6 ms·

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine,

by rscho 4y ago

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers. What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice. You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...

titanomachy 4y ago
If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.
- rscho 4y ago
  I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful. As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
- thaumasiotes 4y ago
  Medical treatment is obviously not fully-solved, or anywhere close. But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient. I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
- barry-cotter 4y ago
  General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners. > Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care > Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28). https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=doctor+vs+nurse+practitioner+effectiveness&btnG=#d=gs_qabs&t=1668851171508&u=%23p%3DRafdM6k_aWQJ https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/
  - lostlogin 4y ago
    More tests isn’t a good things. The doctor was significantly quicker and could see 3 patients for every two the nurse saw. I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.
warner25 4y ago
I appreciate your perspective as a professional in this area. Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.
dimal 4y ago
Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again. Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably. I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.
- opportune 4y ago
  Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do
  - rscho 4y ago
    > Any educated layperson can figure out and follow a clinical decision tree. 12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.
    - dimal 4y ago
chrismorgan 4y ago
> n° Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`. For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.
- rscho 4y ago
  not all of us live in the US
  - joenot443 4y ago
    I don’t either but fully agree GP’s assessment, you chose a strange character to use there.
    - rscho 4y ago
      It's the default on my keyboard, and the commonly accepted symbol in my language. Next time, I'll choose something else.
      - chrismorgan 4y ago
        I was not familiar with keyboard layouts including DEGREE SIGN handily, so I though there was at least a decent chance you had deliberately gone fancy. (I double-checked that it was ° and not º U+00BA MASCULINE ORDINAL INDICATOR, which I would expect to see on some keyboards, and “Nº” is incidentally distinctly better than “N°”, since it’s the shape of an o rather than a circle.) To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n. Looking through <https://en.wikipedia.org/wiki/Numero_sign#Usages https://en.wikipedia.org/wiki/Numero_sign#Usages>… hmm, French AZERTY? I see now that it does have ° readily accessible. I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.) P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.
Gatsky 4y ago
Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him. Creativity also has a role for non-critical conditions when standard treatments aren’t working.
- rscho 4y ago
  So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.
  - Gatsky 4y ago
    Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised. I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
- Aeolun 4y ago
  I guess this is why the hospital asks me to list historical surgeries.

by rscho 4y ago

titanomachy 4y ago

If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.

rscho 4y ago
I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful. As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
thaumasiotes 4y ago
Medical treatment is obviously not fully-solved, or anywhere close. But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient. I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
barry-cotter 4y ago
General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners. > Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care > Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28). https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=doctor+vs+nurse+practitioner+effectiveness&btnG=#d=gs_qabs&t=1668851171508&u=%23p%3DRafdM6k_aWQJ https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/
- lostlogin 4y ago
  More tests isn’t a good things. The doctor was significantly quicker and could see 3 patients for every two the nurse saw. I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.

warner25 4y ago

I appreciate your perspective as a professional in this area. Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.

dimal 4y ago

Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again. Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably. I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.

opportune 4y ago
Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do
- rscho 4y ago
  > Any educated layperson can figure out and follow a clinical decision tree. 12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.
  - dimal 4y ago

chrismorgan 4y ago

> n° Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`. For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.

rscho 4y ago
not all of us live in the US
- joenot443 4y ago
  I don’t either but fully agree GP’s assessment, you chose a strange character to use there.
  - rscho 4y ago
    It's the default on my keyboard, and the commonly accepted symbol in my language. Next time, I'll choose something else.
    - chrismorgan 4y ago
      I was not familiar with keyboard layouts including DEGREE SIGN handily, so I though there was at least a decent chance you had deliberately gone fancy. (I double-checked that it was ° and not º U+00BA MASCULINE ORDINAL INDICATOR, which I would expect to see on some keyboards, and “Nº” is incidentally distinctly better than “N°”, since it’s the shape of an o rather than a circle.) To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n. Looking through <https://en.wikipedia.org/wiki/Numero_sign#Usages https://en.wikipedia.org/wiki/Numero_sign#Usages>… hmm, French AZERTY? I see now that it does have ° readily accessible. I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.) P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.

Gatsky 4y ago

Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him. Creativity also has a role for non-critical conditions when standard treatments aren’t working.

rscho 4y ago
So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.
- Gatsky 4y ago
  Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised. I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
Aeolun 4y ago
I guess this is why the hospital asks me to list historical surgeries.