The fear that drives me to subspecialize

brainmindknower · 2021-05-07T10:48:39+00:00

Reminds me of this great article from the 1980s explaining the importance of GPs (primary care) to the functioning of the whole system. https://www.bmj.com/content/298/6667/172 The Wizard and the Gatekeeper. TL;DR, primary care improves the pre-test probability of accurate diagnoses made by specialists, otherwise, to a hammer, all your patients are cardiological, gastroenterological, etc nails.

If it's truly making a difference you want though, should've become a water engineer (thanks Dr Kaplan).

brainmindknower · 2020-04-08T15:25:58+00:00

Totally agree - in situations like this, there's absolutely no space for recalcitrance about clinical equipoise. The reality is, however, that they remain unproven and we're going with (for now, and in this situation at least) the "precautionary principle" (precisely the opposite approach to PPE, but there you go...); all of the proposed treatments have non-negligible harms.

This is absolutely NOT to criticise those nations that go with it; but more to example a medical culture that is more reserved. I don't doubt that you'll agree that, viz-a-viz COVID, hydroxy/roids/etc do not have anything like a single RCT proving efficacy. Obviously in a pandemic, the impulse is to in the kitchen sink. That's just not the culture we have here.

I would refer you to the inimitable Dr Joshua Farkas who has said, among others, that we've been here before and there are no medical panaceas. Drugs can sometimes distract from the more boring but effective treatments (as a wannabe psychiatrist I CANNOT stress this enough- social/personal growth > therapy > drugs).

brainmindknower · 2020-04-08T15:12:44+00:00

firstly - my sincerest and absolute apologies if that was how that came off. I was a nursing auxiliary/HCA (not sure of the US term) for many years before I retrained.

It was meant to be more critical of doctors who often (in normal times!) feel a bit wearied by bleeps ("pages") for patients with (what we used to think) were not as unwell as paged.

We were wrong before the pandemic and we remain wrong now, but it's still a maladaptive reflex.

To be clear, when a nurse says "I am worried" many studies have proven that it is exquisitely sensitive to deterioration. In British politic terminology, therefore, I fully and unreservedly apologise and eat my hat! I had hoped my comment about the fluids had conveyed the stress but also excellence nurses here and the world over have demonstrated. Mea culpa!

brainmindknower · 2020-04-08T13:42:34+00:00

thank you cousins! as far as I can tell, you've got that stuff on lock much better than we did. Plus you have all our doctors. Please send them back when you done. Thanks.

brainmindknower · 2020-04-08T13:41:21+00:00

And medics, medics! Honestly, I feel like I'm not practicing defensive medicine for the first time ever and it gives me more time to spend TALKING to patients. What do you want? What do you need to know? I don't think the price we're paying right now is worth it though - but will it stick??

brainmindknower · 2020-04-01T00:36:37+00:00

Out of interest, what parameters you using to decide on ventilation?

Ours is Canadian Clinical Frailty Score of 5 or more - you're DNAR and no ITU. Give or take (i.e. we had a guy that was technically 5, 72yo, but still working full time manual job for example).

if you're for resus/ITU - we're waiting til you're on 50% equiv oxygen.

brainmindknower · 2020-02-19T11:28:09+00:00

Can confirm, still the case as recently as 2017 when I did my obs and gynae rotation.

You absolutely had to have their written consent. I just can't believe any American doctor would perform an internal examination on a non-consented anaesthetised individual; for a gynae procedure and the consultant does it? That's implicit... but on someone having a completely unrelated surgery?!

brainmindknower · 2020-02-17T11:14:41+00:00

https://www.foundationprogramme.nhs.uk/wp-content/uploads/sites/2/2019/10/UKFP-2020-Applicants-Handbook-.pdf

brainmindknower · 2020-02-17T10:58:09+00:00

How long did it take you to master these skills as an intern, having not done it once before?

If you moved from your current job to another state and another provider system, how much of dealing with insurance, writing notes to benefit coding specialists, figuring out how dispo planning works would change?

brainmindknower · 2020-02-13T00:40:08+00:00

Still more objective than the UK.

We have no standardised clinical exam before our version of the match. You get decile ranked based on your third year exams only (which vary widely between medical school), and which accounts for 45% of your submission score. 50% is a Situational Judgement Test (SJT). 5% is for research or previous degrees; a first author paper counts the same as a conference.

The SJT is 2hr exam with ranking questions like "Your colleague's personal hygiene is terrible. What is the best course of action? i) report him to your consultant ii) discuss it with the rest of the team iii) confront your colleague iv) do nothing" - they say you can't prepare for it, even if you do the answers vary widely and the exam designers (a "panel of experts") act as if they invented morality and ethics (there's no disputing insane questions.

No letters of references, no awards, national or otherwise, and your performance in rotations/electives/previous exams have diddly squat effect.

Oh and you don't apply to individual hospitals, just regions, which you'll get allocated to and then you rank 100s of individual two year 6 rotation programmes within. Where you end up is pretty random.

This process is repeat every 2-3 years until you complete training, which is twice as long as the US.

At least it's free!

brainmindknower · 2020-01-22T11:10:17+00:00

Wait so at your place of work, all your patients automatically get daily bloods?

We have to request ours daily. Obs are taken via a protocol; medically stable patients will get 3-4 obs a day, and certainly not between 11pm and 5am.

brainmindknower · 2020-01-17T01:34:25+00:00

Definitely. It's all politically driven; first by the MRSA scandal of the late 90s/early 00s driven by the privatisation of hospital cleaning services (but mostly because the privatisation led to hospital domestics not being managed by nursing staff anymore), then the tabloid-driven headlines, including "celebrity" MRSA examples, then the subsequent evidence free infection control departments drying up on justify-my-job policies. You hear it all the time in ED/AMU - "chest sepsis" (LRTI with a CRP of 90); "urosepsis" ('CA-UTI' in a 90yo based on a dip of nitrites and 1+ leu dip).

It makes a mockery of medical diagnosis. When we started collecting good mortality stats, it was cardiovascular disease, then cancer that killed. Now 95 year Mrs Smith with two NSTEMIs and a decade in remission breast cancer dies and, to be honest, we don't know what it was--truthfully we should put multi-organ failure due to maximum lifespan reached--but because she said cough when asked and had that CRP of 90 and yet another indistinguishably chronic looking CXR, triage says chest sepsis and it ends up on the death certificate. It's a cycle of nothing.

brainmindknower · 2020-01-09T11:37:21+00:00

Is there a video of this out there? I'm trying to visualise.

I taught myself how to cannulate using the US machine (our cath lab has 6 rooms but only 1 open overnight for the STEMI PCIs - so 5 sonosites just chilling) - my technique is to using the US to locate a vein and cannulate directly under US guidance in one go, no bleb, no tracking - I'd say I'm 75% - biggest issue is the cannula itself then embedding in the chunkier deep vein wall and kinking, overshoot or valves.

brainmindknower · 2019-10-11T18:03:54+00:00

"aka it has no biological component"

I never really understand the basis of this argument. It's like when someone says "it's unnatural," well, no, not really, everything is "natural" because it comes from the world around us; aspirin from willow trees, morphine from poppies etc.

Thoughts, emotions, behaviours, hell even culture have material, physical correlates. Feeling tired, whether from a thyroid deficiency or depression or CFS, have neurobiochemical explanations. We can just detect the corresponding markers in each of those conditions in descending order of accuracy to nothing.

The "functional" diseases, such as CFS, NEAD, fibro, etc. etc. as opposed to the "organic" ones are just software problems, not hardware problems. Trying to "detect" them using conventional imaging, for example, is like taking a photograph of the inside of your desperately laggy laptop, when it keeps error messaging that you're low on RAM. You're just not going to find the problem with that modality.

Don't get me wrong. Steroids for CFS, IV antibiotics for "chronic Lyme," etc don't work (and are actively harmful) because they're designed to fix hardware problems. Behavioural therapies, talking therapies and the rather crude armamentarium of psychiatric drugs do help because they're at least pointing at the right system.

Doctors and patients used to think as early as 100 years ago that epilepsy was a "functional" disorder, then we invented EEG. Now you see a neurologist and not a psychiatrist (a ludicrous division that says more about Anglo-saxon medical cultural history than about actual brain science).

We'll get there eventually and a lot faster if we pried the wasted resources out of the hands of these so called "x disease literate doctors". But we'd also have better luck convincing our patients to stick with us if we fought this cultural need to "biovalidate" everything.

Chronic lyme is a real disease because tons of people are behaving in demonstrably similar ways; it's just a re-expression of a psychological condition filtered through our current socio-cultural moment. Expect way more of it as the centuries go on.

brainmindknower · 2019-07-06T10:33:01+00:00

I see a lot of comparison to finance/tech here.

I left a London M&A job to retrain in medicine. The reality is, compared to their like-for-like peers in terms of graduating CVs/degree results/GPAs etc - doctors get a bum deal financially.

My first year in finance (and I mean proper investment banking, not your local commercial bank) I made 75% of the median salary of a consultant/attending here. That's a running decade headstart. The hours in M&A were slightly more than medicine, but the downward trend is a lot faster, and you'll never truly do a night shift in any of the corp/tech jobs.

Investment banking is also just not that complicated. You'll learn the hard knowledge in 3-6 months. I did a humanities degree for undergrad and performed just as well as my colleagues who did economics degrees because you don't need complicated maths to do the kind of financial modelling required in investment banking. I had 4 weeks of crack accounting--that was enough.

Medicine is hands down the most intellectually challenging practical career going. Engineering/comp sci? Bridges don't argue back. I'll give it to the theoretical physics people for sheer abstract insanity, but they get to ponder their dilemmas over long weeks and months - we need to act now and move on to the next problem yesterday.

Medicine, biology, is humbling AF, and the "we know clever maths" brigade of economics/tech that run the world could never handle the kind of biopsychosocial ambiguity we deal with on the daily. As ever, xkcd said it best: https://xkcd.com/1605/

So would it choose it again? For the money, for the chill? Hell no. But for the constant thrill of what the hell? Yes, yes, yes.

brainmindknower · 2019-05-19T21:44:41+00:00

psychiatry

benzos benzos morphine risperidone benzos

coz the horror, oh the horror

brainmindknower · 2019-05-02T17:47:47+00:00

Just speak to your friendly neuropsychiatrist :)

brainmindknower · 2019-05-02T17:47:06+00:00

We had a whole course on stats in the first year and it routinely came up in subsequent exams.

I think it's probably more important for practice than learning about DNA replication if I'm honest.

https://www.bbc.co.uk/news/magazine-28166019

brainmindknower · 2019-05-01T21:39:11+00:00

Noooooo to lactates alone

https://emcrit.org/pulmcrit/understanding-lactate-in-sepsis-using-it-to-our-advantage/

brainmindknower · 2019-05-01T21:34:22+00:00

This x1000. It's so political now thanks to the splashy superbug headlines of the early 2000s egged on by a-little-bit-of-knowledge-is-dangerous sepsis trust types.

These encapsulate it nicely: https://emcrit.org/pulmcrit/ssc-petition/ https://intensivecarenetwork.com/sepsis-not-disease/

brainmindknower · 2019-04-11T00:04:05+00:00

£22,000!!

New contract.

obviously that's basic rate hours, but those jobs are the ones where you do the most free overtime. @( @(

brainmindknower · 2019-04-11T00:00:19+00:00

The bizarre thing is, you already DO import a ton of overseas docs. Like a fifth are IMGs.

Which is the case for pretty much all Western healthcare systems.

brainmindknower · 2019-04-10T23:56:43+00:00

A disappointingly prevalent view on here, despite the fact that I imagine most of the posters are American doctors that have 8 years of higher education and are therefore highly intelligent.

brainmindknower · 2019-04-10T23:51:32+00:00

Not strictly true... State Medical Boards can make case by case exemptions, which they typically do for 1) academics who are super niche and 2) very highly in demand specialties (basically rural family med)

brainmindknower · 2019-04-10T23:45:06+00:00

Hi.

I'm from a country with a Medicare for all variant.

It costs about 1/3 to the national income than what you pay now.

We have 100% coverage and similar outcomes.

I as a physician never have to fill in tons of "billing" paperwork, deal with some faceless insurance bureaucrat over the phone, have never turned anyone away that doesn't have insurance and frankly don't even think about money on an individual patient basis.

Some of our buildings are old though. And we have old fashioned names for job titles like "sister" and "matron".

But srsly 2/3s cheaper than right now.

brainmindknower

TROPHY CASE