7 ms·

Letter to an Aspiring Doctor

114 points by wormold 8y ago

nickpsecurity 8y ago
This is a great letter. I do want to pause on this, though, about doctors prescribing opiates: "The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach" He could be totally right about causes of that problem in that time. Currently, though, drug companies offer all kinds of financial incentives anyone that will increase drugs use in ways ranging from BS studies to incorrect info in textbooks to actual prescriptions. I've also read they give free samples. Examples I found in quick DuckDuckGo: https://www.bostonglobe.com/opinion/2016/04/11/medical-research-financial-conflicts-interest-matter/FfGc04GpdBXztO6m3kcT1I/story.html https://www.bostonglobe.com/opinion/2016/04/11/medical-resea... https://www.nytimes.com/2004/06/27/us/medical-marketing-treatment-incentive-doctor-writes-prescription-drug-company.html https://www.nytimes.com/2004/06/27/us/medical-marketing-trea... http://content.time.com/time/health/article/0,8599,1883449,00.html http://content.time.com/time/health/article/0,8599,1883449,0... This stuff could've been going on a long time. Maybe back when the push to use addictive drugs started. Or maybe that was just bad science like author says with the current push involving massive amounts of corruption. I say don't forget what's going on in any current debate about drugs, though.
- classichasclass 8y ago
  No, we didn't get free opioid samples. I can't imagine many docs got paid, either (I certainly got neither, nor would I have accepted them). What we actually got was a tsunami of alleged literature that said we should be doing more about non-malignant pain and that addiction was a minor risk. And, well, most of us bought it. Of course, look at who turned out to be behind it.
  - deleted 8y ago
    [deleted]
  - Domenic_S 8y ago
    Yep. The fifth vital sign and all that.
  - tastythrowaway 8y ago
    respectfully, what remotely well-trained doctor _didn't_ realize that part about an opiate being only a minor addiction risk was obviously bullshit?
    - MRD85 8y ago
      The doctors were getting shown a whole host of studies which all said that there was only a minor addiction risk. You need to be able to put trust into what the studies are showing.
    - cco 8y ago
      I'm shocked to the point of disbelief on this as well, this does not pass the smell test for me. Anybody, especially doctors, should have been well aware of the risks, this was not a surprise to anybody with as much as a toe in the public health sector.
    - jmalicki 8y ago
      The book Dreamland[1] chronicles a lot of this history... but a belief in science means that if scientific studies challenge some of your preexisting beliefs, you accept that evidence. [1] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic/dp/1511336404 https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...
- msla 8y ago
  There was also a push to have pain as a fifth vital sign: https://www.medpagetoday.com/publichealthpolicy/publichealth/57336 https://www.medpagetoday.com/publichealthpolicy/publichealth... > In 2001, the Joint Commission rolled out its Pain Management Standards, which helped grow the idea of pain as a "fifth vital sign." It required healthcare providers to ask every patient about their pain, given the perception at the time was that pain was undertreated. My parents have complained about this; my mom's an RN, who's been everything from a home health nurse to an ICU nurse to a clinic nurse in a podiatrist's office, and my dad's a CRNA, and they talk about people who are likely drug-seeking and people who just don't like any discomfort, even stuff that, if you felt like that on a normal day, wouldn't cause you to take anything for it if you were a normal person. So you have a mandate to Take Pain Really, Really Seriously. You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do?
  - srinivgp 8y ago
    > You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do? In practice, living the years I have with my wife, the answer seems to usually be "assume that you, as a doctor, have much more knowledge about your patient's experience and that because no test you know how to do dings 'yep, a problem', that the patient in fact _does not_ have a problem, that their claims of being in enough pain to want to die at least a few times a week are made-up, that they've lived this long with their 'must be just in their head' problem that surely it's not so bad and they can keep doing so". From a purely probabilistic standpoint, they might be right. From my wife's perspective, they are torturing her, hopefully not to death. What _do_ you do?
    - MRD85 8y ago
      I had a post viral illness this year after glandular fever. The post viral illness is related to chronic fatigue and if it hadn't resolved I would have been diagnosed with chronic fatigue. I had every test the doctors could think of and I was seeing specialists, yet every test said I was a bill of health. It's incredibly frustrating to have medical practitioners not believe you when the illness is ruining your life.
- jseliger 8y ago
  For most aspiring doctors, it's also worth contemplating the physicians assistant and nurse practitioner routes: https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school https://jakeseliger.com/2012/10/20/why-you-should-become-a-n.... The number of actual doctors who lament not knowing about, or understand, these routes is notable.
- weliketocode 8y ago
  There also was a very strong emphasis on pain treatment as part of standard-of-care. When pain management is legislated, it becomes a lot easier for doctors to accept it as necessary.
saturdaysaint 8y ago
If you detect a stealth agenda between the lines, it's not your imagination. From wikipedia: First Things is an ecumenical, conservative and, in some views, neoconservative[1][2][3][4][5] religious journal aimed at "advanc[ing] a religiously informed public philosophy for the ordering of society".[6] The magazine, which focuses on theology, liturgy, church history, religious history, culture, education, society and politics, is inter-denominational and inter-religious, representing a broad intellectual tradition of Christian and Jewish critique of contemporary society. https://en.wikipedia.org/wiki/First_Things https://en.wikipedia.org/wiki/First_Things
- mikeatgl 8y ago
  This jumped out at me. "Abortion was originally intended to be performed in limited circumstances only, but now has become an inalienable right in any circumstances whatever—into which, indeed, it is impermissible to inquire." followed coyly a paragraph later by "This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory."
  - manfredo 8y ago
    Interesting, I interpreted this in a completely different manner. I read the part about abortion as urging people to be receptive to changing social norms since many things we consider to be just were considered unethical not so long ago. The latter part I saw as urging caution against accepting the mandates of authority and conformity, because there's no guarantee that the authority or concensus is right (like society's past views on abortion). Of course, I didn't really know the background of the platform, so who knows what the author really intended. Likely, this is an instance of writing phrased in such a way that the reader can project their own views into it.
    - lliamander 8y ago
      Although a possible interpretation, I consider that unlikely. Immediately preceding the section on abortion we have the following comment: > There is nowadays a tendency for rights to spread, like ink through blotting paper. And then immediately following: > A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of conscientious objection. Having read some of the author's other work, I'm fairly confident he is against abortion. However, think the broader point here is that increasingly doctors are being legally required to act in ways that run contrary to their own personal moral judgments. Regardless of how the young aspiring doctor feels about abortion (or anything else) It seems reasonable to prepare them for the possibility that they may have to choose between their conscience and the demands of their profession.
databag 8y ago
Having been privy to the coarse reality of about 20 students who survived 5 years of medical school, followed by FY1, FY2, and junior positions in the NHS, the intellectualized "best effort" mulling-over in the article couldn't be further away from reality.
- thomasfedb 8y ago
  As a student doctor not quite yet exposed to the true harshness of reality I feel that this article does give some perspective into the issues that I have grappled with so far in my training. The frustrations, the conundrums, the uncertainty, the humanity.
toastermoster 8y ago
I'm surprised there was no mention about insurance and billing requirements, etc.
- siberianbear 8y ago
  Yeah, that surprised me, too. At one time in my life, I considered becoming a doctor, and had even started to take some of the required undergraduate coursework required to apply to medical school (organic chemistry, biology, etc.) I started to talk to doctors about my choice, and nearly all of them advised me not to go into medicine and often went into a long rant about dealing with insurance companies, billing issues and being told how to practice medicine by people with only a high school diploma at an insurance company. I might be a doctor today if it wasn't for them. I think it was for the best: I found electrical engineering in Silicon Valley to be interesting and highly remunerative.
  - daodedickinson 8y ago
    Same here. My father is a veterinarian, and we have many family friends who are doctors, and they all drove me away from going into medical practice. It is a tragic waste, because my brain is not compatible with many jobs, but medicine as practiced from the 90s back would have been up my bailiwick, as it gave my father, who shares most of my neuroatypical quirks, tremendous upward mobility. But we are men of ethical scruples. I've dropped out of multiple grad programs due to witnessing academic fraud committed by students and professors working in tandem to keep money flowing into administrators who believe it is their utmost responsibility to perform a Nietzschean transvaluation of all values until a hauntingly extreme vices become considered virtues. If I picked the medical profession, it would be because it would be so motivating to me to work in a highly motivating high-stakes environment where finding the moral thing to do is not so everloving exhausting. Then have a statist regime begin to intimidate and relentlessly attempt to suborn you into destroying the voice of your conscience and the essential goodness of the caring profession is utterly lost. After leaving a university just a few credits shy of a degree due to learning that university administrators have knowingly destroyed the value of their degree by handing out 50% of their CS degrees to people the professors consider completely incompetent, I was not tempted in the slightest when the university attempted to bribe me with a full scholarship for their Ph.D. program and a guaranteed tenure track teaching job. Why the hell would I want to perpetuate the scam of a completely decadent educational husk? I am terrified that misuse and/or ignorant design of the internet is threatening our social health; it is destroying the quality of people's education in return for monetary "profit". EDUCATION IS PROFIT IN ITSELF, money is merely potential energy that may help or hinder us toward enlightenment. So this is why our "education" system is actually a "maleducation" system: universities as founded were dedicated to making the best possible people, but they are now committed to making the most possible profit.
afpx 8y ago
Couldn’t the negativity and cynicism of this letter be applied to most fields?
waylandsmithers 8y ago
> You will no doubt hear a great deal about patient autonomy, the principle that the patient must be allowed to choose treatment that he wants. This must really be tough on doctors. I have a few people in my life who love seeking out medical advice but rarely follow it. "You have to help me doc, I'll do anything!" "Ok, do X" "Well anything but that."

114 points by wormold 8y ago

This is a great letter. I do want to pause on this, though, about doctors prescribing opiates: "The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach" He could be totally right about causes of that problem in that time. Currently, though, drug companies offer all kinds of financial incentives anyone that will increase drugs use in ways ranging from BS studies to incorrect info in textbooks to actual prescriptions. I've also read they give free samples. Examples I found in quick DuckDuckGo: https://www.bostonglobe.com/opinion/2016/04/11/medical-research-financial-conflicts-interest-matter/FfGc04GpdBXztO6m3kcT1I/story.html https://www.bostonglobe.com/opinion/2016/04/11/medical-resea... https://www.nytimes.com/2004/06/27/us/medical-marketing-treatment-incentive-doctor-writes-prescription-drug-company.html https://www.nytimes.com/2004/06/27/us/medical-marketing-trea... http://content.time.com/time/health/article/0,8599,1883449,00.html http://content.time.com/time/health/article/0,8599,1883449,0... This stuff could've been going on a long time. Maybe back when the push to use addictive drugs started. Or maybe that was just bad science like author says with the current push involving massive amounts of corruption. I say don't forget what's going on in any current debate about drugs, though.

classichasclass 8y ago
No, we didn't get free opioid samples. I can't imagine many docs got paid, either (I certainly got neither, nor would I have accepted them). What we actually got was a tsunami of alleged literature that said we should be doing more about non-malignant pain and that addiction was a minor risk. And, well, most of us bought it. Of course, look at who turned out to be behind it.
- deleted 8y ago
  [deleted]
- Domenic_S 8y ago
  Yep. The fifth vital sign and all that.
- tastythrowaway 8y ago
  respectfully, what remotely well-trained doctor _didn't_ realize that part about an opiate being only a minor addiction risk was obviously bullshit?
  - MRD85 8y ago
    The doctors were getting shown a whole host of studies which all said that there was only a minor addiction risk. You need to be able to put trust into what the studies are showing.
  - cco 8y ago
    I'm shocked to the point of disbelief on this as well, this does not pass the smell test for me. Anybody, especially doctors, should have been well aware of the risks, this was not a surprise to anybody with as much as a toe in the public health sector.
  - jmalicki 8y ago
    The book Dreamland[1] chronicles a lot of this history... but a belief in science means that if scientific studies challenge some of your preexisting beliefs, you accept that evidence. [1] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic/dp/1511336404 https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...
msla 8y ago
There was also a push to have pain as a fifth vital sign: https://www.medpagetoday.com/publichealthpolicy/publichealth/57336 https://www.medpagetoday.com/publichealthpolicy/publichealth... > In 2001, the Joint Commission rolled out its Pain Management Standards, which helped grow the idea of pain as a "fifth vital sign." It required healthcare providers to ask every patient about their pain, given the perception at the time was that pain was undertreated. My parents have complained about this; my mom's an RN, who's been everything from a home health nurse to an ICU nurse to a clinic nurse in a podiatrist's office, and my dad's a CRNA, and they talk about people who are likely drug-seeking and people who just don't like any discomfort, even stuff that, if you felt like that on a normal day, wouldn't cause you to take anything for it if you were a normal person. So you have a mandate to Take Pain Really, Really Seriously. You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do?
- srinivgp 8y ago
  > You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do? In practice, living the years I have with my wife, the answer seems to usually be "assume that you, as a doctor, have much more knowledge about your patient's experience and that because no test you know how to do dings 'yep, a problem', that the patient in fact _does not_ have a problem, that their claims of being in enough pain to want to die at least a few times a week are made-up, that they've lived this long with their 'must be just in their head' problem that surely it's not so bad and they can keep doing so". From a purely probabilistic standpoint, they might be right. From my wife's perspective, they are torturing her, hopefully not to death. What _do_ you do?
  - MRD85 8y ago
    I had a post viral illness this year after glandular fever. The post viral illness is related to chronic fatigue and if it hadn't resolved I would have been diagnosed with chronic fatigue. I had every test the doctors could think of and I was seeing specialists, yet every test said I was a bill of health. It's incredibly frustrating to have medical practitioners not believe you when the illness is ruining your life.
jseliger 8y ago
For most aspiring doctors, it's also worth contemplating the physicians assistant and nurse practitioner routes: https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school https://jakeseliger.com/2012/10/20/why-you-should-become-a-n.... The number of actual doctors who lament not knowing about, or understand, these routes is notable.
weliketocode 8y ago
There also was a very strong emphasis on pain treatment as part of standard-of-care. When pain management is legislated, it becomes a lot easier for doctors to accept it as necessary.

saturdaysaint 8y ago

If you detect a stealth agenda between the lines, it's not your imagination. From wikipedia: First Things is an ecumenical, conservative and, in some views, neoconservative[1][2][3][4][5] religious journal aimed at "advanc[ing] a religiously informed public philosophy for the ordering of society".[6] The magazine, which focuses on theology, liturgy, church history, religious history, culture, education, society and politics, is inter-denominational and inter-religious, representing a broad intellectual tradition of Christian and Jewish critique of contemporary society. https://en.wikipedia.org/wiki/First_Things https://en.wikipedia.org/wiki/First_Things

mikeatgl 8y ago
This jumped out at me. "Abortion was originally intended to be performed in limited circumstances only, but now has become an inalienable right in any circumstances whatever—into which, indeed, it is impermissible to inquire." followed coyly a paragraph later by "This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory."
- manfredo 8y ago
  Interesting, I interpreted this in a completely different manner. I read the part about abortion as urging people to be receptive to changing social norms since many things we consider to be just were considered unethical not so long ago. The latter part I saw as urging caution against accepting the mandates of authority and conformity, because there's no guarantee that the authority or concensus is right (like society's past views on abortion). Of course, I didn't really know the background of the platform, so who knows what the author really intended. Likely, this is an instance of writing phrased in such a way that the reader can project their own views into it.
  - lliamander 8y ago
    Although a possible interpretation, I consider that unlikely. Immediately preceding the section on abortion we have the following comment: > There is nowadays a tendency for rights to spread, like ink through blotting paper. And then immediately following: > A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of conscientious objection. Having read some of the author's other work, I'm fairly confident he is against abortion. However, think the broader point here is that increasingly doctors are being legally required to act in ways that run contrary to their own personal moral judgments. Regardless of how the young aspiring doctor feels about abortion (or anything else) It seems reasonable to prepare them for the possibility that they may have to choose between their conscience and the demands of their profession.

databag 8y ago

Having been privy to the coarse reality of about 20 students who survived 5 years of medical school, followed by FY1, FY2, and junior positions in the NHS, the intellectualized "best effort" mulling-over in the article couldn't be further away from reality.

thomasfedb 8y ago
As a student doctor not quite yet exposed to the true harshness of reality I feel that this article does give some perspective into the issues that I have grappled with so far in my training. The frustrations, the conundrums, the uncertainty, the humanity.

toastermoster 8y ago

I'm surprised there was no mention about insurance and billing requirements, etc.

siberianbear 8y ago
Yeah, that surprised me, too. At one time in my life, I considered becoming a doctor, and had even started to take some of the required undergraduate coursework required to apply to medical school (organic chemistry, biology, etc.) I started to talk to doctors about my choice, and nearly all of them advised me not to go into medicine and often went into a long rant about dealing with insurance companies, billing issues and being told how to practice medicine by people with only a high school diploma at an insurance company. I might be a doctor today if it wasn't for them. I think it was for the best: I found electrical engineering in Silicon Valley to be interesting and highly remunerative.
- daodedickinson 8y ago
  Same here. My father is a veterinarian, and we have many family friends who are doctors, and they all drove me away from going into medical practice. It is a tragic waste, because my brain is not compatible with many jobs, but medicine as practiced from the 90s back would have been up my bailiwick, as it gave my father, who shares most of my neuroatypical quirks, tremendous upward mobility. But we are men of ethical scruples. I've dropped out of multiple grad programs due to witnessing academic fraud committed by students and professors working in tandem to keep money flowing into administrators who believe it is their utmost responsibility to perform a Nietzschean transvaluation of all values until a hauntingly extreme vices become considered virtues. If I picked the medical profession, it would be because it would be so motivating to me to work in a highly motivating high-stakes environment where finding the moral thing to do is not so everloving exhausting. Then have a statist regime begin to intimidate and relentlessly attempt to suborn you into destroying the voice of your conscience and the essential goodness of the caring profession is utterly lost. After leaving a university just a few credits shy of a degree due to learning that university administrators have knowingly destroyed the value of their degree by handing out 50% of their CS degrees to people the professors consider completely incompetent, I was not tempted in the slightest when the university attempted to bribe me with a full scholarship for their Ph.D. program and a guaranteed tenure track teaching job. Why the hell would I want to perpetuate the scam of a completely decadent educational husk? I am terrified that misuse and/or ignorant design of the internet is threatening our social health; it is destroying the quality of people's education in return for monetary "profit". EDUCATION IS PROFIT IN ITSELF, money is merely potential energy that may help or hinder us toward enlightenment. So this is why our "education" system is actually a "maleducation" system: universities as founded were dedicated to making the best possible people, but they are now committed to making the most possible profit.

afpx 8y ago

Couldn’t the negativity and cynicism of this letter be applied to most fields?

waylandsmithers 8y ago

> You will no doubt hear a great deal about patient autonomy, the principle that the patient must be allowed to choose treatment that he wants. This must really be tough on doctors. I have a few people in my life who love seeking out medical advice but rarely follow it. "You have to help me doc, I'll do anything!" "Ok, do X" "Well anything but that."