5 ms·

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 in

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 3y ago
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.
- vrc 3y ago
  1) isn’t being entirely fair. MDs or any other practitioner are generally restricted by what they can bill insurance since only a minority of patients opt for concierge care. So if insurance allows for “X minutes for Y service”, that’s what they generally do in most “eat what you kill” practices (which is most). Some will go above and beyond, but that’s to their detriment. Insurance billing generally makes care “billability”-centric.
  - OldGuyInTheClub 3y ago
    Believe it or not, I tried concierge care. Pretty much the same thing only with a big "cover charge" and a lot of gorilla juice about personalized attention. Left after three months - initial comprehensive exam where the practice owner/doctor was distracted by multiple phone calls and a student he was teaching on my time. I was telling him about my bad Achilles tendon which he proceeded to whack when the reflex test on my knee didn't go the way he expected. The pain was excruciating and when I found my voice, I let him have it. He was late to the followup, couldn't explain the results his machines had given him, and then rushed me out after the usual 10 minutes. I think family practice/primary care is on the ropes. The big lie is that some doctor will "get to know you as an individual." Reality is that s/he's given a quota and time limits by some MBA and the Epic system will make damn sure that the doctor does not use any initiative in solving the patient's problem. I am still at the point where I can prepare and advocate for myself. When that goes, it'll be curtains.
- giardini 3y ago
  The future is here: https://www.youtube.com/watch?v=hmUVo0xVAqE https://www.youtube.com/watch?v=hmUVo0xVAqE The film Idiocracy reviewed: https://www.imdb.com/title/tt0387808/ https://www.imdb.com/title/tt0387808/
FireBeyond 3y ago
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 3y ago
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 3y ago
  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.
  - kortilla 3y ago
    Then why not include high school? Unless the degree was exclusive to medicine, including it is bullshit. MDs have a glorified 4 year masters and an on the job training program not significantly different than what it takes to become a PE.
    - nextaccountic 3y ago
      what's PE?
      - kortilla 3y ago
        Professional Engineer
    - s1artibartfast 3y ago
      But you can become a PE without a masters. Would you say that PEs the only requirement for PE is 2 year Mentorship? Maybe people should be able to go straight into medschool with an associates or hs diploma
ngngngng 3y ago
> 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 3y ago
  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 3y ago
  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 3y ago
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 3y ago
  Is there such a cap?
  - junofan 3y ago
    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 3y ago
    "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-healthcare-workers-why-doesnt-the-u-s-just-make-more-doctors https://www.washingtonian.com/2020/04/13/were-short-on-healt...
    - lolinder 3y ago
      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 3y ago
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.
- imagainstit 3y ago
  I have experienced the flip of this: a less experienced MD specialist not recognizing a lab error, and wanting to act on it, which was recognized (correctly) as an error by PA primary care and confirmed in retesting. In this case the MD was significantly younger/less total years of experience and maybe that had to do with it? PA experience isn't the equivalent of training as a resident (and I think we should be training more MDs) but the MD isn't always right either.
kortilla 3y ago
The system is completely broken with you taking 12 years to train. It means that: - you are expected to learn way too much and only have a surface understanding of a lot of things (see tick example from sibling comment) - your time is very valuable so you can’t put any time effort into patients at all to try to deeply understand anything that doesn’t pass your “known expertise” classifier. My son has back pain that most closely matches descriptions of sciatica. The 3 MDs he has been given a cumulative exposure time of maybe 15 minutes to have resulted in prescriptions for various muscle relaxers and steroids based on a single xray. No attempt to look at any soft tissues and none of it has helped. The industry is an absolute dumpster fire of ineffective care unless you land in the top 20 issues for each sub category. No offense, but the job of diagnosing one of the thousands of possible issues should not be yours. This is what computers are ripe to disrupt. ChatGPT isn’t there yet but something like it that can just crunch data and known results for every obscure thing is going to blow you out of the water. We can both only hope…
- codeTired 3y ago
  I’m so fed up with doctors it’s not even funny. I’ve had positive test showing nerve damage. Doctor messages me saying all my tests were fine. I message them in the portal pointing out one of tests showing insufficient sweating means small fiber neuropathy. They confirm I am correct. Then, I have to tell them what meds to prescribe, that the dosage is too small. It was like pulling nails. I have seen physicians at top facilities in the US. Some are better some are there for prestige and paycheck. We need to collect symptoms using words and visual representation, not everyone will know what tingling feels like. I welcome AI. Also, if you search an illness and look for support groups you will quickly find handful of “recommended” physicians in a country.
sneak 3y ago
Fact: babies not born in hospitals are 2x more likely to die during childbirth. Brings the rest of the equation into focus, at least for me.
jjtheblunt 3y ago
I wonder if MDs realize that engineering and math can easily be longer schooling, without being paid like an MD that last four.

OldGuyInTheClub 3y ago

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.

vrc 3y ago
1) isn’t being entirely fair. MDs or any other practitioner are generally restricted by what they can bill insurance since only a minority of patients opt for concierge care. So if insurance allows for “X minutes for Y service”, that’s what they generally do in most “eat what you kill” practices (which is most). Some will go above and beyond, but that’s to their detriment. Insurance billing generally makes care “billability”-centric.
- OldGuyInTheClub 3y ago
  Believe it or not, I tried concierge care. Pretty much the same thing only with a big "cover charge" and a lot of gorilla juice about personalized attention. Left after three months - initial comprehensive exam where the practice owner/doctor was distracted by multiple phone calls and a student he was teaching on my time. I was telling him about my bad Achilles tendon which he proceeded to whack when the reflex test on my knee didn't go the way he expected. The pain was excruciating and when I found my voice, I let him have it. He was late to the followup, couldn't explain the results his machines had given him, and then rushed me out after the usual 10 minutes. I think family practice/primary care is on the ropes. The big lie is that some doctor will "get to know you as an individual." Reality is that s/he's given a quota and time limits by some MBA and the Epic system will make damn sure that the doctor does not use any initiative in solving the patient's problem. I am still at the point where I can prepare and advocate for myself. When that goes, it'll be curtains.
giardini 3y ago
The future is here: https://www.youtube.com/watch?v=hmUVo0xVAqE https://www.youtube.com/watch?v=hmUVo0xVAqE The film Idiocracy reviewed: https://www.imdb.com/title/tt0387808/ https://www.imdb.com/title/tt0387808/

FireBeyond 3y ago

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 3y ago

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 3y ago
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.
- kortilla 3y ago
  Then why not include high school? Unless the degree was exclusive to medicine, including it is bullshit. MDs have a glorified 4 year masters and an on the job training program not significantly different than what it takes to become a PE.
  - nextaccountic 3y ago
    what's PE?
    - kortilla 3y ago
      Professional Engineer
  - s1artibartfast 3y ago
    But you can become a PE without a masters. Would you say that PEs the only requirement for PE is 2 year Mentorship? Maybe people should be able to go straight into medschool with an associates or hs diploma

ngngngng 3y ago

> 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 3y ago
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 3y ago
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 3y ago

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 3y ago
Is there such a cap?
- junofan 3y ago
  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 3y ago
  "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-healthcare-workers-why-doesnt-the-u-s-just-make-more-doctors https://www.washingtonian.com/2020/04/13/were-short-on-healt...
  - lolinder 3y ago
    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 3y ago

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.

imagainstit 3y ago
I have experienced the flip of this: a less experienced MD specialist not recognizing a lab error, and wanting to act on it, which was recognized (correctly) as an error by PA primary care and confirmed in retesting. In this case the MD was significantly younger/less total years of experience and maybe that had to do with it? PA experience isn't the equivalent of training as a resident (and I think we should be training more MDs) but the MD isn't always right either.

kortilla 3y ago

The system is completely broken with you taking 12 years to train. It means that: - you are expected to learn way too much and only have a surface understanding of a lot of things (see tick example from sibling comment) - your time is very valuable so you can’t put any time effort into patients at all to try to deeply understand anything that doesn’t pass your “known expertise” classifier. My son has back pain that most closely matches descriptions of sciatica. The 3 MDs he has been given a cumulative exposure time of maybe 15 minutes to have resulted in prescriptions for various muscle relaxers and steroids based on a single xray. No attempt to look at any soft tissues and none of it has helped. The industry is an absolute dumpster fire of ineffective care unless you land in the top 20 issues for each sub category. No offense, but the job of diagnosing one of the thousands of possible issues should not be yours. This is what computers are ripe to disrupt. ChatGPT isn’t there yet but something like it that can just crunch data and known results for every obscure thing is going to blow you out of the water. We can both only hope…

codeTired 3y ago
I’m so fed up with doctors it’s not even funny. I’ve had positive test showing nerve damage. Doctor messages me saying all my tests were fine. I message them in the portal pointing out one of tests showing insufficient sweating means small fiber neuropathy. They confirm I am correct. Then, I have to tell them what meds to prescribe, that the dosage is too small. It was like pulling nails. I have seen physicians at top facilities in the US. Some are better some are there for prestige and paycheck. We need to collect symptoms using words and visual representation, not everyone will know what tingling feels like. I welcome AI. Also, if you search an illness and look for support groups you will quickly find handful of “recommended” physicians in a country.

sneak 3y ago

Fact: babies not born in hospitals are 2x more likely to die during childbirth. Brings the rest of the equation into focus, at least for me.

jjtheblunt 3y ago

I wonder if MDs realize that engineering and math can easily be longer schooling, without being paid like an MD that last four.