[HN Gopher] A fourth of U.S. health visits now delivered by non-...
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A fourth of U.S. health visits now delivered by non-physicians
Author : geox
Score : 93 points
Date : 2023-10-29 14:22 UTC (8 hours ago)
(HTM) web link (hms.harvard.edu)
(TXT) w3m dump (hms.harvard.edu)
| subharmonicon wrote:
| Honestly I'm surprised the number isn't already much higher. For
| at least the last 15 years most healthcare providers I deal with
| try to get you into a nurse practitioner or physicians assistant,
| and most have quite a few more of those than MDs and DOs.
|
| Perhaps that's a West Coast thing, though, and it's not as common
| in other parts of the country?
| SoftTalker wrote:
| MDs are limited in supply by the AMA. NPs and PAs are not, and
| for routine cases, sore throats, minor injuries, vaccinations,
| routine physical exams, etc. there is no reason an MD needs to
| be involved.
| a_e_k wrote:
| And for the routine stuff I often have a pretty good idea
| what's ailing me from past experience and I just need someone
| to write up the prescription again for whatever's worked well
| before. I have no problems with seeing an NP for that.
|
| In some cases, an NP may have _more_ current experience with
| figuring out the routine stuff than an MD who 's a bit more
| removed from that kind of practice now.
| georgehaake wrote:
| Where I work we have a physician who doesn't see patients. He
| reads procedures and supervises 8 mid-levels. It's an assembly
| line. There are inservices that in effect ensure maximum level of
| encounter complexity to maximize billing.
| fnfjfkdngh wrote:
| Because PA time is cheaper to the provider than MD time. Give it
| a few years and a trip to the doctor's office will mean using a
| touch screen a-la-mcdonalds to describe your symptoms and then
| the first-line medication pops out of a drawer.
|
| I'm pretty jaded with our (US) healthcare system. As long as you
| stay on the happy path it's fine, but if you stray from that,
| good luck. Over the last few years I was given antibiotics for a
| gut infection, a lung infection, and currently a sinus infection.
| None were improved by antibiotics, but no doctor was willing to
| do a culture to see what the infection was before prescribing
| antibiotics because that's the happy path (most infectious are
| bacterial). I think it might be a systemic fungal infection (I've
| also had bouts of what I think is thrush), but that possibility
| is immediately rejected without investigation because 'only
| immunocompromised people get fungal infections'. Similar for
| SSRIs. Asked the shrink why SSRIs versus something else - 'got to
| start somewhere'. Asked them why one SSRI over another, same
| answer.
|
| Throwing shit at the wall to see what sticks is fine if the cost
| of being wrong is just the list time of needing to recompile your
| code. It's 100% not ok when being wrong means fucking up your
| tendons or making you suicidal.
| foolish79 wrote:
| Just smart enough to ask why take an SSRI, still dumb enough to
| attribute everything to systemic fungal infections.
|
| No wonder MDs are retiring at a blistering pace.
|
| The American people are getting the healthcare they deserve.
| Spivak wrote:
| There's nothing actually stopping you from getting a fungal
| culture yourself. The turnaround time is over a month though.
| Unless you're at a huge hospital they just farm it out to
| Labcorp and the like and you can buy direct. Like it makes
| sense, if it's high-probability bacterial you might as well try
| the z pack first. It's faster to just treat it and see than to
| test if it's bacterial.
|
| Also for SSRIs there's nothing to test, you just try them under
| medical supervision and if they help they help. There is an
| experimental DNA test that might be able to narrow down the
| antidepressant options but unless you're struggling to find one
| that works for you it's usually not worth bothering.
|
| Medicine is crazy advanced in some specific areas but for the
| long tail we're not that far from leeches.
| mv wrote:
| leeches are still in use...
| FireBeyond wrote:
| > Similar for SSRIs. Asked the shrink why SSRIs versus
| something else - 'got to start somewhere'. Asked them why one
| SSRI over another, same answer.
|
| At the risk of over-simplifying - and certainly not justifying
| blase, ambivalent answers... the brain is a very complex
| organism. And we have barely scratched the surface of how it
| actually works. Most of it, we just don't know.
|
| So, from this to psychiatric drugs - SSRIs, MAOIs, SNRIs. Read
| the drug information sheet in the packet. Not just the
| "standard" paragraphs on side effects and warnings. All
| prescription drugs are required to specify "how" the drug
| works.
|
| For a startlingly high number of these drugs, this paragraph
| starts with the words:
|
| > It is not understood precisely how [drug] works. It is
| _believed_ that it does X, Y and Z...
|
| (emphasis mine).
|
| We know that they can work for some people and not others. But
| while we can perhaps make decent educated guesses, a lot of the
| time, we can't, because, hell, we don't really know how it even
| actually works, so we can't know it will work for you.
|
| Disclaimer: while I am medically educated and work as a
| prehospital provider, I'm not a MHP, despite my use of 'we' in
| the previous para.
| hn_throwaway_99 wrote:
| Honestly, I don't have any problem with this, and I see it as a
| great thing. 95% of the time when I go to the doctor it's
| something routine and basic, e.g. I just need someone to diagnose
| my cold/flu/infection etc.
|
| My question, though, is where are all the "savings" going if so
| many visits are now seen by lower paid professionals? I was
| referred to a sleep study, where a PA or nurse practitioner just
| proceeded to ask me some basic questions from a form to see if I
| qualified for the study. She added practically nothing to the
| process (literally she was just reading questions from a form)
| and then charged my insurance company $200 for 15 minutes of her
| time. The whole thing was insane. That visit should have cost $20
| max, yet people are lining their pockets at every step.
| twoodfin wrote:
| That my insurer gives me _significant_ financial incentive to
| see an NP at an urgent care clinic vs. going to the ER suggests
| the cost savings are translating into lower premiums, all else
| being equal.
| jdsleppy wrote:
| Why go to the doctor to be told it's a flu or a cold? There's
| nothing to do but treat yourself well and wait, right? I wonder
| what portion of visits are for common viruses.
| bshacklett wrote:
| Many jobs require a "doctor's note" for absences.
| hn_throwaway_99 wrote:
| Because if it's flu and it's early enough there is treatment
| (Tamiflu), and it's helpful to differentiate from things like
| strep, where there is also treatment.
| penjelly wrote:
| canadian anecdote: i havent seen my GP _ever_. He just oversees
| resident (student doctors). Ive had chronic health issues for 3
| years now without much relief, despite having been to the doctors
| office 20+ in that time. Most of the time they deflect me from
| specialist care.
| hahahb3nme wrote:
| Im sure in a years time they will begin recommending MAID to
| you.
| rafram wrote:
| That's a horrible thing to say.
| sterlind wrote:
| there's been an issue with MAID being recommended or
| encouraged to people who don't want to die, but who have
| complex chronic illnesses that are expensive to treat.
| there's been a few really shocking cases of that happening,
| even sometimes crossing the line into coersion.
| acover wrote:
| It's a morbid joke but 30% of bc residents don't have a
| family doctor. Maid is being used as a tool to lighten the
| load on the system.
| rchaud wrote:
| I'm Canadian too, and the only time I didn't see my family
| doctor (phone appointment) was at the height of the COVID
| lockdown. Are you located in a remote area?
| penjelly wrote:
| no i am in ottawa, and i go to a major hospital, their family
| health division.
| userinanother wrote:
| Don't go to a teaching hospital that's always a mistake
| unless you have some really abnormal problem
| drpgq wrote:
| I'm in Hamilton and I mostly see residents.
| robomartin wrote:
| > Ive had chronic health issues for 3 years now without much
| relief, despite having been to the doctors office 20+ in that
| time.
|
| This is the problem with all of these systems that try to
| violate the laws of physics (aka: free market economics). They
| invariably results in substandard care, if you receive care at
| all. Keeping people alive isn't the same thing as actually
| solving problems with quality care.
|
| This is my big gripe with the ACA (Obamacare) in the US. It's a
| shit system that was sold as a quality system. There are so
| many things wrong with it I am sick of listing them.
|
| My wife is a doctor, so I've been privy to behind the scenes
| effects. If you think your doctor gives a shit about you when
| you come to the office with one of the stupid plans, enjoy the
| fantasy.
|
| Doctors do care. However, they can't see thousands of patients
| at a loss. They have bills to pay, just like anyone else. More
| than anyone else, actually. And do, what happens in a lot of
| practices, is that doctors are forced to become numb to their
| caring impulse upon realizing that there's a dividing line
| between quality care and going broke. And so, they churn
| through patients at a rapid rate because the only way to make
| it is quantity.
|
| My wife was telling me that the office next to hers has four
| PA's. They each see 40 to 50 people per day. That's an average
| of 10 minutes per patient. That's not care. That's medical
| professionals being forced by a shit system to push on the cash
| register button as quickly as they are able to just to make it.
|
| It is important to keep context in mind when thinking about
| some of these things. Imagine an office with a couple of MD's,
| a few PA's, a few medical assistants and one or two
| administrators. Collectively, this is a group of people with
| somewhere around, say, $1.5 million dollars in student loans to
| repay. They each have homes, cars, kids and other bills to
| support.
|
| That sets-up a situation where it is impossible for that
| medical practice to exist below a certain revenue threshold.
| More accurately, below a certain profit level. If the insurance
| system they have to work with is shit, they have two options:
| Close the doors and everyone becomes an Uber driver or keep
| them open and run as many people as possible through the doors
| with a $10 to $50 per person gross profit probability per
| person.
|
| No, do the math. Don't just react to this through emotion.
| People have to get paid for their work, just like you.
|
| So, let's assume $50 per person average profit (not sure that's
| a good assumption, it depends on the practice). What I mean by
| "profit" here is what you get paid (not what you bill, because
| sometimes you don't get what you bill) vs. what it costs for a
| medical professional (say, a PA) to provide that service.
|
| Now assume you can churn through 100 people per day. That means
| $5,000 per day in gross profit. If you are open 20 days per
| month, the gross profit is $100K per month.
|
| You now have to pay, say $25K per month for rent, utilities,
| insurance and various other expenses. That means $80K per
| month. Let's say two MD's own the practice and each gets paid
| $25K per month salary. You are left with $30K in the bank. You
| likely have other expenses that will easily consume half of
| that, cleaning, legal, accounting, software licenses, IT, etc.
| You are now down to $15K. Which is a formula for going
| bankrupt.
|
| What do you do? Well, you have to crunch through more people
| per day and try to maintain the same cost structure per
| patient. So, you try to see 150 to 200 people per day --if you
| can, not all practices can do that-- and pump them through as
| fast as possible. In other words, you cannot prioritize quality
| care.
|
| Anyone thinking "Just provide better care and bill for it". It
| doesn't work that way. Say you decide to see only 50 patients
| per day. Obamacare shit plans are not going to magically pay
| you double for taking someone's pressure and temperature or
| going through a basic diagnostic check. The limit function here
| is that these plans are shit, they don't pay for quality care,
| they pay for delivering the fantasy of having medical care.
|
| Not to mention the horrible problems of Medicaid/Medicare.
| That's another half dozen paragraphs.
|
| Yes, everyone should have access to *quality* healthcare at a
| reasonable cost. No, that isn't possible if imbeciles in
| government make the decisions. These are the same people who,
| through incompetence and mismanagement can't seem to give us a
| world without war and misery. What makes anyone think they can
| actually deliver solid quality healthcare?
|
| BTW, my wife and her partners finally had enough. They launched
| a boutique medical care office. They provide high quality care
| at a reasonable price. Patients are well taken care of,
| employees make a sustainable salary and nobody has to engage in
| the soul-crushing practice of treating patients like cattle.
| penjelly wrote:
| i already understand the economics, these types of systems
| exist everywhere, usually to the detriment of everyone.
| However, all they need to do is _not_ deflect me from
| specialist care, so im not sure it applies 100% here. Check
| back in a month when i go to the office again and insist on
| seeing a specialist.
| robomartin wrote:
| Mine was more of a general comment on these types of
| systems rather than an explanation for what you are going
| through. I have no clue why they are treating you in the
| way you describe. It might be interesting if you could ask
| them why they haven't referred you. Even more interesting
| if they gave you an honest answer.
|
| Good luck.
| penjelly wrote:
| my best guess is theyre trying not to "over-treat" me,
| the problem being its a different doctor every single
| time i go in, so if they all do that i never get anywhere
| if i have a real issue. also, at my office its tough to
| get followups with the same doctor. Note that its partly
| my own fault for backing down when they do deflect me
| though, but its hard to argue with a doctor when they say
| "lets just try this for now". Also, Fwiw i didnt downvote
| you, im not sure why you were downvoted.
| zo1 wrote:
| Not sure what you need a specialist for specifically, but
| for ~$300 you can get an appointment here in South Africa
| for any specialist you want. If I want to see a specialist,
| any specialist, I call their office, book, and X amount of
| time later, they see me. The reason I mention it is that SA
| has a medical tourist visa you can get, so flying here for
| your medical needs may well be within the realm of cost-
| effective for a lot of people in the Western world.
|
| As a general aside. That you have to plead, motivate or beg
| your government to let you get healthcare from a specialist
| seems alien to me. I just don't even have the words - your
| government does not own you!
| srj wrote:
| Your per person figures seem low to me, and you're calling it
| profitability but then taking expenses out of that. Is that
| an industry term? Where does that number come from?
|
| I would think at least before expenses it would be quite high
| as medical visits cost hundreds if not thousands of dollars.
| oramit wrote:
| "They provide high quality care at a reasonable price."
|
| What's the cost to the patient for this boutique care?
| vsskanth wrote:
| The number of new physicians in the US are restricted because you
| need to go through residency and the number of residency slots
| are limited because they have to be funded by Medicare (why ?).
|
| There's a huge lobby (AMA) to keep it that way, to ensure their
| members salaries remain high.
|
| PAs and NPs don't have the same restriction so hospital systems
| are pushing to have them handle office visits as much as
| possible. This also has the advantage of being more profitable
| because they can charge the same.
|
| In the last 5 years me and my wife have never been able to see a
| doctor, only a PA, even though we pay the same.
| rcpt wrote:
| AMA stopped lobbying for that around ten years ago
| Afforess wrote:
| Which given the 8-10 year pipeline to become a physician,
| means we have yet to see the effects. It will take years
| more.
| sseagull wrote:
| It doesn't help that doctors and other healthcare
| professionals are leaving because of burnout. It will only
| get worse in my opinion.
|
| "Warning signs for the U.S. health system are piling up"
|
| "Nearly half of practicing U.S. physicians are older than
| 55"
|
| https://www.axios.com/2023/10/26/health-care-doctor-
| shortage...
| userinanother wrote:
| Did congress fix the pipeline problem? Seems like no
| j-bos wrote:
| It wouldn't be so bad, except so many MDs, PAs, and NPs are just
| bad. This is coming from someone who has been traveling with a
| sick family member for a few years. There are great (read:
| skilled, thoughful, patient, investigative, this.patient data
| driven) professionals out there, but they are badly outnumbered
| and booked for months near a year into the future. A huge bunch
| display the interest, skill, or attention of someone working a a
| declining fast food franchise. Worst of all, most of the good
| medical practitioners don't even have their own practices, they
| can't afford the combo of liquidity and red tape, at least that's
| what a couple have told me.
| mips_r4300i wrote:
| This was my experience going through a half dozen doctors. I
| found a great one finally, but they didn't even bother taking
| insurance, and it was very expensive.
| monero-xmr wrote:
| Excluding emergency situations, the biggest issue IMO is
| diagnosis. So many tests, scans, listening, observation, etc.
| is all about understanding what the problem actually is. Once
| you accurately identify the problem, treatment can be
| effectively given (if one exists) via the current system.
|
| For mysterious problems that elude a simple diagnosis you can
| really be stuck. Most doctors don't have the time for complex
| cases. It's worth becoming your own health researcher if no
| one else can identify the issue.
| hirvi74 wrote:
| > It's worth becoming your own health researcher if no one
| else can identify the issue.
|
| This is something I have been a big advocate of. I would
| never claim to know more than a professional nor would I
| ever give medical advice to another individual.
|
| However, it has helped me plenty of times. I feel like I
| have been able to ask more important and impactful
| questions to doctors, and I have been able to push back on
| some choices that doctors would have made that I think
| might have been incorrect.
|
| For example, I was almost prescribed a medication. That
| particular medication might have treated its indicated
| condition well, but it is known to exacerbate my immune-
| mediated disease as a side-effect (to clarify, the
| medication was not for the immune-mediated disease).
|
| When I mentioned it to the NP I was under the care of, she
| said, "I have never heard that side-effect." Well, she
| looked into it, and it turns out I was right. Had I not
| done my research prior to our visit, then I might have been
| subjugated to changes to a disease that could have been
| entirely been avoided.
|
| I still think she is a wonderful NP, and no one can know
| everything.
|
| I even have another account.
|
| I asked an MD about a newer medication for my immune-
| mediated disease. He said, "I have never heard of that
| before." After discussing it with him, he did not seem to
| be interested in trying it. I swapped doctors, mentioned it
| to the new doctor, and she prescribed it. It's actually the
| single most effective treatment I have tried since I
| acquired the disease 7 years ago.
|
| As Schoolhouse Rock once said, "It's great to learn 'cause
| knowledge is power!"
| mips_r4300i wrote:
| The first doctor I had wanted to send me to get my thyroid
| nuked because it was inflamed after a viral infection.
|
| After 2 years and 6 doctors I found I basically had long
| covid years before it was recognized. Probably from a low
| grade garden variety viral infection. My gut developed food
| sensitivities and I started to develop autoimmune problems
| from that.
|
| After finding the right doctor who could handle researching
| chronic conditions, things improved within months and a few
| years later I completely recovered.
|
| Typical doctors have 5-10 minutes to listen to you and
| click on drop-down boxes on the computer. They won't care
| about chronic or complex issues. They are good for low
| hanging fruit and steering you towards pharmacological
| intervention but unusable for anything more involved.
| gnicholas wrote:
| I get annoyed when I send a message to my doctor and it takes 3
| back-and-forths to get a message from him, and not the nurse. The
| nurse's advice tends to be along the lines of what I would find
| with Google, some semi-relevant copy/pasted advice. I get the
| sense that they make the messaging system useless so that you
| have to sign up for appointments/video appointments. They know
| that for GP appointments, you only pay 30 bucks or so, but they
| get paid 10x that by your insurance company.
|
| I try to resist this, partly because I generally don't need an
| appointment to answer a simple question, and partly because this
| is one of the causes of rising insurance premiums.
| ejb999 wrote:
| They don't want to solve your problem over a messaging system -
| and prefer you to come in - the MD can't bill anyone for
| answering you questions over the phone or even via messaging -
| which is why they push for an appointment.
|
| Not sure what line of work you are in, but are you willing to
| answer endless emails and or voice mails from customers, all
| for free? I know I am not - and while you personally may only
| ask one question a year, a typical MD may have a panel size of
| 1000 to 3000 patients (at least the ones I know); multiply one
| question per patient by 2000 patients, and all of a sudden you
| find out you worked for free for most of the year.
|
| Maybe if insurance companies had a billing model that allowed
| the MDs for charge for this type of 'support', that made them
| some money it would be workable - but I can't blame them for
| not wanting to give out free care this way.
| nyx wrote:
| This is a problem they're working on solving, I think. The
| hospital group I've been using in the Portland area recently
| announced that patient-initiated messages that take more than
| a few minutes, and require e.g. digging through a chart, are
| billable to insurance: https://www.legacyhealth.org/messages
|
| MyHealth is just what this hospital system calls their
| patient-facing Epic portal.
| hx8 wrote:
| > Not sure what line of work you are in, but are you willing
| to answer endless emails and or voice mails from customers,
| all for free?
|
| It's common practice to answer emails and take calls from
| customers and not charge them for it in many industries. If
| you have 3000 patients, and you spend 3 minutes/patient/year
| on these interactions, then you spend ~30 minutes a day
| answering emails or leaving voice mails which is pretty
| standard.
| ejb999 wrote:
| No way a typical question takes 3 minutes to answer; just
| by time you read the message, pull up the chart, read the
| chart, make the call, talk with the patient and then
| document the outcome of the call back into the chart, you
| are in it for 15 minutes at least ... not to mention the
| context-switching time you need as you move from one task
| to the next.
|
| And I disagree that it is 'common' in other industries -
| ever try to get on the phone with an Amazon or Google or
| Facebook senior level developer to solve a technical
| problem -without being on a paid support plan? Sure, you
| might get some low level clerical person or entry level
| tech support, but you aren't getting to those senior folks
| for free.
| tssva wrote:
| When I have sent a message to my provider it has been because
| I had a follow up question because the direction given during
| a visit was unclear once it came time to implement it or
| there was an issue with a prescription (for instance a
| particular drug ended up not on my formulary and an
| alternative needed to be prescribed). The last time I sent a
| message is because the doctor said he was prescribing a
| medication and it appeared in my post visit summary but the
| prescription never was submitted. Even in these cases it can
| be like pulling teeth to get a response.
|
| "Maybe if insurance companies had a billing model that
| allowed the MDs for charge for this type of 'support', that
| made them some money it would be workable - but I can't blame
| them for not wanting to give out free care this way."
|
| Most primary care physicians today work for a base salary
| plus incentives. The base salary is the compensation for
| dealing with this kind of support.
| OldGuyInTheClub wrote:
| > the MD can't bill anyone for answering you questions over
| the phone or even via messaging
|
| My patient portal clearly states that the Corporation can
| bill for questions sent as messages.
|
| The Corporation by the way is a religiously-affiliated non-
| profit whose CEO earns tens of millions a year. In the past
| couple of years they have stopped doing vaccinations and
| blood draws. We go to the drugstore for those now.
|
| So, why stay with them? The alternatives are even worse.
| NegativeK wrote:
| I listen to a veterinarian frequently complain about people
| trying to skip the exam fee via various methods -- and the
| owner probably doesn't even know that what they're doing is a
| problem.
|
| A free diagnosis over the phone is a lost exam fee. A health
| certificate over the phone -- exam fee. A vaccine appointment
| that turns into a sick pet and the owner just has some
| question -- exam fee. Trying to skip an exam before boarding:
| exam fee.
| gnicholas wrote:
| If they don't want to have a way to ask a question, they
| shouldn't have one. The assistant who answers questions has
| literally never provided value. She is just wasting her time,
| and mine. I would actually prefer if they didn't pretend you
| could get useful info through the "ask a non-emergency
| medical question" option.
|
| And as tssva said, these questions are often follow-ups on
| topics discussed at an appointment, so it's not untethered
| from revenue.
| ejb999 wrote:
| They are willing to answer some questions, I.e. the ones a
| nurse or medical assistant can answer; it's the medical
| questions that only a provider can answer that they need to
| be able to bill for.
| pen2l wrote:
| In a very meaningful way the line between physician and non-
| physician had been blurring anyway.
|
| There's a software called Epic which is used by virtually all
| large healthcare centers, and while most know it as a database
| system to store patient history and health records (problems and
| conditions they've been diagnosed for, lab work results, medicine
| they're currently taking or have taken in the past), it also has
| a little tab where a healthcare worker can put in some keywords,
| e.g. the symptoms a patient has, and Epic guidelines gives the
| health-provider an action plan for that patient, as well as
| guiding them with differential diagnoses for non-simple issues.
|
| Of course for common ailments a nurse practitioner knows as much
| as a primary care physician anyway and their treatment plans
| wouldn't differ, but the thing is a physician basically
| effectively will also only follow one script that the
| healthcare/insurance system in-place allows for, that Epic will
| spit out also.
|
| In the same way some of us see the task of building a CRUD app as
| something fairly unremarkable (owing to existing frameworks,
| existing 'best practices' etc), a physician's day-to-day work is
| really not challenging, and a "people-person" non-physician
| equipped with Epic software could arguably work to deliver equal
| or if not better healthcare outcomes.
| enragedcacti wrote:
| Only planning for the common case is an insane thing to do in
| healthcare. We don't train doctors for 12 years so that they
| are faster or more efficient at diagnosing the common cold, we
| train them so that they have a wide breadth of knowledge,
| experience, and skills. People already have difficulty getting
| satisfying diagnoses from MDs with 12 years of training + Epic,
| imagine how much worse it would be if the person had no clue
| illnesses other than what Epic spits out even exist.
| FireBeyond wrote:
| Exactly. Not everything is a zebra, plenty of horses, but...
|
| When I teach new EMTs, there's a common topic that comes up.
| For clarity, EMTs undergo about 200 hours of training, for
| what is called BLS (basic life support) - essentially non-
| invasive processes. _Generally_ they can only administer
| about 5 medicines (oxygen, aspirin, epinephrine, glucose,
| nitroglycerin). Paramedics undergo up to 1600 hours of
| training, for ALS (advanced life support), and can start IVs,
| administer ~40 medications, and do a variety of invasive
| procedures.
|
| So our local EMS protocols say that if you administer a
| caloric supplement (i.e. glucose) for someone with
| hypoglycemia, you must "upgrade" that call to ALS and have a
| paramedic respond.
|
| "But what if the patient is getting better?" As expected, as
| hoped. And if the hypoglycemia is really just that, then 99%
| of those patients won't need, or want, further
| care/transport. And for 99% of that 99% (arbitrary, but very
| high, percentages), it's probably entirely reasonable. "So if
| they're getting better, why do we want a higher level of
| care?"
|
| For the zebras. For the person with endocrine issues, or for
| whom hypoglycemia isn't a simple diabetes-related thing, but
| actually symptomatic of early organ failure, or other things,
| to get a deeper review to make sure we don't say "Sure thing,
| Mrs Smith, just stay home and have your husband make you a
| PB&J or two for some complex carbs" to the patient who has
| something more serious going on.
| FireBeyond wrote:
| Having worked in healthcare IT, and as a prehospital provider
| who has seen and interacted with many EHR systems, including
| Epic, Meditech, and ESO (moreso for prehospital)... the sooner
| Epic dies in a fire the better.
|
| Keyword-driven differentials should be, if anything, the
| baseline, bottom rung, pattern matching to inspire and drive
| critical thinking, focused assessment, and diagnostic skills.
| Not to "easy mode" the path of least resistance.
| pen2l wrote:
| Epic very much is poised to take over and every week it
| appears a new large healthcare center makes the switch to it.
|
| I think the hard lesson everyone must learn eventually is
| that they have to take control of/become deeply involved with
| their healthcare as much as possible, because dragons are
| everywhere. For the average person acute care is not needed
| when they're thinking of reaching out to the doctor, and they
| shouldn't because elevating intervention can quickly result
| in shit: got a headache or a hip injury? The doctors will
| give you a plethora of CT scans and you end up with cancer.
| Got pain? They'll give you opioids so you end up with
| crippling addiction.
|
| It's true on a national level:
| https://www.wesh.com/article/us-health-care-worst-
| outcomes-h... and at a local level iatrogenesis is seen
| abound.
|
| Indeed, of paramount importance for us is to learn how to
| take care of ourselves by going back to the basics (avoid
| processed diets, increase fibre-intake, etc, exercise,
| cultivate your link to a positive community so it is there
| for you in your time of need). And download Epic and learn
| about healthcare/medicines and take charge as much as
| possible of your own fate. But when faced with a truly acute
| problem, see a specialist doctor and follow their commands.
| underseacables wrote:
| A few years ago I saw a young doctor and all she did was put
| stuff into an iPad that told her what to do next. I could not
| run from her fast enough. Medical care of my iPad app is not
| the way to go
| Waterluvian wrote:
| A month ago my kids had pink eye. One resolved within days, the
| other got worse. Instead of a doctor's appointment the next day,
| we went to the pharmacy where the pharmacist evaluated him and
| prescribed an antibiotic. Whole thing took 15 minutes. Really
| made sense for "a parent could diagnose this" kinds of minor
| ailments.
|
| Also: if it's the pharmacist determining a med and immediately
| administering it, is she really "pre-scribing" anything?
| diogenescynic wrote:
| If you go to urgent care, you most likely won't get a physician.
| 9/10 visits are urgent care you only see a PA or NP and they
| can't even really do much. Urgent care seems to also provide
| really poor results--every time I've gone it's a long wait, the
| workers seem over-stressed, you barely get any time with the
| doctor, and usually they just do a strep test or give you a
| Zithromax pack and hope you'll go away.
| philwelch wrote:
| If all you need is a strep test or a Z pack, urgent care is a
| great deal.
| diogenescynic wrote:
| Sure, but what about those outlier scenarios? How do I know
| the NP or PA is actually going to catch those nuances? For
| example, a few years back I had a sinus infection in the
| spring and the NP/PA thought it was just allergies and tried
| to get me to try allergy medication... it was a useless trip.
| I'd much prefer a physician, but my primary doctor usually is
| booked out.
| NegativeK wrote:
| Anecdote that isn't remotely data: I went to an urgent care
| facility the first time I had a migraine aura without headache.
| I described it to the receptionist as a "visual hallucination",
| since it was a flashing checkerboard pattern that obviously
| wasn't real.
|
| The receptionist _ran_ to the back to get a doctor. The doctor,
| in an exam room, very careful, and with significant compassion,
| explained that they don't have the ability to treat me at that
| location -- but would I accept an ambulance if they called it?
|
| I took an Uber to the ER, where the admitting nurse gave me a
| flat stare and said "That's not a hallucination," but still put
| me at the front of the line to have an attending doctor and a
| bunch of students stare into my eyeballs before confirming that
| it was a headacheless migraine.
|
| To this day, I use that experience as an example of a lay
| person and a professional completely failing to understand each
| others' word choice.
| sys_64738 wrote:
| > If you go to urgent care, you most likely won't get a
| physician.
|
| Not my experience. Every time I've gone to urgent care I am
| always seen by a MD.
| subharmonicon wrote:
| Related: I was shocked when I tried to get a COVID booster in NY
| State and they told me they didn't have a registered nurse on
| staff that day so they couldn't do any vaccinations.
|
| In California, all of my vaccinations have come from
| phlebotomists, and it seems that pharmacists can also do them
| here.
|
| Why does NY State require an RN?
| FireBeyond wrote:
| WA state during COVID basically authorized EMTs to administer
| the vaccine. I mean it's literally "find this landmark on the
| lateral arm, steadily insert needle into muscle tissue, depress
| plunger, withdraw needle, massage site, bandaid". They had to
| do a 30 minute "training" on it.
| outlace wrote:
| MD here. I'm of two minds about this. On the one hand, obviously
| there's a bit of defensiveness since I went through 12 years of
| school and training to be an independent physician (4 years
| college, 4 years medical school, 4 years residency) and I've
| definitely seen subpar care from other "providers" (not a fan of
| the term) with less training. The wide variety of different
| "providers" is also confusing to patients who have little idea
| the differences in training and scope. The training for non-MD
| "providers" seems very variable, unlike the quite standardized MD
| training. I definitely think residency training is a much more
| robust and you need to have that critical feedback from
| supervising physicians to improve, which I think can be lacking
| in non-residency based training. Overall, nothing against
| PAs/NPs, I know some great ones.
|
| On the other hand, a lot of what I do doesn't require 12 years of
| training, so I am sympathetic to making health care more
| accessible. I am also a bit jealous that my non-MD colleagues can
| easily switch from e.g. being a primary care PA to being
| dermatology PA, whereas as an MD I'm pretty much stuck in my
| specialty unless I go through another 4+ year residency. Instead
| of MD-training getting shorter to compete, it's actually getting
| longer in many cases. Residency trainings are getting longer not
| shorter for a number of specialties (e.g. neurosurgery,
| interventional cardiology, pediatric hospitalist).
| OldGuyInTheClub wrote:
| The current choices are
|
| 1) Uniterested, slapdash care from an MD with 12+ years of
| training and no ability to listen or empathize but eager to
| make the money s/he went into medicine to make
|
| 2) The same from an assistant of some kind who uses ever-
| degrading search engines to look up not-your-problem and give
| you potentially dangerous suggestions
|
| The future will undoubtedly be worse. As someone mentioned
| below, we'll pay current premiums (+inflation) for a
| touchscreen interface to Chat-whatever-it-will-be.
| FireBeyond wrote:
| I definitely understand your perspective here.
|
| I'm a critical care paramedic, have several friends who are
| (perhaps unsurprisingly) generally emergency medicine
| physicians and related (surgeons, anesthesiology, nurses,
| etc.).
|
| I see the spectrum too. Extremely competent PAs who have long
| and detailed in depth discussions with physicians as "peers",
| on one side, and then I see horror shows from people who went
| from zero to ARNP in programs with "accelerated RN" where they
| are not functioning providers with far less schooling and
| clinical experience than even a PA (which is then galling to
| the PAs, as why are NPs independent practitioners, and PAs
| not?).
|
| I do think a lot of the issue is in the education and
| certification process. The AMA is only recently making the
| slightest inroads into well, not _admitting_ they went too far
| in restricting physician flow, but maybe acknowledging that
| there is a problem there. Nature abhors a vacuum, and all.
|
| I had a friend, extremely intelligent, in a BSN program. Called
| me one day to ask about flow rates for various oxygen adjuncts
| (nothing fancy, just like "what do you typically run your nasal
| cannulas at? What about NRBs?") and I was blown away. "Oh yeah,
| somehow that got overlooked. I know how to set them up, add
| humidifiers, etc., etc. - they just assume, I suppose, that
| someone at some point will say some magic numbers to us".
|
| And I'll also say that you see the same pre-hospital too. In
| PNW, while there are valid criticisms that can be leveled
| against two of the pre-eminent paramedic programs (UW
| Harborview, and Tacoma Community), there are far, far, too many
| "strip mall schools" in other states that will take you from
| "zero to hero" in 4 or 5 months (of 6 days a week, 8 hours a
| day, of just class time), and dump you out on the world with
| just enough retained knowledge to pass your NREMT and the
| barest amount of ride time to meet DOT mandated minimums. It's
| scary, to be blunt. These people go out with no clinical
| experience and are now expected not just to work as a team on a
| 911 call, but to _lead_ it.
|
| It's the medical equivalent of high school > college > MBA >
| management position without a day of work experience in your
| life beforehand. Except now there are literally (at least
| occasionally) lives at stake.
| syedkarim wrote:
| Why do you include your undergraduate degree as part of your
| medical training? I've asked dozens of doctors (and lawyers)
| about the relevance of their college/undergraduate education to
| their day-to-day work and none have said it was critical, most
| have said it was not relevant, and some have had completely
| non-medical majors (music and physics). Of course, maybe it's
| different for you, which is why I ask.
| WirelessGigabit wrote:
| It could be more of explaining the total duration and cost of
| how long they went to college.
|
| If it's required to have an undergrad I believe one can
| mention it, even if the undergraduate isn't required.
|
| Like in Belgium you need to have a masters for certain
| government jobs, but it's not relevant in which field.
| coryrc wrote:
| Anatomy and many other highly relevant undergraduate courses
| in biology and chemistry are mandatory for the postgraduate
| degrees.
| ngngngng wrote:
| > On the other hand, a lot of what I do doesn't require 12
| years of training
|
| What, besides surgery, really requires 12 years of training?
| I've found I have a greater success rate with self diagnosis
| and treatment than I have with seeing my physician, and I've
| found a very good internist. An hour spent with ChatGPT and
| Google and I always find a couple options that fit what I'm
| experiencing as well as detailed descriptions on how to narrow
| it down. And since I'm the one experiencing the symptoms,
| there's no chance of a communications breakdown between me and
| the doctor who is trying to diagnose me.
| nharada wrote:
| I think where this breaks down is when you have something
| rare that requires immediate attention. My impression is that
| a lot of that medical training is being able to say "oh
| that's unusual, you need to see a specialist".
| SOLAR_FIELDS wrote:
| A recent occurrence I will share related to this was having
| to convince my doctor that I had Lyme disease. I Googled the
| symptoms, saw the trademark bullseye, and of course concluded
| that I had Lyme disease. It was right where I got the tick
| bite, 8 weeks later.
|
| My doctor refused to believe me. He told me to see a
| dermatologist about it, thinking it was some skin rash, even
| though it was exactly where the tick had bit me and it was a
| bullseye. I shortly thereafter went to an urgent care center
| where fortunately an RN happened to be from Maryland (I live
| in the South, where Lyme disease is not really a thing) and
| she immediately saw my rash and prescribed me the appropriate
| antibiotics.
|
| The reason my doctor did not believe me? It took 8 weeks for
| the bullseye to develop. I had gotten the tick bite in Europe
| (which of course I informed the doctor of very first thing).
| Typically American Lyme disease displays symptoms much faster
| (days instead of weeks). The doctor did not bother to do any
| research to discover what I had found in a few minutes of
| Googling: that European Lyme disease takes much longer to
| display symptoms (and I had told him as such as well). He was
| happy to simply assume that all Lyme disease takes only days
| to display symptoms instead of weeks, because that's what he
| knew of, and since mine had taken weeks, well, I just must
| simply be wrong.
|
| My doctor did have a small redemption: once he was confronted
| with evidence and did the research himself on what I was
| saying (after the RN had already treated me), he did call me
| and apologize. But still. This is a daily occurrence,
| especially for people that are of underserved genders and
| races.
|
| I realize this turned into a bit of a rant, but in essence I
| just want to affirm what you're saying. A lot of doctors,
| especially PCP, are often not much more than glorified
| technicians. Combine that with the ego problems that
| typically accompany being an MD and you get a recipe for
| people getting subpar care, especially women and minorities.
|
| In the end, unfortunately, only you are responsible for your
| own medical care and getting the best outcome. It is not
| sufficient to just trust someone else because they have the
| words MD after their name.
| lumost wrote:
| Isn't this the natural outcome of the American medical
| associations license cap? A growing country will always need
| more medical professionals , if MDs cannot be accessed - then
| an alternative will emerge.
| konschubert wrote:
| Is there such a cap?
| peyton wrote:
| AMA lobbied for a cap on CMS residency funding, and I
| believe you need to do a residency to get a license, so
| effectively yes.
| lionsdan wrote:
| "In 1997, Congress passed the Balanced Budget Act, a
| bipartisan effort to cut back on spending. The act put a
| cap on the number of annual residencies CMS would support,
| and froze the funding at 1996 levels. . . . Since 2007, a
| bill to increase the number of residencies has been
| introduced in every Congress . . . but never passed."
|
| https://www.washingtonian.com/2020/04/13/were-short-on-
| healt...
| lolinder wrote:
| But why aren't more residencies paid for through other
| channels?
|
| I wasn't under the impression that medical residents were
| _solely_ a drain on hospital resources--my sense was they
| did a lot of the smaller tasks to free up licensed
| physicians to do more. At some point, if there aren 't
| enough CMS-funded residencies and there aren't enough
| licensed doctors, wouldn't hospitals just start hiring
| more residents?
|
| The article you linked to has a heading that touches on
| this ("how did we end up with Medicare basically
| determining the number of new doctors per year?"), but
| doesn't actually answer the question it poses. It
| explains why the government _started_ funding
| residencies, but not why the industry is now completely
| dependent on that funding.
| russdill wrote:
| I argued with a PA because they were convinced that the most
| likely reason for a high white blood cell count in my sample
| was that it was contaminated post collection. It was a very
| frustrating discussion that seemed to have gone around in
| circles many times. I eventually just had to agree to retest. I
| feel like this would not be an issue talking to an MD.
| RecycledEle wrote:
| I'd like to see every visit for a chronic illness attended by a
| medical professional, the patient who is paying for the visit,
| and another patient who is farther along in the progression of
| that chronic illness.
|
| The input of someone who has been there and seen their disease
| progress farther is valuable.
| thenerdhead wrote:
| Visits delivered by non-physicians, but charged as if they're all
| MDs. Late stage capitalism is great.
| ultra_nick wrote:
| Quick care beats quality care past a certain level of time and
| money.
| dukeofdoom wrote:
| I hope AI replaces most of them. My experience in the ER, at
| least in Canada. You're not getting a doctor. You're getting a
| doctor's 10 minutes attention, while they're running around from
| patient to patient. Don't expect your diagnosis to be anything
| more then the most obvious, A -> B diagnosis. When your problems
| conflate from the drugs they just wrongly gave you, and add in
| random screw ups, staff and equipment shortages. You will be
| getting reactive medicine, as your condition worsens. A death
| spiral, from which you will not escape. Many will be transitioned
| to the after life in hospital in this way. Give AI better
| diagnostic testing data, and AI will make better care decisions
| then any doctor. The doctors/nurses will still be needed to take
| care of the patient. But it seems pretty clear that AI will be
| making the decisions, in the short future.
| underseacables wrote:
| It's getting harder to see a doctor, they only let you see a
| physicians assistant, Who acts like a doctor, but isn't. I
| understand they meet with a doctor later to discuss the case,
| but... It's just not the same. A physicians assistant is not a
| doctor
| HumblyTossed wrote:
| Wait until your insurance demands you use their "AI" first before
| even visiting your doctor.
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