jac241

I think we are seeing literal survivorship bias here where the person whose texts were taken too seriously is alive to tell their tale and everyone whose weren't successfully committed suicide.

In a psych ED it was a lot more common to use 20mg ziprasidone and 2 mg lorazepam - "20 and 2" - for acutely agitated/psychotic patients. Before anyone passes judgement on doing that ask yourself if you've actually seen someone who is truly in psychosis or mania. I almost considered going into psychiatry because of how well antipsychotics and mood stabilizers work, particularly the monthly depot forms of antipsychotics, work and how they really do give patients their lives back.

I think psychiatrists have moved away from haloperidol and the internists or family doctors in nursing homes haven't caught up yet. Not that there's going to be much practical difference between Geodon and Haldol. Of course psych ED is a much different situation than on the floor of a nursing home where it might be more appropriate to use a low dose of Seroquel for delirious patients.

The reason they aren't in a psychiatric hospital is because the only reasons we can involuntarily commit someone is if they are a risk to themselves or others, and like stated elsewhere in the thread is generally reassessed by a judicial process every 72 hours depending on the state. What I'm reading in your post is that you're in favor of involuntarily holding more people which I find interesting because many others in the thread are complaining that it's too easy to have someone committed. There are a lot of armchair psychiatrists in this thread who have never seen someone in psychosis or truly manic suggesting that it's a joke to have someone committed. I spent 3 weeks rotating in a psych emergency department and only saw 2 patients out of probably more than one hundred total patients admitted for being suicidal. Neither were involuntary. From what I've seen unless you have just attempted or have a concrete plan to attempt suicide again you're not going to be admitted. There are just too many people who are in not-on-the-same-planet level of psychosis or mania that are taking up beds to admit someone who is not really about to attempt suicide.

Not trying to pick on your post or anything just thought it is a good example to say that it's maybe not as easy as it may seem to decide who gets admitted/committed, and the dichotomy in this thread shows that point.

Regarding potential overuse of sedation (benzos) or antipsychotics in nursing homes, it's easier for a nurse to push a doctor to prescribe meds to "snow" a patient than to spend time in the room and try to reorient a sundowning delirious dementia patient.

The training length for physicians is pretty much the same in all countries. In the US to become an anesthesiologist: 4 years undergrad, 4 years medical school, 4 years residency. Total: 12 years. In the UK to become an anesthesiologist: 6 years medical school, 2-3 years of general postgraduate training, 5 years specialty training. Total 13-14 years. Why did you not look this simple fact up before saying it authoritatively on here?

There's more to it than you think, and it's easy to think that it's a simple procedure whenever you don't know what can go wrong, why things can go wrong, and how to fix things if it does go wrong.

Also, the doctor isn't why it's expensive. Doctors don't set the prices, hospitals and health insurance companies do.

It's wild that on a site that educated people use that you're seeing people advocate for homebirths. I'm guessing that next to nobody on hacker news have seen a delivery go south and need an emergency C-section. If you're at home, the ambulance is going to be way too late to prevent serious harm to the baby (hypoxic brain injury) or the mom (hemorrhage, hypotensive shock). There's a reason why OB/Gyns don't have their babies at home - it's because they have seen it go wrong.

"Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care." - Cochrane meta analysis: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD....

Have you seen a childbirth, and one without an epidural? There's so much pain that it's not going to be guiding anything. Physicians monitor the status of the infant via fetal heart rate monitoring and monitor the progression of the delivery.

I live in the Midwest. Skin-to-skin is the standard of care. It is not just the coasts that do these things.

What do you have to do before you prescribe a drug? Make a diagnosis, which is what is taught in medical school and not in pharmacy school. Pharmacists are frequently embedded in care teams in hospitals and primary care clinics where they make medication recommendations and know how to get drugs approved by insurance companies (sad that this has to happen...).

Your access to care is the result of the direct primary care model not your NP necessarily. Your NP might be good, but I'm willing to bet on average the people who have a minimum of 15,000 hours of clinical training (MDs/DOs) before independent practice are more competent than the ones who only are required to get 500.

More motivated? Why wasn't she more motivated to go to school for four years, get in-depth training in residency, and become an expert in her field rather than taking the easy "route" to practice "medicine"? I guarantee the IM docs and surgeons slugging it for 80+hour work weeks in residency to become experts are more dedicated and motivated to care for patients than the NPs who train part-time and online.

Cheaper salary and they order more unnecessary tests, imaging, and consults, which, what do you know, the hospital system also makes money off of. It's a win-win for the hospital, but patients and the healthcare system lose.

Does the AMA want that or is that the purview of state medical boards? AMA doesn't set practice laws. The people who lobby against new grad MDs having the same practice rights as NPs/PAs are NPs and PAs (more NPs). NPs lobby against assistant-physician laws because why would you want someone who has had 500 hours of clinical shadowing while completing their part-time online, direct-entry, 100% acceptance, diploma-mill school (NP) vs. a new-grad physician who's had 2 years of physiology, anatomy, and pharmacology and 2 years with 5000 clinical hours where there's actually an expectation that you contribute treatment plans and care to the team. The fact that the AMA has been asleep at the wheel and unable to stop NPs from getting independent practice in 20+ states show that they don't have any real influence on who practices where.

With you on this. There is no diagnostic test for glucose/dopamine depletion, and it is unlikely theory in my opinion. Even when you haven't eaten the circulatory system keeps the brain flushed with glucose from the liver or muscle glycogen, and then ketone bodies from ketogenesis. Unless you have a constant flow of these nutrients supported by a normal blood pressure, you pass out quickly. I don't think it's a surprise that he started to improve when he started antidepressants, started seeing a therapist (the psychologist), started exercising more, and took a less stressful job. To me it sounds like anxiety that built up repeatedly after 30 minutes of working. He states that he felt a numb nothingness (anhedonia), had trouble concentrating, and had psychomotor slowing. Only needs one more to hit the criteria for major depressive disorder, and I'm guessing he was having trouble sleeping at this time. From what he wrote ("It was a physical issue.") it looks like he was going to search until he found a non-psychiatric diagnosis, seeking out a neuro-psychologist (someone with likely no biochem/physiology background), to propose a theory about something that is unlikely.

Regarding the post up above about a TIA (thank you for sharing this story) or the one below about the Microsoft engineer who had neck pain and then a stroke (carotid or vertebral artery dissection, often caused in younger people by car crashes or neck manipulation by a chiropractor..), I think a TIA/stroke is much less likely in this guy's case because of the recurrence of the symptoms after being able to work for a period of time. Someone who's had a TIA hitting Broca's area (motor speech) won't be able to work for a little and then have to stop, they're just not going to be able to speak/type. And unless they're very unlucky they're not going to have them repeatedly only after working for a short period of time. Maybe it is an exact match with the TIA post above with anxiety/PTSD after the initial TIA with word finding difficulty, but it doesn't seem like this guy had word finding difficulty at first because he was able to work after sleeping off his stroke.

If you want to run with glucose, he could have type I diabetes or an insulinoma if you want to go rare, but the symptoms are going to be resolved immediately after eating anything with carbs.

But what do I know, just a student in the American medical system.

Maybe plastic surgery, dermatology, rheumatology, and psychiatry don't, but other doctors are going to be splitting weekends and call among the members of their group. For specialties that have fewer doctors nationwide like vascular surgery, cardiothoracic surgery, and neurosurgery you can expect to be on home-call every third night and covering the weekend every third weekend. You might have to come in to operate every other call, and on the weekend you'll have to round on all of your group's patients on Saturday and Sunday and operate if anything operative comes in.

I am a US medical student so I am in a hospital or clinic almost every day. Our hospital is a tertiary care safety net hospital and all the patients are sick as hell because they have poor access to healthcare. So I know what that looks like, and I'm not arguing that the American "system" is good. I just think you can't say that patients present with higher stage cancers in America based on what's presented in that paper. America likely has worse health outcomes for lower income people, and my guess based on what I've seen is that that's driven by untreated diabetes, hypertension, and higher rates of smoking leading to increased incidence of MI, stroke, and kidney disease, but I have no data to back that up. I would also guess that the reason you're not seeing higher stage presentation in those papers is that poor people who would have had those later presentations are dying of heart disease and CKD before they can develop those cancers. Just my suspicion and I am happy to be proven wrong by data. It is just frustrating to me when people on this site who are generally more educated than your average person will toss anecdotes and unsupported claims around, particularly about healthcare.

Thank you for questioning this. I'll take your evidence and the evidence provided elsewhere in the thread (CONCORD-3 trial, a trial including millions of cancer patients in the US and AUS) over the secondhand anecdote of one physician. Is Stanford even the safety-net hospital for the Bay Area?

Maybe the urology society pushes for PSA tests but the USPTF - https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - the set of guidelines that medical students in the US are taught do not recommend PSA screening.

We do have guidelines provided by the US Preventative Services Task Force - https://www.uspreventiveservicestaskforce.org/uspstf/recomme... - and other specialty organizations may have their own. All medical students in the US are expected to know all of these screening guidelines and generally learn them during their Family Medicine rotation.

Here are the cancer screening guidelines - https://www.uspreventiveservicestaskforce.org/uspstf/topic_s... - You can see that many of these carry the D recommendation, meaning they should not be done because the harm outweighs the benefit of the screening. Screening only makes sense if the cost of the test is low, the test is very accurate, and the benefit of the treatment you're going to undertake after a positive screen is large.

The 14% gap in US population coverage is from Illinois, Nevada, Arizona, North and South Dakota, Maryland, and Kansas not providing data to this registry. Canada is only at 76.5% of their population included. If you're going with the premise that people in the US present with higher stage cancers like other posters in this thread, then it paints US cancer care in an even better light that they are able to have comparable 5 year survival despite their average cancer presenting later and having a worse prognosis.

I have trouble seeing the reason for your argument about mortality. This is one paper that looks at 5 year survival across many countries. The authors may have chosen this outcome measure because it is the easiest and most objective outcome measure we have. Other papers can look at disability adjusted life years or quality adjusted life years. Those measures just were not used in this paper.

The 0.7% margin is not within the margin of error for for that cancer (breast cancer). US is 90.2 [90.1-90.4], AUS is 89.5 [89.1-90]. US compares well to other countries on Breast cancer as well, UK 85.6 (85.4–85.9), France 86.7 (85.5–88.0). The Affordable Care Act has required insurance companies to cover the cost of mammograms (the breast cancer screening test) with no out of pocket costs. Same with colonoscopies (the colon cancer screening test).

I am with you on this. What's magical in Rails? It imports classes for you by name based on their file path, "resources" routes to one of seven methods, templates are expected to be in a directory and named based on controller name and action, it defines methods on models for you based on the column names in the database, it runs files you you put in the initializers directory. All of this stuff is convenient, gets rid of boilerplate, and isn't hard to understand.

Glad someone brought up the residents. Guarantee any IM or surgical resident taking care of you at SF general, Columbia, NYU, Mass Gen, UPMC, etc. is spending at least 80hrs/week in the hospital and probably at least 10 more a week studying when they get home. They even grind the pediatrics residents into dust and there is no payout on the other end for pediatricians who only make 180k on average.

Hospitals are hiring more and more nurse practitioners, who study for 18 months, part time, online while working full time as nurses, who are only required to get 500hrs of "clinical experience" aka shadowing (only 3mos at 40/wk...), and have somehow managed to get independent practice to harm you in >20 states. Schools have no requirement to be a nurse beforehand (not that experience being a nurse is the same as coming up with treatment plans as a doctor...) and have 100% acceptance rates. A quarter to a third of the credit hours they take are courses that boil down to how to lobby state governments for independent practice. Hospitals love them because, to make up for their complete lack of experience, they order a ton of imaging, labs, and referrals which all generate more $$$ for the hospital at your expense (and they don't know how to interpret). You pay the same for an MD/DO vs an NP/PA, but only one group is trained well. All of this is to say, that the payout at the end of residency is going away quickly for a lot of specialties, particularly ones like peds where mismanagement isn't as obvious to lay people as it is in neurosurgery.

Resident salaries are more like 55-70k nowadays but minimum wage at $15/hour would mean a pay raise for a lot of residents.

Would you consider Joe Rogan straight up old? He's 53.

There are specialty board exams that you take once you're done with residency. Some are written exams. Surgical specialties do oral board exams where they present cases to you and question you on management. Pass rates for those are not as high. Many specialty boards make you take recertification exams every x number of years.

I created an add-on (Anki Killstreaks - https://ankiweb.net/shared/info/579111794) that uses the killstreak feature from Halo and COD to make the reviews more fun. Has a corresponding leaderboard (https://AnkiAchievements.com) that shows your rank while reviewing in Anki to help you stay motivated. Both are FOSS.

You can use the ReMemorize add-on to distribute the cards you missed over the next X days. Here's a good video explaining how to manage it: https://www.youtube.com/watch?v=UXgck-g0nQA&t=1189s . If I get home too late and don't have time to do all my cards, that's what I do.

In my experience it's faster for learning because you will recall more after a study period if you do the flash cards vs. rereading things a few times. Not an either or thing as well. I would put a lot of my lecture notes in the extra section of the flash cards, then if I want to get more context I can scroll through my cards sorted by created_at in the browser.

Ideal workflow is watching lecture online at 2x speed with Anki add card window open along side lecture window, pausing when it's time to make a card, write the text for the card and use Lightshot screenshot to quickly grab any images or text (or for image occlusion if you're using that, rebind screenshot capture to F4 so you don't need to use your mouse hand to press PrntScrn). Once you're done adding cards, go through them once that day. Or, if you're using a premade deck, watch the lecture, unsuspend cards relevant to the lecture, then go through them right away.

Not sure if you're using it for school or not, but I think the process will work the same either way. Works even better if you're using it along with a memory palace kind of thing like SketchyMicro or Pixorize. Those images will be burned in your brain and your recall will be insane.

Bury (Press = when reviewing) makes Anki not show you a card until the next day. Suspending (! to suspend all cards based on a note [if you have more than 1 cloze on a card, it will stop showing you all of them], @ just to suspend that one card) will make Anki never show you a card until you unsuspend it in the browser.

Thank you for the knowledge. I'm an M3 who hasn't had surgery, EM, or anesthesia rotations yet. Probably should have thought about the airway though...

I'd love to see the study for this and how they controlled for the fact that being sick enough to require general at a young age probably will ding your IQ a couple points. I'm guessing they didn't do a randomized controlled trial.

Great point and I see that commenters above are suggesting conscious sedation (benzos) instead of general, which would probably be propofol in this case. Both benzos and propofol act at the same chloride channel...