same time and with the same quality result as someone who has learnt it in university and with a few years work experience. Quite hard.
I had a 55+ year old dentist who wanted to pull out my tooth and replace it with a bridge. The tooth was cracked and 1/3 of the tooth had fallen off. Luckily he worked only half time and was on vacation a lot so difficult to get an appointment so I got to see a young dentist who could fix the tooth by repairing it (building up the missing part). She said it could last a month or forever, but if not lasting then the next option would be a titanium implanted tooth. Making a bridge would have been considered malpractice nowadays she said. The old dentist was probably a master at putting in bridges, but if that method is bad and he never practiced the other technique, which you probably cannot learn in a 1 week yearly course, then tough luck.
Not the perfect example maybe, but imagine you have learnt assembler and C in school and programmed in that for 30 years doing say embedded applications. You maybe update yourself regularly in that very field of assembler and C. Then one day you are asked to program a web app using HTML, javascript and CSS and complete it in the same time and with the same quality result as someone who has learnt it in university and with a few years work experience. Quite hard.
Not the perfect example. OT, but dentistry is unlike other fields of medicine, a huge amount of the practice is outright scam. See past thread: https://news.ycombinator.com/item?id=37022911
[deleted]
Not in all countries. Doctors in e.g. Japan aren’t required to take any continuing education (IIUC).
(This is my understanding as a layman, so I’m happy to be corrected if wrong.)
(This is my understanding as a layman, so I’m happy to be corrected if wrong.)
Perhaps. But they have advantage of 30-40 years of experience.
But here's the things I'm not clear about: Surgeon get immediate feedback if they make mistakes because their patient might die or get severely disabled, but is there any feedback to GPs about the effectiveness of their work?
Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it?
For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH.
How do doctors who operate on this assumption going to learn from experience, if they mostly don't know that their patients have cardiac events as a result?
Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it?
For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH.
How do doctors who operate on this assumption going to learn from experience, if they mostly don't know that their patients have cardiac events as a result?
> Surgeon get immediate feedback if they make mistakes because their patient might die or get severely disabled, but is there any feedback to GPs about the effectiveness of their work?
I disagree with this. If a patient dies from a surgical complication, it is often weeks or months later, on a nonsurgical service because there are no surgical options left for the patient.
> Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it?
Yes, they get to know about it. But ascribing cause and effect in a chronic disease is difficult.
Eventually everyone will die, even if they get perfect treatment. I'm not saying there's no such thing as medical error - in some cases there is clear and obvious error - but what's much more common is a situation of "Did I do the wrong thing, or did I do the right thing but they were so sick that they died anyway?" And there are often many years separating cause and effect, which muddies the picture even further. That's why learning from specific patient outcomes is tricky and why doctors lean so heavily on evidence based medicine, which means learning from large medical trials with rigorous statistical controls.
> For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH.
There's a difference between serious pathology and serious pathology you can do something about. I agree that LVH on EKG is a bad sign, even if the ultrasound is normal. But what is your GP going to do about it? There are many test results that are abnormal and/or correlated with bad outcomes, but only a subset of those can be labeled with a concrete diagnosis that is well understood medically, and only a subset of those can be treated.
All your GP can do for an ECG finding of LVH is advise blood pressure control, cholesterol control, exercising frequently, and other things that are generally good for heart health.
On the other hand, if there is anatomical LVH, then the next question is whether there's hypertrophic obstructive cardiomyopathy. That's a concrete diagnosis where we know a lot about the underlying mechanism, which leads to specific advice like avoiding strenuous activity. And some patients with HOCM can benefit from a septal ablation. That's why anatomic LVH gets more attention from doctors.
I disagree with this. If a patient dies from a surgical complication, it is often weeks or months later, on a nonsurgical service because there are no surgical options left for the patient.
> Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it?
Yes, they get to know about it. But ascribing cause and effect in a chronic disease is difficult.
Eventually everyone will die, even if they get perfect treatment. I'm not saying there's no such thing as medical error - in some cases there is clear and obvious error - but what's much more common is a situation of "Did I do the wrong thing, or did I do the right thing but they were so sick that they died anyway?" And there are often many years separating cause and effect, which muddies the picture even further. That's why learning from specific patient outcomes is tricky and why doctors lean so heavily on evidence based medicine, which means learning from large medical trials with rigorous statistical controls.
> For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH.
There's a difference between serious pathology and serious pathology you can do something about. I agree that LVH on EKG is a bad sign, even if the ultrasound is normal. But what is your GP going to do about it? There are many test results that are abnormal and/or correlated with bad outcomes, but only a subset of those can be labeled with a concrete diagnosis that is well understood medically, and only a subset of those can be treated.
All your GP can do for an ECG finding of LVH is advise blood pressure control, cholesterol control, exercising frequently, and other things that are generally good for heart health.
On the other hand, if there is anatomical LVH, then the next question is whether there's hypertrophic obstructive cardiomyopathy. That's a concrete diagnosis where we know a lot about the underlying mechanism, which leads to specific advice like avoiding strenuous activity. And some patients with HOCM can benefit from a septal ablation. That's why anatomic LVH gets more attention from doctors.
> Yes, they get to know about it.
I’m curious. How do they get to know about it? Maybe the process differs between countries. I’m from Ghana, by the way.
> All your GP can do for an ECG finding of LVH is advise blood pressure control, cholesterol control, exercising frequently, and other things that are generally good for heart health
Mostly true, but taking ECG LVH more seriously helps the patient understand how important it is for them to improve their general heart health. It also makes LVH regression (which is possible in more cases than doctors believe) a therapeutic target.
I’m curious. How do they get to know about it? Maybe the process differs between countries. I’m from Ghana, by the way.
> All your GP can do for an ECG finding of LVH is advise blood pressure control, cholesterol control, exercising frequently, and other things that are generally good for heart health
Mostly true, but taking ECG LVH more seriously helps the patient understand how important it is for them to improve their general heart health. It also makes LVH regression (which is possible in more cases than doctors believe) a therapeutic target.
I'm in the US. Part of my hospital's workflow for a deceased patient is calling their GP's office to notify them of the death. As far as I am aware, this is mandated by state law. If a patient is discharged, a summary of their hospital course is faxed to their GP's office at the time of discharge. Or transmitted electronically, if possible.
What is the GP expected to do with that? Does the doctor (ideally) review case notes and their own interventions? Or does the office staff close the patient's file - without necessarily even telling the doctor "Mr So-and-so passed away", unless it happens to come up in conversation?
Genuine question, and I can see totally valid reasons for each course of action.
Genuine question, and I can see totally valid reasons for each course of action.
It's up to them what they do with the information. Ideally the doctor would take the opportunity review the patient's chart, but I'm sure there are some clinics that just close the file and call it a day.
The feedback loop tends to be stronger on the inpatient side. In academic settings, it's common for each department to have a "morbidity and mortality" conference once or twice a month. This is a meeting where one or two physicians will present a case that they think went poorly and the rest of the physicians in attendance will give feedback on what could have been done differently.
The feedback loop tends to be stronger on the inpatient side. In academic settings, it's common for each department to have a "morbidity and mortality" conference once or twice a month. This is a meeting where one or two physicians will present a case that they think went poorly and the rest of the physicians in attendance will give feedback on what could have been done differently.
Surgeons don't get immediate feedback because the advisability of procedure X ends up being a statistical matter that might not be decided in the surgeon's lifetime. It depends what it is. They will have opinions of course, but will work with the system and follow process.
I don't know about GPs, but for surgeons I believe it's not so clear cut (pun not intended). From what I understand bad outcomes in surgery often take a while to manifest - but more importantly, it seems that even when they do, and get tracked in the medical record, not much is done about it either way. I recall reading an article a while back about investigations showing there's a wide disparity in outcomes among surgeons, but not much is done about it, and there's no way for patients to get access to this data. This was several years ago, though, so maybe things have changed since then.
The importance of "feedback loops" was my key takeaway from my time larping as a QA/Test manager.
> ...but is there any feedback to GPs about the effectiveness of their work?
Specialties too. esp for any misdiagnosis or hard to diagnosis conditions.
> ...but is there any feedback to GPs about the effectiveness of their work?
Specialties too. esp for any misdiagnosis or hard to diagnosis conditions.
It's my understanding that the significance of that age can and does vary wildly. In some specialties, age makes errors more likely: https://psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-...
30-40 years of experience using the old knowledge and techniques.
Human biology doesn't change in 30-40 years.
90% of what doctors do is completely routine and they all know and keep up with what the "standard of care" is for common conditions and in many cases it's the same today as was the standard of care in 1984.
Sure, if you have something unusual you might want to go to a younger specialist or a specialty clinic where they focus on leading-edge care for that condition.
A 60-year old GP will do fine for your annual physical.
90% of what doctors do is completely routine and they all know and keep up with what the "standard of care" is for common conditions and in many cases it's the same today as was the standard of care in 1984.
Sure, if you have something unusual you might want to go to a younger specialist or a specialty clinic where they focus on leading-edge care for that condition.
A 60-year old GP will do fine for your annual physical.
The biology doesn't change of course, but the procedures, drugs, medical devices, treatments and overall knowledge and best practices does.
An annual physical is such a small and simple subset of the total medical field so not sure why you bring it up.
An annual physical is such a small and simple subset of the total medical field so not sure why you bring it up.
In 2021 I presented my doctor a hypothesis that a COVID infection I had recently was persisting in my body leading to long term symptoms. They told me I was completely wrong and that RNA viruses do not do that.
Fast forward to today and the NIH director and leading scientists believe this has backing proof.
https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-...
https://www.science.org/content/article/long-covid-trials-ai...
It has taken me almost three years to convince my doctor on the rationale of using therapeutics acting as COVID antivirals to treat my chronic symptoms. I now have to wait until clinical trials present data hopefully this summer to at least try.
So I hope this is a story to show that patients are helping doctors think. And it is very slow going.
Fast forward to today and the NIH director and leading scientists believe this has backing proof.
https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-...
https://www.science.org/content/article/long-covid-trials-ai...
It has taken me almost three years to convince my doctor on the rationale of using therapeutics acting as COVID antivirals to treat my chronic symptoms. I now have to wait until clinical trials present data hopefully this summer to at least try.
So I hope this is a story to show that patients are helping doctors think. And it is very slow going.
In 2021 there was almost no evidence of persistent long-term symptoms because very, very few people had COVID far enough in the past (and survived) to have these symptoms start to show up. It's completely reasonable for a front-line GP physician to not go down a rabbit hole like that because their lay patient has a hunch.
Not true. There has been evidence of long term symptoms months after the first wave in 2020. By 2021 established hypotheses of viral persistence existed.
Viral persistence(2021): https://www.frontiersin.org/journals/microbiology/articles/1...
Persistent symptoms(2020): https://pubmed.ncbi.nlm.nih.gov/32644129
Viral persistence(2021): https://www.frontiersin.org/journals/microbiology/articles/1...
Persistent symptoms(2020): https://pubmed.ncbi.nlm.nih.gov/32644129
I've come to the same conclusion about long COVID in April May of 2020. The evidence is shockingly overwhelming and has been grossly ignored. Some of us have found cocktails that work. Would love to discuss if you are interested.
Hypothetically, if one had good reason to believe a certain medication/treatment would work, and has some degree of risk-tolerance, they could acquire said medication online from other countries without trying to convince some doctor willing to listen to prescribe it.
People have and have been successful. Especially repurposing HIV/AIDS drugs and ordering Paxlovid from India. Mostly due to USA prices being ridiculously high and insurance companies refusing to prescribe more than a 5 day dose.
The other major challenge is that certain approved drugs in other countries can be held by shipping due to FDA approval.
The other major challenge is that certain approved drugs in other countries can be held by shipping due to FDA approval.
Not sure why you would be taking Paxlovid for long covid.
There is rationale in the science article I posted above. The current hypothesis is viral reservoirs that are replication competent. Here is the blurb as well:
> Paxlovid targets virus that is rapidly replicating—which may or may not be the case for the virus lingering in Long Covid cases.
> Paxlovid targets virus that is rapidly replicating—which may or may not be the case for the virus lingering in Long Covid cases.
In the US, it seems like insurance companies teach doctors how to think.
How many times have we all heard from a doctor "we don't like to do so many tests each year because of costs"
How many times have we all heard from a doctor "we don't like to do so many tests each year because of costs"
On the contrary, US doctors are significantly more aggressive with testing and treatment than doctors in most other countries. There's multiple reasons for that, but I think the main one is trying to CYA in the event of a malpractice lawsuit.
Source?
And does more (or "significantly more") even mean it's making a difference?
It's well known that younger and younger people are being diagnosed with cancer, yet only a few major tests have been recommended to be done sooner (colon, prostate, breast) and by just a few years.
Unfortunately I will probably not take the time to help you find a source, but FWIW this was taught to me several times in medical school and is generally believed to be true by myself and many colleagues.
It is one huge reason I work as a federal employee -- FTCA helps me feel free to do what I think is right for my patient without worrying nearly as much about getting sued. In my line of work, a tremendous amount of absurd testing is done because there could be a 0.01% chance of missing something serious, and if you see 1,000 pts per year and plan to have a multi-decade career, it's easy to justify almost certainly unnecessary testing.
It is one huge reason I work as a federal employee -- FTCA helps me feel free to do what I think is right for my patient without worrying nearly as much about getting sued. In my line of work, a tremendous amount of absurd testing is done because there could be a 0.01% chance of missing something serious, and if you see 1,000 pts per year and plan to have a multi-decade career, it's easy to justify almost certainly unnecessary testing.
I wouldn't say "teach". But you're right that docs are forced to obey insurance companies. Not only in the US, but everywhere insurance companies are a thing. Yet, docs are almost always the main target for complaints, while insurance companies act in a very capitalistic way by optimizing for C-suite bonuses.
> Not only in the US, but everywhere insurance companies are a thing.
No, not at all. Insurance exists in plenty of places, without significantly influencing doctors' treatment.
No, not at all. Insurance exists in plenty of places, without significantly influencing doctors' treatment.
The secondary purpose of insurance is for the best-positioned allocator of risk to explore new means of reducing risk by leveraging lower premiums against adoption of risk reduction methodologies.
In other words, an insurance market that does not influence doctors’ behavior seems to be a pretty inefficient insurance market.
In other words, an insurance market that does not influence doctors’ behavior seems to be a pretty inefficient insurance market.
Really? I feel like whenever a doctor sees that I have really good insurance they feel the need to use every single machine they have as a diagnostic. I generally don't care because my copay is generally the same regardless and I figure it is good to be thorough, but I do realize that is probably driving up the costs for everyone in the long run.
“really good insurance”
I’d guess a massive % of the us population is having a different experience than you.
I’d guess a massive % of the us population is having a different experience than you.
I think OP is quite right that insurance drives tests and costs up because contrary to what we think it is good for the insurance companies if the doctor bill is high because then people buy more expensive insurances and thus higher revenue for the insurance company.
If the cost would be low there would be no need for an insurance.
If the cost would be low there would be no need for an insurance.
Sure, my wife and I had to deal with that not too long ago when I was unemployed and had to use the subsidized MetroPlus stuff in NYC. It wasn’t as bad as I thought it would be but it was definitely not as good as my fancy PPO I get from sexy desk jobs.
I guess what I am getting at is that insurance sort of makes things worse for everyone here. When a person comes in with good insurance the doctor has incentive to abuse it, artificially driving up costs, making it harder for people with crappy/no insurance to get the treatments they need because insurance won’t cover it. It’s a messy system.
A large part of me would prefer that we abolish private insurance entirely, but I fear that’s not likely in the states.
I guess what I am getting at is that insurance sort of makes things worse for everyone here. When a person comes in with good insurance the doctor has incentive to abuse it, artificially driving up costs, making it harder for people with crappy/no insurance to get the treatments they need because insurance won’t cover it. It’s a messy system.
A large part of me would prefer that we abolish private insurance entirely, but I fear that’s not likely in the states.
Yeah like almost everything wrong in the economy, the question is where is the stabilizing feedback loop? Where can patients choose something better, and how do they get the information to choose the best option?
That the answer to a cultural-intellectual problem is monetary is not fully convincing to me. Do we really want 30% more attending physicians of the orientation this article describes?
These all seem like valid, but unrelated complaints. On one hand, there is a complaint that doctors are judged subjectively, rather than objectively. But in the next breath those same objective metrics are skewered as deductive and maybe even greedy.
The current attending physicians, according to the author, have a population-wide cultural problem where they don't believe they should have to teach. The author's solution to this problem is to hire more attending physicians.
Many of the issues raised in this article merit investigation, but this piece feels too eclectic in its thesis to serve as a launchpad for policy direction.
These all seem like valid, but unrelated complaints. On one hand, there is a complaint that doctors are judged subjectively, rather than objectively. But in the next breath those same objective metrics are skewered as deductive and maybe even greedy.
The current attending physicians, according to the author, have a population-wide cultural problem where they don't believe they should have to teach. The author's solution to this problem is to hire more attending physicians.
Many of the issues raised in this article merit investigation, but this piece feels too eclectic in its thesis to serve as a launchpad for policy direction.
It seems to me that nobody teaches anybody how to think. Instead we teach people to do things that require thinking, and trust that they will develop an ability to think as a “byproduct”. Which is a bit strange to me, since there are definitely some general principles that can be taught.
Let's poke this, how would you teach how to think?
I took a class psychology class on learning that was superb.
It taught how to memorize stuff: spaced repetition and semantic encoding. Spaced repetition is reviewing the thing at increasingly spaced intervals of time. Semantic encoding is coming up with connections to the idea. The wilder the better as that tends to be memorable.
The class taught some strategies for creativity such as use of analogies and trying to combine disparate ideas.
The class also taught cognitive biased, like loss aversion.
This class was life changing. It was also easy because the teacher applied the best practices she was teaching.
I would say something like that class is the basis for teaching people how to think.
It taught how to memorize stuff: spaced repetition and semantic encoding. Spaced repetition is reviewing the thing at increasingly spaced intervals of time. Semantic encoding is coming up with connections to the idea. The wilder the better as that tends to be memorable.
The class taught some strategies for creativity such as use of analogies and trying to combine disparate ideas.
The class also taught cognitive biased, like loss aversion.
This class was life changing. It was also easy because the teacher applied the best practices she was teaching.
I would say something like that class is the basis for teaching people how to think.
wow, this inspires me to find something like that on coursera
Breaking a problem down into smaller problems, solving those that are immediately obvious or known from experience, for harder or new problems: gathering evidence if available, coming up with a hypothesis, testing this against the available evidence, looking for reasons why the hypothesis must be wrong and abandoning it if reasons are found, iterating on the hypothesis until an adequate one is found (adequate being provably correct, or "sounding sensible" based on solutions to similar problems). My 2c is being ok with uncertainty and being wrong, and an awareness of cognitive biases can be helpful.
Traditionally? Humanities. Those fields have the advantage of starting with common experience and a natural-language corpus, so there isn't as high a barrier to entry as STEM disciplines. But, you know... we don't do that anymore. (And yes, I know, some of the reasons are intrinsic to choices made by people within the Humanities.) We've abandoned that, but not found a better way.
I think part of this is about staying up to date. I'm not sure if there's a legal requirement for ongoing training? But I've had the experience of going to an older physician and being told my theory is impossible, based on a hypothesis that was disproven in the early 1970s (incidentally, right after the physician graduated).
Yes. Doctors in the US have to get a certain amount of Continuing Medical Education (CME) credits (usually done by attending conferences and lectures).
I'm not sure about it being a legal requirement in all states (may be) but is generally done by the boards that oversee one's specialties (with some very vague and inconsequential requirements by the state licensing boards).
Unfortunately it seems mostly to be a money grab in many specialties, with passing rates in the high 90s for recertification exams, fees of over a thousand dollars, and often with multiple retries if one fails (as long as you pay the fee for each attempt).
Unfortunately it seems mostly to be a money grab in many specialties, with passing rates in the high 90s for recertification exams, fees of over a thousand dollars, and often with multiple retries if one fails (as long as you pay the fee for each attempt).
So they are being taught by the pharmaceutical industry?
I have what is a rather rare disease in the United States. I recognized it for what it was about a month in, purely by accident -- I recalled an interesting article I had read when I was about twelve. It took roughly a year to convince the appropriate doctors to run the tests, yes because they were fixated on the "hoofbeats, horses, not zebras" mantra, despite my symptoms aligning so perfectly you'd think a constellation had been traced on onionskin paper. Each specialist who drifted through behaved like a sage in the tale of the six blind sages and the elephant. Then you consider the overwork -- why? It's hazing, but we know that it causes people to underperform.
> we often mistake the speed of initial understanding with a students’ capacity for mastery
This is one of those assumptions that I didn't notice I was making till it was pointed out.
It is hard to predict capacity for mastery. It seem natural to adopt initial understanding speed as a heuristic, but I think it is the kind of heuristic that while effective, also tends creates a significant overestimation of it's own effectiveness through confirmation bias.
This is one of those assumptions that I didn't notice I was making till it was pointed out.
It is hard to predict capacity for mastery. It seem natural to adopt initial understanding speed as a heuristic, but I think it is the kind of heuristic that while effective, also tends creates a significant overestimation of it's own effectiveness through confirmation bias.
Seems like a good thing that purdue lets many students into engineering who can't hack it(i couldn't!). If they didn't have mayn failing that would mean they would be rejecting too many edge case students who might be able to make it through the program.
Don't get her argument that someone willing to show up to a 7:30am class is necessarily smart enough for o-chem. Tendentious
Don't get her argument that someone willing to show up to a 7:30am class is necessarily smart enough for o-chem. Tendentious
The author prefers to believe that it was poor instruction. The implication is that because they were willing to show up for a 7:30am lecture, they were capable of making it.
On the one hand, the author is on to something. Most people learn much better with intensive, one-to-one instruction than with large lectures. The real issue, as with all educational programs, is the cost in time and money to teach. More personalized, intensive training from more specialists in teaching a specialized subject simply costs more to get the to the same goals as bulk lectures. Nobody wants to say "There was a very rational cost-benefit analysis and I lost out". Instead, it's all framed as a need to dedicate more time and money at an already demonstrably drawn-out and expensive process.
On the other hand, a person's ability and willingness to show up at 7:30am are probably irrelevant. No matter how relevant it feels to a person who wants to show their dedication, passion, and drive.
On the one hand, the author is on to something. Most people learn much better with intensive, one-to-one instruction than with large lectures. The real issue, as with all educational programs, is the cost in time and money to teach. More personalized, intensive training from more specialists in teaching a specialized subject simply costs more to get the to the same goals as bulk lectures. Nobody wants to say "There was a very rational cost-benefit analysis and I lost out". Instead, it's all framed as a need to dedicate more time and money at an already demonstrably drawn-out and expensive process.
On the other hand, a person's ability and willingness to show up at 7:30am are probably irrelevant. No matter how relevant it feels to a person who wants to show their dedication, passion, and drive.
They were complaining about a weed-out class being a weed-out class. The students wanted to get into an extremely prestigious career. Weed-out courses exist because there's a limited number of prestigious spots, or because most students need the pressure to work harder. It would make sense if she then explained that we should make medicine less prestigious (letting far more students become doctors) but that wasn't the point.
The point was that learning the fundamentals was prioritised, instead of "deep learning". However there's a ton of research that suggests that in many cases, learning the fundamentals is one of the best ways to get students to start the process of deep learning. Obviously there's a point where overtraining the fundamentals is no longer a good thing (e.g. trying to memorise every possible edge case and combination) but that's a rare edge case. In most cases, simply getting the grips with the basics quickly, then thinking for yourself (e.g. looking at hard cases rather than asking how someone can teach you how to think at a higher level) is what works.
Education has a long-running holy war between implicit vs. explicit instruction (though "implicit instruction" has a lot of name changes as it always seems to lose credibility and need rebranding). Saying "we need to stop teaching students what to think, but how to think" isn't deep, it's a cliché, and it needs a lot more than vague criticisms of explicit instruction to be worth listening to.
Probably the worst thing about the "deep learning" crowd is that so many of them are in medicine, where it kind of works. You can teach medical students badly, and they'll figure things out. Giving them more independence and teaching badly (while pretending to be wise) can perversely work, in some ways, for medical students who've survived the weed-out classes. But then a few academic studies on how to teach medical students better (apparently they haven't yet learnt how to learn, or how to think critically?) is then used to convince politicians, education academics, and other people who understand little about teaching that it's the best way to teach reading in underprivileged elementary schools.
The point was that learning the fundamentals was prioritised, instead of "deep learning". However there's a ton of research that suggests that in many cases, learning the fundamentals is one of the best ways to get students to start the process of deep learning. Obviously there's a point where overtraining the fundamentals is no longer a good thing (e.g. trying to memorise every possible edge case and combination) but that's a rare edge case. In most cases, simply getting the grips with the basics quickly, then thinking for yourself (e.g. looking at hard cases rather than asking how someone can teach you how to think at a higher level) is what works.
Education has a long-running holy war between implicit vs. explicit instruction (though "implicit instruction" has a lot of name changes as it always seems to lose credibility and need rebranding). Saying "we need to stop teaching students what to think, but how to think" isn't deep, it's a cliché, and it needs a lot more than vague criticisms of explicit instruction to be worth listening to.
Probably the worst thing about the "deep learning" crowd is that so many of them are in medicine, where it kind of works. You can teach medical students badly, and they'll figure things out. Giving them more independence and teaching badly (while pretending to be wise) can perversely work, in some ways, for medical students who've survived the weed-out classes. But then a few academic studies on how to teach medical students better (apparently they haven't yet learnt how to learn, or how to think critically?) is then used to convince politicians, education academics, and other people who understand little about teaching that it's the best way to teach reading in underprivileged elementary schools.
In the military we train this as being “brilliant on the basics” with the follow on, as you said, that it is the way to train an adaptable and competent professional who works in high stress situations.
But, assuming we take the facts of the post at face value, there clearly wasn’t a rational cost-benefit analysis that resulted in only teaching large lecture-style courses and deliberately serving only those who could thrive that way. The instructor’s claim was not that the author needed more instruction that wasn’t available (indeed, they turned her away from seeking such instruction). Rather, it was that people like her simply can’t “hack it”, which the author demonstrated to be false.
There was no cost-benefit analysis on offer, you are correct. This is not the same as there being none, though. Weed-out courses are a classic example implemented at the institutional level - they exist to find as early as possible who is likely to be compatible with the educational program to come. Like any system working on messy humans (who like to defy neatly delineated categories), there are marginal cases who just need a little help to flip from one category to the other. The author calculated that they were such a marginal student and invested accordingly. This should not be confused for assuming that every passionate, driven student is a marginal case who just needs a little help.
The author is essentially arguing at length for a greater emphasis on benefit and less on cost. Not just in o-chem, but at every stage of medical training.
The author is essentially arguing at length for a greater emphasis on benefit and less on cost. Not just in o-chem, but at every stage of medical training.
I just wish I had known that o-chem gets easier if you start first thing in the morning.
The real issue, as with all educational programs, is the cost in time and money to teach.
LLMs should help with that.
LLMs should help with that.
I know we hold doctors in high regard, but I must decline in allocating some magical "vibe" or "spidey-sense" as the article writes.
In my opinion a well built system will replace all doctors in non-research, medical functions.
The notion that somehow one needs "vibe" to recognize something is wrong when Gladys in the example "vomited a huge quantity of blood" is concerning, and wee bit self-aggrandizing. The doctor reacted because there was clear evidence of an issue, not because supernatural abilities.
> A doctor’s foundational clinical mental models are built during residency...
And, sad to say often stays that way for the rest of their careers. Anecdotally, I have seen this clearest with dentists and ophthalmologists. They will fossilize into their own thinking and unable or unwilling to pick up new methods and procedures (unless sufficiently incentivized by the selling company).
another problem is frailty. I walked out on Monday dental appointment when I could tell the dentist had a "rough weekend". I do not need a person with a hang-over digging in my mouth with sharp spinning objects.
A system that is updated near real time with new research, new medical advances, not getting tired or distracted is more preferable to me than a human. Maybe the actions are not performed by the machine, it just prompts the human to do and feed the information back, maybe it will also perform the actions. All is possible in the future.
When it comes to research and emotional interaction, yes, doctors still hold an edge.
In my opinion a well built system will replace all doctors in non-research, medical functions.
The notion that somehow one needs "vibe" to recognize something is wrong when Gladys in the example "vomited a huge quantity of blood" is concerning, and wee bit self-aggrandizing. The doctor reacted because there was clear evidence of an issue, not because supernatural abilities.
> A doctor’s foundational clinical mental models are built during residency...
And, sad to say often stays that way for the rest of their careers. Anecdotally, I have seen this clearest with dentists and ophthalmologists. They will fossilize into their own thinking and unable or unwilling to pick up new methods and procedures (unless sufficiently incentivized by the selling company).
another problem is frailty. I walked out on Monday dental appointment when I could tell the dentist had a "rough weekend". I do not need a person with a hang-over digging in my mouth with sharp spinning objects.
A system that is updated near real time with new research, new medical advances, not getting tired or distracted is more preferable to me than a human. Maybe the actions are not performed by the machine, it just prompts the human to do and feed the information back, maybe it will also perform the actions. All is possible in the future.
When it comes to research and emotional interaction, yes, doctors still hold an edge.
I don’t think anybody would claim it’s supernatural. Only that for doctors who have seen lots of patients, they (their subconscious?) pick up on signals that they cannot consciously articulate, which means they can’t be easily taught or checked for. (Over time I think we do catalog more of these things but it takes a lot of instances and some explicit reflection before people can identify and describe the pattern.) I’ve got plenty of criticisms for doctors and medicine but I absolutely think this is true because I experience the same in my own personal and professional life.
A patient who is vomiting blood does not need a "vibe" or "spidey-sense" to figure out something is wrong. There are, however, a surprisingly large number of situations in which doctors have to work with rather less information about what is going on, especially when you move to the hospital.
I'm an anesthesiologist, so I don't have a clinic at all. I meet you just before surgery and we go. Vibes and spidey-senses matter a lot, because I don't have time to run down a two-week-long investigation of your problem - I have to fix it right now or you're dead.
Could AI improve me? Probably. Can the AI observe the way humans can? Not yet. Can they intervene like humans can? Not even close. When you have an autonomous robot that can successfully run down the American Society of Anesthesiologists' difficult airway algorithm, you're getting there.
I'm an anesthesiologist, so I don't have a clinic at all. I meet you just before surgery and we go. Vibes and spidey-senses matter a lot, because I don't have time to run down a two-week-long investigation of your problem - I have to fix it right now or you're dead.
Could AI improve me? Probably. Can the AI observe the way humans can? Not yet. Can they intervene like humans can? Not even close. When you have an autonomous robot that can successfully run down the American Society of Anesthesiologists' difficult airway algorithm, you're getting there.
Almost all medical specialties require a massive amount of know-how, and are only very weakly data-driven. I'm an anesthesiologist, and even anesthesia is weakly data-driven. Honestly, people who think AI can replace a doc in the current state of tech do not understand anything about practical medical care. The day of AI will come, but not today nor in the close future.
> The notion that somehow one needs "vibe" to recognize something is wrong when Gladys in the example "vomited a huge quantity of blood" is concerning, and wee bit self-aggrandizing. The doctor reacted because there was clear evidence of an issue, not because supernatural abilities.
For the record: The doctor stayed in the room due to a “spidey-sense” or “vibe”. The impressive part was predicting the vomit, not reacting to it.
For the record: The doctor stayed in the room due to a “spidey-sense” or “vibe”. The impressive part was predicting the vomit, not reacting to it.
Agree with most of what you said, which is unfortunate (except for the silver lining that machines have the potential to massively increase both the supply and quality of medical treatment).
One bit puzzles me though, why would human doctors have an edge in research? Wouldn't the "person" who can read a trillion times more, remember everything, cross-reference it, and monitor billions of realtime data points (from billions of patients) for patterns, have a slight advantage?
One bit puzzles me though, why would human doctors have an edge in research? Wouldn't the "person" who can read a trillion times more, remember everything, cross-reference it, and monitor billions of realtime data points (from billions of patients) for patterns, have a slight advantage?
I find it interesting that you are so bullish on AI to replace doctors. Similar to fully autonomous driving, I think we need a leap towards GAI to really replace doctors. At the moment we see way too many failure modes that seem to be inherit in how ML systems work.
Don't get me wrong I think ML systems will be great helper systems but I don't see them replace doctors any time soon, if not for the simple reason that a person is much more likely to trust another person than an electronic system and that is actually part of both diagnostics and treatment
Don't get me wrong I think ML systems will be great helper systems but I don't see them replace doctors any time soon, if not for the simple reason that a person is much more likely to trust another person than an electronic system and that is actually part of both diagnostics and treatment
My conjecture is that some research requires a type of out of the box thinking that is not readily available in current technical solutions.
Wonder about Canada and nhs doctor training?
Btw anyone knows what happen in Korea?
Btw anyone knows what happen in Korea?
A lot of this really hits home. Some of my personal observations across residency and practice:
1. There are some attendings who have a subconscious inbuilt assumption that there are "good" residents and "bad" residents and that any team will contain a mix of both, even if it's a team of just two residents. God forbid that you should be just a "good" resident paired with a superstar resident, because then you are the one who must get the "bad" label by default. If this happens early enough in residency, it may be the first piece of feedback that your program director gets about you, which puts you at risk of being labeled "bad" by the program at large and finding yourself being pushed towards a remedial track. I feel that residency programs are shockingly bad at identifying which residents actually need remediation. Residents with serious knowledge or work ethic issues can get ushered along through the program, while very bright residents who don't understand how to play up their own successes get put on remediation plans.
2. More generally, confidence is often misinterpreted as skill, and introversion is often misinterpreted as a lack of skill. Many attendings are shockingly bad at differentiating the two.
3. Departmental culture has a huge effect on residency education. I trained at a busy county hospital and now practice at an ivory tower type place. Much to my surprise, I think the EM program here (which gets residents who were the cream of the crop of their med school classes) does a worse job of treating patients than the county hospital (which failed to even fill its residency class a couple years ago). The difference, at least in my view, is that attendings at the county hospital were extraordinarily hands on, which taught residents that a "normal" ED physician is extraordinarily hands on. As another example, the ED at my current hospital is very aggressive with CT scans, to the point that probably 20% of the patients that I admit have been panscanned (CT scan from head to pelvis). I attribute this to attendings here being more risk averse in cases with a ~1% possibility of malpractice. And it trickles down to the residents too, because again, that's what their reference for "normal" is.
4. Basic science education in med school is a joke and needs to be overhauled from the ground up. As it stands, 1st year is "pure" basic science, 2nd year is learning about the library of various diseases, and 3rd year is learning how to treat those diseases. I still remember reading the nephrology section of my 1st year textbook, a large chunk of which was a breakdown of why cystatin C is a better indicator of GFR than creatinine and a description of a procedure in which contrast is injected into the renal artery and sampled at the renal vein to measure true GFR, worked out step by step with mathematical equations. What was never mentioned: What the hell is GFR even used for anyway? Why would someone want to measure it? These pieces don't fall into place until 2nd and 3rd year.
Imagine if you learned symbolic algebra in 3rd grade but the concept of a word problem wasn't introduced until two years later. That's essentially what medical school basic science education is.
The faculty who design med school curricula are not blind to this issue, but their attempts at fixing it are laughably bad. There is "case based learning" where 1st year students are told a vignette about a hypothetical patient and are asked to generate a differential (a list of possible diagnoses) before they dive into the basic science component. This turns into a comedy skit show because 1st year students barely know any diseases, they are only vaguely familiar with the symptoms even for the ones they do know, and they haven't had much, if any, explicit teaching on how to generate a differential.
Why not take a more vertical slice approach to teaching? Introduce a limited number of bread and butter diagnoses in 1st year and gradually layer on rarer and more complicated diseases in 2nd and 3rd. Put more weight on the basic science aspect in 1st year, put more weight on aspects that require knowing a large number of diseases (like generating a differential) in 2nd and 3rd year.
1. There are some attendings who have a subconscious inbuilt assumption that there are "good" residents and "bad" residents and that any team will contain a mix of both, even if it's a team of just two residents. God forbid that you should be just a "good" resident paired with a superstar resident, because then you are the one who must get the "bad" label by default. If this happens early enough in residency, it may be the first piece of feedback that your program director gets about you, which puts you at risk of being labeled "bad" by the program at large and finding yourself being pushed towards a remedial track. I feel that residency programs are shockingly bad at identifying which residents actually need remediation. Residents with serious knowledge or work ethic issues can get ushered along through the program, while very bright residents who don't understand how to play up their own successes get put on remediation plans.
2. More generally, confidence is often misinterpreted as skill, and introversion is often misinterpreted as a lack of skill. Many attendings are shockingly bad at differentiating the two.
3. Departmental culture has a huge effect on residency education. I trained at a busy county hospital and now practice at an ivory tower type place. Much to my surprise, I think the EM program here (which gets residents who were the cream of the crop of their med school classes) does a worse job of treating patients than the county hospital (which failed to even fill its residency class a couple years ago). The difference, at least in my view, is that attendings at the county hospital were extraordinarily hands on, which taught residents that a "normal" ED physician is extraordinarily hands on. As another example, the ED at my current hospital is very aggressive with CT scans, to the point that probably 20% of the patients that I admit have been panscanned (CT scan from head to pelvis). I attribute this to attendings here being more risk averse in cases with a ~1% possibility of malpractice. And it trickles down to the residents too, because again, that's what their reference for "normal" is.
4. Basic science education in med school is a joke and needs to be overhauled from the ground up. As it stands, 1st year is "pure" basic science, 2nd year is learning about the library of various diseases, and 3rd year is learning how to treat those diseases. I still remember reading the nephrology section of my 1st year textbook, a large chunk of which was a breakdown of why cystatin C is a better indicator of GFR than creatinine and a description of a procedure in which contrast is injected into the renal artery and sampled at the renal vein to measure true GFR, worked out step by step with mathematical equations. What was never mentioned: What the hell is GFR even used for anyway? Why would someone want to measure it? These pieces don't fall into place until 2nd and 3rd year.
Imagine if you learned symbolic algebra in 3rd grade but the concept of a word problem wasn't introduced until two years later. That's essentially what medical school basic science education is.
The faculty who design med school curricula are not blind to this issue, but their attempts at fixing it are laughably bad. There is "case based learning" where 1st year students are told a vignette about a hypothetical patient and are asked to generate a differential (a list of possible diagnoses) before they dive into the basic science component. This turns into a comedy skit show because 1st year students barely know any diseases, they are only vaguely familiar with the symptoms even for the ones they do know, and they haven't had much, if any, explicit teaching on how to generate a differential.
Why not take a more vertical slice approach to teaching? Introduce a limited number of bread and butter diagnoses in 1st year and gradually layer on rarer and more complicated diseases in 2nd and 3rd. Put more weight on the basic science aspect in 1st year, put more weight on aspects that require knowing a large number of diseases (like generating a differential) in 2nd and 3rd year.
This person fucking gets it.
I want to force every software engineer and manager and MBA and anyone else to read this until they've internalized it.
I want to force every software engineer and manager and MBA and anyone else to read this until they've internalized it.
[deleted]
It's kind of incredible that we've let a bunch of weenies with MBAs put our lives and health in the kind of risk that the modern medical system puts us in. Every single story from a doctor or a nurse over the last decade involves being overworked, not having time to actually diagnose patience, lack of sleep, and rapid burnout. On the patient side, what we get for that level of hospital "efficiency" are medical bills that would bankrupt anyone below the top 3% if they don't have insurance, rapidly rising medical insurance costs, and what could charitably be described as prescription drug costs that are not based on the cost of the drug.
The business side, though, is going swimmingly, so there's that, at least.
The business side, though, is going swimmingly, so there's that, at least.
The doctors themselves have as much to blame for this too, not to mention most hospital administrators are MBAs with a healthcare background, they are not art students.
Medicine perpetuates a hazing culture of overworking residents thanks to a jumped up medicine pioneer who took too much cocaine. They refuse to come up with a way to train doctors at scale and instead restrict it to physical residency spots, keeping their compensations high. Train doctors like engineers, break up the medical unions and lobby groups with the anti trust act and most of the problems will be solved.
Medicine perpetuates a hazing culture of overworking residents thanks to a jumped up medicine pioneer who took too much cocaine. They refuse to come up with a way to train doctors at scale and instead restrict it to physical residency spots, keeping their compensations high. Train doctors like engineers, break up the medical unions and lobby groups with the anti trust act and most of the problems will be solved.
Exactly, it's the AMA that's a big part of it. Doctors could stop this by just refusing to work that way. They are the ones with the knowledge and skills and licenses to do what they do, so they are ultimately in the driver's seat.
Refuse to work that way?? And how are we supposed to do that? Stop working until our requirements are met and leave everyone on their own during that time? Who do you think people would blame? The C-suite execs?
The only choice you really have is to leave medicine. After dedicating ten years of your life to it's study, a fucking huge debt and no guarantee of finding a better life elsewhere.
The only choice you really have is to leave medicine. After dedicating ten years of your life to it's study, a fucking huge debt and no guarantee of finding a better life elsewhere.
This is not unique to the US where MBAs / business-minded people are the driving factor for healthcare workers being overworked.
In Canada most fully-trained doctors are paid per patient (AKA fee-for-service)[1] and so there is a huge incentive to rush through as many patients in a day, which results in overwork for the residents (who are salaried) and nurses (also salaried), and no time for adequate education of medical students and residents.
[1] https://www.dr-bill.ca/blog/billing-tips/physician-payment-m...
In Canada most fully-trained doctors are paid per patient (AKA fee-for-service)[1] and so there is a huge incentive to rush through as many patients in a day, which results in overwork for the residents (who are salaried) and nurses (also salaried), and no time for adequate education of medical students and residents.
[1] https://www.dr-bill.ca/blog/billing-tips/physician-payment-m...
The insurance scam in this country sets a worldwide standard for fleecing the stupid. Or, more accurately, fleecing everyone by taking advantage of the stupid.
The failure to divorce your health insurance from your job is what created the mess we have today. It arose from wage caps during WWII, and instead of fixing the defective legislation at the time... Congress just let it fester until it became the life-ruining disgrace that Americans live with daily.
With the strident support of fools who believe that they're getting "free" insurance from their employers... and anything else insurance companies tell them, legislators, lobbyists, drug companies, big corporations all line up against affordable health insurance. Big corporations get workers chained to dead-end jobs by their insurance. Insurance companies and big pharma get windfall profits because the real costs to consumers are buried behind "free" insurance that is profoundly not free.
And nobody in government or politics has the balls to call this out. Subsidizing this rip-off is, in some ways, even worse. Just like subsidizing the obscene rip-off that college has become.
The failure to divorce your health insurance from your job is what created the mess we have today. It arose from wage caps during WWII, and instead of fixing the defective legislation at the time... Congress just let it fester until it became the life-ruining disgrace that Americans live with daily.
With the strident support of fools who believe that they're getting "free" insurance from their employers... and anything else insurance companies tell them, legislators, lobbyists, drug companies, big corporations all line up against affordable health insurance. Big corporations get workers chained to dead-end jobs by their insurance. Insurance companies and big pharma get windfall profits because the real costs to consumers are buried behind "free" insurance that is profoundly not free.
And nobody in government or politics has the balls to call this out. Subsidizing this rip-off is, in some ways, even worse. Just like subsidizing the obscene rip-off that college has become.
It's easy to get what's going on once you realise it's a sickness industry, nothing to do with health.
You want lots of sick people to treat a lot. Doctors being short on time etc, is fine - it's business.
You want lots of sick people to treat a lot. Doctors being short on time etc, is fine - it's business.
> The center for Medicare and Medicaid is the primary source of graduate medical education (residency) funding. Per the Graham Center interactive GME data tool Mt. Sinai received around $175k a year per resident, and pays them a salary of $84,479\year, leaving 90K to pay for their “education.”
This is straight up fraud and should be treated as such.
My wife wanted to be a nurse her whole life, went to school and got a good job, after 3 years at the hospital she had to quit for her own sanity. Every nurse and resident in her circle had a similar story.
U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees.
Seemingly every motivated and caring person in this field is systematically chewed up and spit out.
This is straight up fraud and should be treated as such.
My wife wanted to be a nurse her whole life, went to school and got a good job, after 3 years at the hospital she had to quit for her own sanity. Every nurse and resident in her circle had a similar story.
U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees.
Seemingly every motivated and caring person in this field is systematically chewed up and spit out.
According to https://en.wikipedia.org/wiki/Mount_Sinai_Hospital_(Manhatta..., Mt Sinai is a 'non-profit', but in my opinion, we need a much more expansive definition of 'for-profit'. It's true that there are no shareholders, but the salaries the executives make is a form of profit, and ought to be treated as such. In some ways it's worse because in a company, the board sets the CEOs and execs compensation, and can adjust it according to their own financial interests (which means there's less desire by CEOs to 'waste', because waste means the board / shareholders make less money, and then their compensation is lowered -- theoretically).
In a non-profit, the board uses arbitrary criteria, the board is incentivized to waste all money on executive compensation, because that means the execs throw them excellent parties, galas, soirees, and other social events where they can network with more people to make more profit in their for-profit ventures. Ask me how I know.
In a non-profit, the board uses arbitrary criteria, the board is incentivized to waste all money on executive compensation, because that means the execs throw them excellent parties, galas, soirees, and other social events where they can network with more people to make more profit in their for-profit ventures. Ask me how I know.
I find this notion completely alien. Paraphrasing (with some exaggeration): "it's outrageous we are paying people working at hospitals/schools/non-profits high salaries, they really should be doing it from the goodness of their hearts. The only people that should be earning big bucks are the engineers devolving the tech to keep us addicted to social media, the ad tech that extracts more value from every person and the fiance people to extract the maximum from the general economy to funnel it into some rich pockets! Really people working on things that are actually good for society, should be happy with that and work for free! "
Please re-read my comments. I am not against corporations (for-profit or non-profit), however I don't think we can simply say there is no profit motive in non-profits simply because there are no shareholders. I'm arguing that executive compensation is a form of profit and that -- contrary to what they are held up to be -- non-profits often suffer from an even more personal form of greed than for-profits. As I said above, for-profit entities are at least nominally forced to look out for the profit of the CEO + the shareholders, whereas non-profits are incentivized to look after just the CEO's compensation.
In no way does this mean no non-profit should ever pay someone well.
In no way does this mean no non-profit should ever pay someone well.
The comment was about high salaries for nonprofit executives. If you claim to be a nonprofit but pay your CEO $10 million a year, are you really a nonprofit or are you just as guilty of “funneling money” into “rich pockets” as anyone else?
Hospital donations are also interesting to me as you get billionaires donating amounts of money that.. a FAANG engineer could feasibly have left to give on their demise. Or giving amounts similar to like their 3rd homes value and getting a wing named after them (though the donation clearly only pays for a small fraction of the construction).
Similarly I have a friend whose spouse is extremely talented with a PHD (not MD), and has worked in admin roles at a big nonprofit NYC hospital as well. They have at times had pretty similar compensation, one working at a hedge fund and the other working at a nonprofit hospital. Interesting that. Each side can argue they need to attract talent, and one can argue that hospital admin is closer to doing good for society. It is just surprising to see nonprofit and very high compensation.
Similarly I have a friend whose spouse is extremely talented with a PHD (not MD), and has worked in admin roles at a big nonprofit NYC hospital as well. They have at times had pretty similar compensation, one working at a hedge fund and the other working at a nonprofit hospital. Interesting that. Each side can argue they need to attract talent, and one can argue that hospital admin is closer to doing good for society. It is just surprising to see nonprofit and very high compensation.
>> This is straight up fraud and should be treated as such.
They have to cover overhead for that person. In e gineering that adds 30 to 50 percent. I think doctors have additional overhead, like malpractice insurance, and since this is an educational environment more oversight. 2x doesn't seem bad.
They have to cover overhead for that person. In e gineering that adds 30 to 50 percent. I think doctors have additional overhead, like malpractice insurance, and since this is an educational environment more oversight. 2x doesn't seem bad.
> This is straight up fraud and should be treated as such.
Running a residency program takes resources, staffing, and people. If you expect everyone in the doctor education and residency chain to work for free, there wouldn’t be much of a residency program to speak of.
It’s a reality of life: doing things within a business takes money. I know some people scoff at the idea of health care being a business, but even in government-run programs there are still budgets to be managed and costs to be paid.
> U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees.
Your view is very US-centric, but this is a common story in other countries too. Healthcare is a very complicated and demanding field, and it has high turnover rates outside the US as well. The harsh reality is that these organizations are operating like any other: They compensate as necessary to reach the supply/demand equilibrium. As long as new people continue to seek out and take the jobs at a high enough rate to keep the organization running, they’re not going to arbitrarily increase compensation.
That’s always the answer: It’s supply and demand equilibrium. We can complain all we want about who “should” be paid more or similar musings, but as long as the jobs are filled sufficiently at the current rate and the system keeps chugging along, that’s how it will be.
Running a residency program takes resources, staffing, and people. If you expect everyone in the doctor education and residency chain to work for free, there wouldn’t be much of a residency program to speak of.
It’s a reality of life: doing things within a business takes money. I know some people scoff at the idea of health care being a business, but even in government-run programs there are still budgets to be managed and costs to be paid.
> U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees.
Your view is very US-centric, but this is a common story in other countries too. Healthcare is a very complicated and demanding field, and it has high turnover rates outside the US as well. The harsh reality is that these organizations are operating like any other: They compensate as necessary to reach the supply/demand equilibrium. As long as new people continue to seek out and take the jobs at a high enough rate to keep the organization running, they’re not going to arbitrarily increase compensation.
That’s always the answer: It’s supply and demand equilibrium. We can complain all we want about who “should” be paid more or similar musings, but as long as the jobs are filled sufficiently at the current rate and the system keeps chugging along, that’s how it will be.
[deleted]
> see staff as fungible
It's like that in almost every field.
It's like that in almost every field.
You're talking about two unrelated things. Non-clinical MBAs running hospitals is very obviously dumb, but so is pretending the only cost of a resident is the salary they're paid directly.
> Every nurse and resident in her circle had a similar story.
Most don't quit after 3 years.
> U.S. hospitals are for profit assembly lines.
Absolutely true, regardless of the actual IRS profit classification.
> Every nurse and resident in her circle had a similar story.
Most don't quit after 3 years.
> U.S. hospitals are for profit assembly lines.
Absolutely true, regardless of the actual IRS profit classification.
It's a systematic thing. As long as management is decoupled from actually doing the job one is expected to manage, that outcome will be inevitable as a consequence of the overarching fiscal optimization function being applied Procrustean Bed style to all fields of capitalistically orchestrated human endeavor.
[deleted]
ljlolel(2)