8 ms·

Debugging the Doctor Brain: Who's teaching doctors how to think?

116 points by jseliger 2y ago

ljlolel 2y ago
[flagged]
- CoastalCoder 2y ago
  What do you mean?
  - karol 2y ago
    Read the article.
- icholy 2y ago
  [flagged]
barbariangrunge 2y ago
In Canada, subjectively, it feels like the quality of newer doctors has gone up dramatically. The training must be a lot better these days. I’ve been impressed, especially when you go in to a clinic where they actively take in students for their practicums - the old doctors are often stepping up their game as well
- mlinhares 2y ago
  There’s considerable research on the subject: https://www.mdlinx.com/article/are-older-doctors-wiser-not-necessarily/01FmC1yV5CNRDrQpaQpy6R https://www.mdlinx.com/article/are-older-doctors-wiser-not-n...
  - sampo 2y ago
    > https://www.mdlinx.com/article/are-older-doctors-wiser-not-necessarily/01FmC1yV5CNRDrQpaQpy6R https://www.mdlinx.com/article/are-older-doctors-wiser-not-n... Link doesn't work in Europe, redirects to https://eu.m3.com/ https://eu.m3.com/.
    - mlinhares 2y ago
      This freakonomics episode covers some of the research as well: https://freakonomics.com/podcast/how-can-you-choose-the-best-doctor/ https://freakonomics.com/podcast/how-can-you-choose-the-best... From the transcript: > But before you go looking for the oldest doctor you can find, you know, hold on for a second. Turns out that what David and his colleagues found in obstetrics may not apply to all fields of medicine. Let me give you an example. A few years ago, we looked at a similar question among internists who provide care to hospitalized patients. These doctors are called hospitalists and nowadays if you’re hospitalized with a general medical condition like pneumonia or heart failure, chances are you’ll be treated by one of these types of doctors. So, my colleagues and I looked at whether the age of a hospitalist physician was tied to outcomes among elderly patients. We looked at about 730,000 hospital admissions by nearly 19,000 physicians and we found that patients treated by older physicians had a higher rate of mortality within a month of their admission date — it’s called “30-day mortality” — compared to patients treated by younger physicians. More patients died under the watch of doctors who were age 60 or older. And interestingly, doctors who were just five years out from their training lost the fewest patients. That finding appears to contradict David’s data showing that obstetricians continued to improve even 30 years into their career.
    - tim333 2y ago
      There's an archive version https://archive.ph/fpyEG https://archive.ph/fpyEG
- flakeoil 2y ago
  It should be quite naturally so as a lot has happened in the field of medicine in the last 30-40 years. A 60 year old doctor who was trained 35 years ago uses old knowledge and techniques. Even though doctors get some updates via conferences and articles in journals and maybe some hand on course, they cannot absorb all that new knowledge in practice.
  - throwaway8877 2y ago
    Perhaps. But they have advantage of 30-40 years of experience.
    - Kalium 2y ago
      It's my understanding that the significance of that age can and does vary wildly. In some specialties, age makes errors more likely: https://psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-errors https://psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-...
    - prmph 2y ago
      But here's the things I'm not clear about: Surgeon get immediate feedback if they make mistakes because their patient might die or get severely disabled, but is there any feedback to GPs about the effectiveness of their work? Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it? For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH. How do doctors who operate on this assumption going to learn from experience, if they mostly don't know that their patients have cardiac events as a result?
      - xyzzy123 2y ago
        Surgeons don't get immediate feedback because the advisability of procedure X ends up being a statistical matter that might not be decided in the surgeon's lifetime. It depends what it is. They will have opinions of course, but will work with the system and follow process.
- sn9 2y ago
  At least in the US, the widespread use of Anki by medical students has actually impacted the way standardized testing are written/graded IIRC.
  - doesnotexist 2y ago
    Wow, it's amazing to me how much anki eventually caught on with medical students. Back in 2008 I introduced my med school classmates to Anki via a web app front end that I scrapped together. Basically it allowed us to crowdsource a shared flashcard corpus but with individual accounts each with their own state for Anki's SRS, allowing us to practice from any web browser without having to have Anki installed locally. Though it had some success among some of my fellow students, the vast majority of the class did not want to engage with a web app for studying back then, so I'm surprised by how much penetration it has now.
deleted 2y ago
[deleted]
thenerdhead 2y ago
In 2021 I presented my doctor a hypothesis that a COVID infection I had recently was persisting in my body leading to long term symptoms. They told me I was completely wrong and that RNA viruses do not do that. Fast forward to today and the NIH director and leading scientists believe this has backing proof. https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-stay-body-more-year-after-infection https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-... https://www.science.org/content/article/long-covid-trials-aim-clear-lingering-virus-help-patients-need https://www.science.org/content/article/long-covid-trials-ai... It has taken me almost three years to convince my doctor on the rationale of using therapeutics acting as COVID antivirals to treat my chronic symptoms. I now have to wait until clinical trials present data hopefully this summer to at least try. So I hope this is a story to show that patients are helping doctors think. And it is very slow going.
- gavinray 2y ago
  Hypothetically, if one had good reason to believe a certain medication/treatment would work, and has some degree of risk-tolerance, they could acquire said medication online from other countries without trying to convince some doctor willing to listen to prescribe it.
  - thenerdhead 2y ago
    People have and have been successful. Especially repurposing HIV/AIDS drugs and ordering Paxlovid from India. Mostly due to USA prices being ridiculously high and insurance companies refusing to prescribe more than a 5 day dose. The other major challenge is that certain approved drugs in other countries can be held by shipping due to FDA approval.
    - bingbingbing777 2y ago
      Not sure why you would be taking Paxlovid for long covid.
      - thenerdhead 2y ago
refibrillator 2y ago
> The center for Medicare and Medicaid is the primary source of graduate medical education (residency) funding. Per the Graham Center interactive GME data tool Mt. Sinai received around $175k a year per resident, and pays them a salary of $84,479\year, leaving 90K to pay for their “education.” This is straight up fraud and should be treated as such. My wife wanted to be a nurse her whole life, went to school and got a good job, after 3 years at the hospital she had to quit for her own sanity. Every nurse and resident in her circle had a similar story. U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees. Seemingly every motivated and caring person in this field is systematically chewed up and spit out.
- anon291 2y ago
  According to https://en.wikipedia.org/wiki/Mount_Sinai_Hospital_(Manhattan) https://en.wikipedia.org/wiki/Mount_Sinai_Hospital_(Manhatta..., Mt Sinai is a 'non-profit', but in my opinion, we need a much more expansive definition of 'for-profit'. It's true that there are no shareholders, but the salaries the executives make is a form of profit, and ought to be treated as such. In some ways it's worse because in a company, the board sets the CEOs and execs compensation, and can adjust it according to their own financial interests (which means there's less desire by CEOs to 'waste', because waste means the board / shareholders make less money, and then their compensation is lowered -- theoretically). In a non-profit, the board uses arbitrary criteria, the board is incentivized to waste all money on executive compensation, because that means the execs throw them excellent parties, galas, soirees, and other social events where they can network with more people to make more profit in their for-profit ventures. Ask me how I know.
  - steveBK123 2y ago
    Hospital donations are also interesting to me as you get billionaires donating amounts of money that.. a FAANG engineer could feasibly have left to give on their demise. Or giving amounts similar to like their 3rd homes value and getting a wing named after them (though the donation clearly only pays for a small fraction of the construction). Similarly I have a friend whose spouse is extremely talented with a PHD (not MD), and has worked in admin roles at a big nonprofit NYC hospital as well. They have at times had pretty similar compensation, one working at a hedge fund and the other working at a nonprofit hospital. Interesting that. Each side can argue they need to attract talent, and one can argue that hospital admin is closer to doing good for society. It is just surprising to see nonprofit and very high compensation.
ryan93 2y ago
Seems like a good thing that purdue lets many students into engineering who can't hack it(i couldn't!). If they didn't have mayn failing that would mean they would be rejecting too many edge case students who might be able to make it through the program. Don't get her argument that someone willing to show up to a 7:30am class is necessarily smart enough for o-chem. Tendentious
- Kalium 2y ago
  The author prefers to believe that it was poor instruction. The implication is that because they were willing to show up for a 7:30am lecture, they were capable of making it. On the one hand, the author is on to something. Most people learn much better with intensive, one-to-one instruction than with large lectures. The real issue, as with all educational programs, is the cost in time and money to teach. More personalized, intensive training from more specialists in teaching a specialized subject simply costs more to get the to the same goals as bulk lectures. Nobody wants to say "There was a very rational cost-benefit analysis and I lost out". Instead, it's all framed as a need to dedicate more time and money at an already demonstrably drawn-out and expensive process. On the other hand, a person's ability and willingness to show up at 7:30am are probably irrelevant. No matter how relevant it feels to a person who wants to show their dedication, passion, and drive.
  - dap 2y ago
    But, assuming we take the facts of the post at face value, there clearly wasn’t a rational cost-benefit analysis that resulted in only teaching large lecture-style courses and deliberately serving only those who could thrive that way. The instructor’s claim was not that the author needed more instruction that wasn’t available (indeed, they turned her away from seeking such instruction). Rather, it was that people like her simply can’t “hack it”, which the author demonstrated to be false.
    - gopher_space 2y ago
      I just wish I had known that o-chem gets easier if you start first thing in the morning.
ohnononomahboi 2y ago
That the answer to a cultural-intellectual problem is monetary is not fully convincing to me. Do we really want 30% more attending physicians of the orientation this article describes? These all seem like valid, but unrelated complaints. On one hand, there is a complaint that doctors are judged subjectively, rather than objectively. But in the next breath those same objective metrics are skewered as deductive and maybe even greedy. The current attending physicians, according to the author, have a population-wide cultural problem where they don't believe they should have to teach. The author's solution to this problem is to hire more attending physicians. Many of the issues raised in this article merit investigation, but this piece feels too eclectic in its thesis to serve as a launchpad for policy direction.
WaitWaitWha 2y ago
I know we hold doctors in high regard, but I must decline in allocating some magical "vibe" or "spidey-sense" as the article writes. In my opinion a well built system will replace all doctors in non-research, medical functions. The notion that somehow one needs "vibe" to recognize something is wrong when Gladys in the example "vomited a huge quantity of blood" is concerning, and wee bit self-aggrandizing. The doctor reacted because there was clear evidence of an issue, not because supernatural abilities. > A doctor’s foundational clinical mental models are built during residency... And, sad to say often stays that way for the rest of their careers. Anecdotally, I have seen this clearest with dentists and ophthalmologists. They will fossilize into their own thinking and unable or unwilling to pick up new methods and procedures (unless sufficiently incentivized by the selling company). another problem is frailty. I walked out on Monday dental appointment when I could tell the dentist had a "rough weekend". I do not need a person with a hang-over digging in my mouth with sharp spinning objects. A system that is updated near real time with new research, new medical advances, not getting tired or distracted is more preferable to me than a human. Maybe the actions are not performed by the machine, it just prompts the human to do and feed the information back, maybe it will also perform the actions. All is possible in the future. When it comes to research and emotional interaction, yes, doctors still hold an edge.
- dap 2y ago
  I don’t think anybody would claim it’s supernatural. Only that for doctors who have seen lots of patients, they (their subconscious?) pick up on signals that they cannot consciously articulate, which means they can’t be easily taught or checked for. (Over time I think we do catalog more of these things but it takes a lot of instances and some explicit reflection before people can identify and describe the pattern.) I’ve got plenty of criticisms for doctors and medicine but I absolutely think this is true because I experience the same in my own personal and professional life.
- andai 2y ago
  Agree with most of what you said, which is unfortunate (except for the silver lining that machines have the potential to massively increase both the supply and quality of medical treatment). One bit puzzles me though, why would human doctors have an edge in research? Wouldn't the "person" who can read a trillion times more, remember everything, cross-reference it, and monitor billions of realtime data points (from billions of patients) for patterns, have a slight advantage?
Calavar 2y ago
A lot of this really hits home. Some of my personal observations across residency and practice: 1. There are some attendings who have a subconscious inbuilt assumption that there are "good" residents and "bad" residents and that any team will contain a mix of both, even if it's a team of just two residents. God forbid that you should be just a "good" resident paired with a superstar resident, because then you are the one who must get the "bad" label by default. If this happens early enough in residency, it may be the first piece of feedback that your program director gets about you, which puts you at risk of being labeled "bad" by the program at large and finding yourself being pushed towards a remedial track. I feel that residency programs are shockingly bad at identifying which residents actually need remediation. Residents with serious knowledge or work ethic issues can get ushered along through the program, while very bright residents who don't understand how to play up their own successes get put on remediation plans. 2. More generally, confidence is often misinterpreted as skill, and introversion is often misinterpreted as a lack of skill. Many attendings are shockingly bad at differentiating the two. 3. Departmental culture has a huge effect on residency education. I trained at a busy county hospital and now practice at an ivory tower type place. Much to my surprise, I think the EM program here (which gets residents who were the cream of the crop of their med school classes) does a worse job of treating patients than the county hospital (which failed to even fill its residency class a couple years ago). The difference, at least in my view, is that attendings at the county hospital were extraordinarily hands on, which taught residents that a "normal" ED physician is extraordinarily hands on. As another example, the ED at my current hospital is very aggressive with CT scans, to the point that probably 20% of the patients that I admit have been panscanned (CT scan from head to pelvis). I attribute this to attendings here being more risk averse in cases with a ~1% possibility of malpractice. And it trickles down to the residents too, because again, that's what their reference for "normal" is. 4. Basic science education in med school is a joke and needs to be overhauled from the ground up. As it stands, 1st year is "pure" basic science, 2nd year is learning about the library of various diseases, and 3rd year is learning how to treat those diseases. I still remember reading the nephrology section of my 1st year textbook, a large chunk of which was a breakdown of why cystatin C is a better indicator of GFR than creatinine and a description of a procedure in which contrast is injected into the renal artery and sampled at the renal vein to measure true GFR, worked out step by step with mathematical equations. What was never mentioned: What the hell is GFR even used for anyway? Why would someone want to measure it? These pieces don't fall into place until 2nd and 3rd year. Imagine if you learned symbolic algebra in 3rd grade but the concept of a word problem wasn't introduced until two years later. That's essentially what medical school basic science education is. The faculty who design med school curricula are not blind to this issue, but their attempts at fixing it are laughably bad. There is "case based learning" where 1st year students are told a vignette about a hypothetical patient and are asked to generate a differential (a list of possible diagnoses) before they dive into the basic science component. This turns into a comedy skit show because 1st year students barely know any diseases, they are only vaguely familiar with the symptoms even for the ones they do know, and they haven't had much, if any, explicit teaching on how to generate a differential. Why not take a more vertical slice approach to teaching? Introduce a limited number of bread and butter diagnoses in 1st year and gradually layer on rarer and more complicated diseases in 2nd and 3rd. Put more weight on the basic science aspect in 1st year, put more weight on aspects that require knowing a large number of diseases (like generating a differential) in 2nd and 3rd year.
andai 2y ago
I think part of this is about staying up to date. I'm not sure if there's a legal requirement for ongoing training? But I've had the experience of going to an older physician and being told my theory is impossible, based on a hypothesis that was disproven in the early 1970s (incidentally, right after the physician graduated).
- abhisuri97 2y ago
  Yes. Doctors in the US have to get a certain amount of Continuing Medical Education (CME) credits (usually done by attending conferences and lectures).
  - WalterSear 2y ago
    So they are being taught by the pharmaceutical industry?
  - n8henrie 2y ago
    I'm not sure about it being a legal requirement in all states (may be) but is generally done by the boards that oversee one's specialties (with some very vague and inconsequential requirements by the state licensing boards). Unfortunately it seems mostly to be a money grab in many specialties, with passing rates in the high 90s for recertification exams, fees of over a thousand dollars, and often with multiple retries if one fails (as long as you pay the fee for each attempt).
ugh123 2y ago
In the US, it seems like insurance companies teach doctors how to think. How many times have we all heard from a doctor "we don't like to do so many tests each year because of costs"
- tombert 2y ago
  Really? I feel like whenever a doctor sees that I have really good insurance they feel the need to use every single machine they have as a diagnostic. I generally don't care because my copay is generally the same regardless and I figure it is good to be thorough, but I do realize that is probably driving up the costs for everyone in the long run.
  - notnaut 2y ago
    “really good insurance” I’d guess a massive % of the us population is having a different experience than you.
    - tombert 2y ago
      Sure, my wife and I had to deal with that not too long ago when I was unemployed and had to use the subsidized MetroPlus stuff in NYC. It wasn’t as bad as I thought it would be but it was definitely not as good as my fancy PPO I get from sexy desk jobs. I guess what I am getting at is that insurance sort of makes things worse for everyone here. When a person comes in with good insurance the doctor has incentive to abuse it, artificially driving up costs, making it harder for people with crappy/no insurance to get the treatments they need because insurance won’t cover it. It’s a messy system. A large part of me would prefer that we abolish private insurance entirely, but I fear that’s not likely in the states.
    - dandy23 2y ago
      I think OP is quite right that insurance drives tests and costs up because contrary to what we think it is good for the insurance companies if the doctor bill is high because then people buy more expensive insurances and thus higher revenue for the insurance company. If the cost would be low there would be no need for an insurance.
roughly 2y ago
It's kind of incredible that we've let a bunch of weenies with MBAs put our lives and health in the kind of risk that the modern medical system puts us in. Every single story from a doctor or a nurse over the last decade involves being overworked, not having time to actually diagnose patience, lack of sleep, and rapid burnout. On the patient side, what we get for that level of hospital "efficiency" are medical bills that would bankrupt anyone below the top 3% if they don't have insurance, rapidly rising medical insurance costs, and what could charitably be described as prescription drug costs that are not based on the cost of the drug. The business side, though, is going swimmingly, so there's that, at least.
- KRAKRISMOTT 2y ago
  The doctors themselves have as much to blame for this too, not to mention most hospital administrators are MBAs with a healthcare background, they are not art students. Medicine perpetuates a hazing culture of overworking residents thanks to a jumped up medicine pioneer who took too much cocaine. They refuse to come up with a way to train doctors at scale and instead restrict it to physical residency spots, keeping their compensations high. Train doctors like engineers, break up the medical unions and lobby groups with the anti trust act and most of the problems will be solved.
  - SoftTalker 2y ago
    Exactly, it's the AMA that's a big part of it. Doctors could stop this by just refusing to work that way. They are the ones with the knowledge and skills and licenses to do what they do, so they are ultimately in the driver's seat.
    - rscho 2y ago
      Refuse to work that way?? And how are we supposed to do that? Stop working until our requirements are met and leave everyone on their own during that time? Who do you think people would blame? The C-suite execs? The only choice you really have is to leave medicine. After dedicating ten years of your life to it's study, a fucking huge debt and no guarantee of finding a better life elsewhere.
bjornsing 2y ago
It seems to me that nobody teaches anybody how to think. Instead we teach people to do things that require thinking, and trust that they will develop an ability to think as a “byproduct”. Which is a bit strange to me, since there are definitely some general principles that can be taught.
- smrtinsert 2y ago
  Let's poke this, how would you teach how to think?
  - daveydave 2y ago
    Breaking a problem down into smaller problems, solving those that are immediately obvious or known from experience, for harder or new problems: gathering evidence if available, coming up with a hypothesis, testing this against the available evidence, looking for reasons why the hypothesis must be wrong and abandoning it if reasons are found, iterating on the hypothesis until an adequate one is found (adequate being provably correct, or "sounding sensible" based on solutions to similar problems). My 2c is being ok with uncertainty and being wrong, and an awareness of cognitive biases can be helpful.
  - eszed 2y ago
    Traditionally? Humanities. Those fields have the advantage of starting with common experience and a natural-language corpus, so there isn't as high a barrier to entry as STEM disciplines. But, you know... we don't do that anymore. (And yes, I know, some of the reasons are intrinsic to choices made by people within the Humanities.) We've abandoned that, but not found a better way.
  - CleverLikeAnOx 2y ago
    I took a class psychology class on learning that was superb. It taught how to memorize stuff: spaced repetition and semantic encoding. Spaced repetition is reviewing the thing at increasingly spaced intervals of time. Semantic encoding is coming up with connections to the idea. The wilder the better as that tends to be memorable. The class taught some strategies for creativity such as use of analogies and trying to combine disparate ideas. The class also taught cognitive biased, like loss aversion. This class was life changing. It was also easy because the teacher applied the best practices she was teaching. I would say something like that class is the basis for teaching people how to think.
sn9 2y ago
This person fucking gets it. I want to force every software engineer and manager and MBA and anyone else to read this until they've internalized it.
ngcc_hk 2y ago
Wonder about Canada and nhs doctor training? Btw anyone knows what happen in Korea?
shkkmo 2y ago
> we often mistake the speed of initial understanding with a students’ capacity for mastery This is one of those assumptions that I didn't notice I was making till it was pointed out. It is hard to predict capacity for mastery. It seem natural to adopt initial understanding speed as a heuristic, but I think it is the kind of heuristic that while effective, also tends creates a significant overestimation of it's own effectiveness through confirmation bias.
at_a_remove 2y ago
I have what is a rather rare disease in the United States. I recognized it for what it was about a month in, purely by accident -- I recalled an interesting article I had read when I was about twelve. It took roughly a year to convince the appropriate doctors to run the tests, yes because they were fixated on the "hoofbeats, horses, not zebras" mantra, despite my symptoms aligning so perfectly you'd think a constellation had been traced on onionskin paper. Each specialist who drifted through behaved like a sage in the tale of the six blind sages and the elephant. Then you consider the overwork -- why? It's hazing, but we know that it causes people to underperform.

116 points by jseliger 2y ago

ljlolel 2y ago

[flagged]

CoastalCoder 2y ago
What do you mean?
- karol 2y ago
  Read the article.
icholy 2y ago
[flagged]

barbariangrunge 2y ago

In Canada, subjectively, it feels like the quality of newer doctors has gone up dramatically. The training must be a lot better these days. I’ve been impressed, especially when you go in to a clinic where they actively take in students for their practicums - the old doctors are often stepping up their game as well

mlinhares 2y ago
There’s considerable research on the subject: https://www.mdlinx.com/article/are-older-doctors-wiser-not-necessarily/01FmC1yV5CNRDrQpaQpy6R https://www.mdlinx.com/article/are-older-doctors-wiser-not-n...
- sampo 2y ago
  > https://www.mdlinx.com/article/are-older-doctors-wiser-not-necessarily/01FmC1yV5CNRDrQpaQpy6R https://www.mdlinx.com/article/are-older-doctors-wiser-not-n... Link doesn't work in Europe, redirects to https://eu.m3.com/ https://eu.m3.com/.
  - mlinhares 2y ago
    This freakonomics episode covers some of the research as well: https://freakonomics.com/podcast/how-can-you-choose-the-best-doctor/ https://freakonomics.com/podcast/how-can-you-choose-the-best... From the transcript: > But before you go looking for the oldest doctor you can find, you know, hold on for a second. Turns out that what David and his colleagues found in obstetrics may not apply to all fields of medicine. Let me give you an example. A few years ago, we looked at a similar question among internists who provide care to hospitalized patients. These doctors are called hospitalists and nowadays if you’re hospitalized with a general medical condition like pneumonia or heart failure, chances are you’ll be treated by one of these types of doctors. So, my colleagues and I looked at whether the age of a hospitalist physician was tied to outcomes among elderly patients. We looked at about 730,000 hospital admissions by nearly 19,000 physicians and we found that patients treated by older physicians had a higher rate of mortality within a month of their admission date — it’s called “30-day mortality” — compared to patients treated by younger physicians. More patients died under the watch of doctors who were age 60 or older. And interestingly, doctors who were just five years out from their training lost the fewest patients. That finding appears to contradict David’s data showing that obstetricians continued to improve even 30 years into their career.
  - tim333 2y ago
    There's an archive version https://archive.ph/fpyEG https://archive.ph/fpyEG
flakeoil 2y ago
It should be quite naturally so as a lot has happened in the field of medicine in the last 30-40 years. A 60 year old doctor who was trained 35 years ago uses old knowledge and techniques. Even though doctors get some updates via conferences and articles in journals and maybe some hand on course, they cannot absorb all that new knowledge in practice.
- throwaway8877 2y ago
  Perhaps. But they have advantage of 30-40 years of experience.
  - Kalium 2y ago
    It's my understanding that the significance of that age can and does vary wildly. In some specialties, age makes errors more likely: https://psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-errors https://psnet.ahrq.gov/issue/radiologist-age-and-diagnostic-...
  - prmph 2y ago
    But here's the things I'm not clear about: Surgeon get immediate feedback if they make mistakes because their patient might die or get severely disabled, but is there any feedback to GPs about the effectiveness of their work? Let's say someone is not treated that well by his doctor for a chronic condition. He gets to the emergency in a different hospital and probably dies. Does his GP get to know about it? For example, many doctors in my country believe that Left Ventricular Hypertrophy (LVH) on an ECG is nothing much to worry about, as long as there is no anatomical LVH showing up on an Echocardiogram. Yet, study after study online concludes that ECG LVH is a serious marker of cardiac pathology distinct from (but related to) from anatomical LVH. How do doctors who operate on this assumption going to learn from experience, if they mostly don't know that their patients have cardiac events as a result?
    - xyzzy123 2y ago
      Surgeons don't get immediate feedback because the advisability of procedure X ends up being a statistical matter that might not be decided in the surgeon's lifetime. It depends what it is. They will have opinions of course, but will work with the system and follow process.
sn9 2y ago
At least in the US, the widespread use of Anki by medical students has actually impacted the way standardized testing are written/graded IIRC.
- doesnotexist 2y ago
  Wow, it's amazing to me how much anki eventually caught on with medical students. Back in 2008 I introduced my med school classmates to Anki via a web app front end that I scrapped together. Basically it allowed us to crowdsource a shared flashcard corpus but with individual accounts each with their own state for Anki's SRS, allowing us to practice from any web browser without having to have Anki installed locally. Though it had some success among some of my fellow students, the vast majority of the class did not want to engage with a web app for studying back then, so I'm surprised by how much penetration it has now.

deleted 2y ago

[deleted]

thenerdhead 2y ago

In 2021 I presented my doctor a hypothesis that a COVID infection I had recently was persisting in my body leading to long term symptoms. They told me I was completely wrong and that RNA viruses do not do that. Fast forward to today and the NIH director and leading scientists believe this has backing proof. https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-stay-body-more-year-after-infection https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-... https://www.science.org/content/article/long-covid-trials-aim-clear-lingering-virus-help-patients-need https://www.science.org/content/article/long-covid-trials-ai... It has taken me almost three years to convince my doctor on the rationale of using therapeutics acting as COVID antivirals to treat my chronic symptoms. I now have to wait until clinical trials present data hopefully this summer to at least try. So I hope this is a story to show that patients are helping doctors think. And it is very slow going.

gavinray 2y ago
Hypothetically, if one had good reason to believe a certain medication/treatment would work, and has some degree of risk-tolerance, they could acquire said medication online from other countries without trying to convince some doctor willing to listen to prescribe it.
- thenerdhead 2y ago
  People have and have been successful. Especially repurposing HIV/AIDS drugs and ordering Paxlovid from India. Mostly due to USA prices being ridiculously high and insurance companies refusing to prescribe more than a 5 day dose. The other major challenge is that certain approved drugs in other countries can be held by shipping due to FDA approval.
  - bingbingbing777 2y ago
    Not sure why you would be taking Paxlovid for long covid.
    - thenerdhead 2y ago

refibrillator 2y ago

> The center for Medicare and Medicaid is the primary source of graduate medical education (residency) funding. Per the Graham Center interactive GME data tool Mt. Sinai received around $175k a year per resident, and pays them a salary of $84,479\year, leaving 90K to pay for their “education.” This is straight up fraud and should be treated as such. My wife wanted to be a nurse her whole life, went to school and got a good job, after 3 years at the hospital she had to quit for her own sanity. Every nurse and resident in her circle had a similar story. U.S. hospitals are for profit assembly lines. Managers with MBAs that have never worked a shift on the floor in their life see staff as fungible. Throwing a pizza party when patient quotas are met, instead of you know, hiring more to relieve overworked and stressed employees. Seemingly every motivated and caring person in this field is systematically chewed up and spit out.

anon291 2y ago
According to https://en.wikipedia.org/wiki/Mount_Sinai_Hospital_(Manhattan) https://en.wikipedia.org/wiki/Mount_Sinai_Hospital_(Manhatta..., Mt Sinai is a 'non-profit', but in my opinion, we need a much more expansive definition of 'for-profit'. It's true that there are no shareholders, but the salaries the executives make is a form of profit, and ought to be treated as such. In some ways it's worse because in a company, the board sets the CEOs and execs compensation, and can adjust it according to their own financial interests (which means there's less desire by CEOs to 'waste', because waste means the board / shareholders make less money, and then their compensation is lowered -- theoretically). In a non-profit, the board uses arbitrary criteria, the board is incentivized to waste all money on executive compensation, because that means the execs throw them excellent parties, galas, soirees, and other social events where they can network with more people to make more profit in their for-profit ventures. Ask me how I know.
- steveBK123 2y ago
  Hospital donations are also interesting to me as you get billionaires donating amounts of money that.. a FAANG engineer could feasibly have left to give on their demise. Or giving amounts similar to like their 3rd homes value and getting a wing named after them (though the donation clearly only pays for a small fraction of the construction). Similarly I have a friend whose spouse is extremely talented with a PHD (not MD), and has worked in admin roles at a big nonprofit NYC hospital as well. They have at times had pretty similar compensation, one working at a hedge fund and the other working at a nonprofit hospital. Interesting that. Each side can argue they need to attract talent, and one can argue that hospital admin is closer to doing good for society. It is just surprising to see nonprofit and very high compensation.

ryan93 2y ago

Seems like a good thing that purdue lets many students into engineering who can't hack it(i couldn't!). If they didn't have mayn failing that would mean they would be rejecting too many edge case students who might be able to make it through the program. Don't get her argument that someone willing to show up to a 7:30am class is necessarily smart enough for o-chem. Tendentious

Kalium 2y ago
The author prefers to believe that it was poor instruction. The implication is that because they were willing to show up for a 7:30am lecture, they were capable of making it. On the one hand, the author is on to something. Most people learn much better with intensive, one-to-one instruction than with large lectures. The real issue, as with all educational programs, is the cost in time and money to teach. More personalized, intensive training from more specialists in teaching a specialized subject simply costs more to get the to the same goals as bulk lectures. Nobody wants to say "There was a very rational cost-benefit analysis and I lost out". Instead, it's all framed as a need to dedicate more time and money at an already demonstrably drawn-out and expensive process. On the other hand, a person's ability and willingness to show up at 7:30am are probably irrelevant. No matter how relevant it feels to a person who wants to show their dedication, passion, and drive.
- dap 2y ago
  But, assuming we take the facts of the post at face value, there clearly wasn’t a rational cost-benefit analysis that resulted in only teaching large lecture-style courses and deliberately serving only those who could thrive that way. The instructor’s claim was not that the author needed more instruction that wasn’t available (indeed, they turned her away from seeking such instruction). Rather, it was that people like her simply can’t “hack it”, which the author demonstrated to be false.
  - gopher_space 2y ago
    I just wish I had known that o-chem gets easier if you start first thing in the morning.

ohnononomahboi 2y ago

That the answer to a cultural-intellectual problem is monetary is not fully convincing to me. Do we really want 30% more attending physicians of the orientation this article describes? These all seem like valid, but unrelated complaints. On one hand, there is a complaint that doctors are judged subjectively, rather than objectively. But in the next breath those same objective metrics are skewered as deductive and maybe even greedy. The current attending physicians, according to the author, have a population-wide cultural problem where they don't believe they should have to teach. The author's solution to this problem is to hire more attending physicians. Many of the issues raised in this article merit investigation, but this piece feels too eclectic in its thesis to serve as a launchpad for policy direction.

WaitWaitWha 2y ago

I know we hold doctors in high regard, but I must decline in allocating some magical "vibe" or "spidey-sense" as the article writes. In my opinion a well built system will replace all doctors in non-research, medical functions. The notion that somehow one needs "vibe" to recognize something is wrong when Gladys in the example "vomited a huge quantity of blood" is concerning, and wee bit self-aggrandizing. The doctor reacted because there was clear evidence of an issue, not because supernatural abilities. > A doctor’s foundational clinical mental models are built during residency... And, sad to say often stays that way for the rest of their careers. Anecdotally, I have seen this clearest with dentists and ophthalmologists. They will fossilize into their own thinking and unable or unwilling to pick up new methods and procedures (unless sufficiently incentivized by the selling company). another problem is frailty. I walked out on Monday dental appointment when I could tell the dentist had a "rough weekend". I do not need a person with a hang-over digging in my mouth with sharp spinning objects. A system that is updated near real time with new research, new medical advances, not getting tired or distracted is more preferable to me than a human. Maybe the actions are not performed by the machine, it just prompts the human to do and feed the information back, maybe it will also perform the actions. All is possible in the future. When it comes to research and emotional interaction, yes, doctors still hold an edge.

dap 2y ago
I don’t think anybody would claim it’s supernatural. Only that for doctors who have seen lots of patients, they (their subconscious?) pick up on signals that they cannot consciously articulate, which means they can’t be easily taught or checked for. (Over time I think we do catalog more of these things but it takes a lot of instances and some explicit reflection before people can identify and describe the pattern.) I’ve got plenty of criticisms for doctors and medicine but I absolutely think this is true because I experience the same in my own personal and professional life.
andai 2y ago
Agree with most of what you said, which is unfortunate (except for the silver lining that machines have the potential to massively increase both the supply and quality of medical treatment). One bit puzzles me though, why would human doctors have an edge in research? Wouldn't the "person" who can read a trillion times more, remember everything, cross-reference it, and monitor billions of realtime data points (from billions of patients) for patterns, have a slight advantage?

Calavar 2y ago

A lot of this really hits home. Some of my personal observations across residency and practice: 1. There are some attendings who have a subconscious inbuilt assumption that there are "good" residents and "bad" residents and that any team will contain a mix of both, even if it's a team of just two residents. God forbid that you should be just a "good" resident paired with a superstar resident, because then you are the one who must get the "bad" label by default. If this happens early enough in residency, it may be the first piece of feedback that your program director gets about you, which puts you at risk of being labeled "bad" by the program at large and finding yourself being pushed towards a remedial track. I feel that residency programs are shockingly bad at identifying which residents actually need remediation. Residents with serious knowledge or work ethic issues can get ushered along through the program, while very bright residents who don't understand how to play up their own successes get put on remediation plans. 2. More generally, confidence is often misinterpreted as skill, and introversion is often misinterpreted as a lack of skill. Many attendings are shockingly bad at differentiating the two. 3. Departmental culture has a huge effect on residency education. I trained at a busy county hospital and now practice at an ivory tower type place. Much to my surprise, I think the EM program here (which gets residents who were the cream of the crop of their med school classes) does a worse job of treating patients than the county hospital (which failed to even fill its residency class a couple years ago). The difference, at least in my view, is that attendings at the county hospital were extraordinarily hands on, which taught residents that a "normal" ED physician is extraordinarily hands on. As another example, the ED at my current hospital is very aggressive with CT scans, to the point that probably 20% of the patients that I admit have been panscanned (CT scan from head to pelvis). I attribute this to attendings here being more risk averse in cases with a ~1% possibility of malpractice. And it trickles down to the residents too, because again, that's what their reference for "normal" is. 4. Basic science education in med school is a joke and needs to be overhauled from the ground up. As it stands, 1st year is "pure" basic science, 2nd year is learning about the library of various diseases, and 3rd year is learning how to treat those diseases. I still remember reading the nephrology section of my 1st year textbook, a large chunk of which was a breakdown of why cystatin C is a better indicator of GFR than creatinine and a description of a procedure in which contrast is injected into the renal artery and sampled at the renal vein to measure true GFR, worked out step by step with mathematical equations. What was never mentioned: What the hell is GFR even used for anyway? Why would someone want to measure it? These pieces don't fall into place until 2nd and 3rd year. Imagine if you learned symbolic algebra in 3rd grade but the concept of a word problem wasn't introduced until two years later. That's essentially what medical school basic science education is. The faculty who design med school curricula are not blind to this issue, but their attempts at fixing it are laughably bad. There is "case based learning" where 1st year students are told a vignette about a hypothetical patient and are asked to generate a differential (a list of possible diagnoses) before they dive into the basic science component. This turns into a comedy skit show because 1st year students barely know any diseases, they are only vaguely familiar with the symptoms even for the ones they do know, and they haven't had much, if any, explicit teaching on how to generate a differential. Why not take a more vertical slice approach to teaching? Introduce a limited number of bread and butter diagnoses in 1st year and gradually layer on rarer and more complicated diseases in 2nd and 3rd. Put more weight on the basic science aspect in 1st year, put more weight on aspects that require knowing a large number of diseases (like generating a differential) in 2nd and 3rd year.

andai 2y ago

I think part of this is about staying up to date. I'm not sure if there's a legal requirement for ongoing training? But I've had the experience of going to an older physician and being told my theory is impossible, based on a hypothesis that was disproven in the early 1970s (incidentally, right after the physician graduated).

abhisuri97 2y ago
Yes. Doctors in the US have to get a certain amount of Continuing Medical Education (CME) credits (usually done by attending conferences and lectures).
- WalterSear 2y ago
  So they are being taught by the pharmaceutical industry?
- n8henrie 2y ago
  I'm not sure about it being a legal requirement in all states (may be) but is generally done by the boards that oversee one's specialties (with some very vague and inconsequential requirements by the state licensing boards). Unfortunately it seems mostly to be a money grab in many specialties, with passing rates in the high 90s for recertification exams, fees of over a thousand dollars, and often with multiple retries if one fails (as long as you pay the fee for each attempt).

ugh123 2y ago

In the US, it seems like insurance companies teach doctors how to think. How many times have we all heard from a doctor "we don't like to do so many tests each year because of costs"

tombert 2y ago
Really? I feel like whenever a doctor sees that I have really good insurance they feel the need to use every single machine they have as a diagnostic. I generally don't care because my copay is generally the same regardless and I figure it is good to be thorough, but I do realize that is probably driving up the costs for everyone in the long run.
- notnaut 2y ago
  “really good insurance” I’d guess a massive % of the us population is having a different experience than you.
  - tombert 2y ago
    Sure, my wife and I had to deal with that not too long ago when I was unemployed and had to use the subsidized MetroPlus stuff in NYC. It wasn’t as bad as I thought it would be but it was definitely not as good as my fancy PPO I get from sexy desk jobs. I guess what I am getting at is that insurance sort of makes things worse for everyone here. When a person comes in with good insurance the doctor has incentive to abuse it, artificially driving up costs, making it harder for people with crappy/no insurance to get the treatments they need because insurance won’t cover it. It’s a messy system. A large part of me would prefer that we abolish private insurance entirely, but I fear that’s not likely in the states.
  - dandy23 2y ago
    I think OP is quite right that insurance drives tests and costs up because contrary to what we think it is good for the insurance companies if the doctor bill is high because then people buy more expensive insurances and thus higher revenue for the insurance company. If the cost would be low there would be no need for an insurance.

roughly 2y ago

It's kind of incredible that we've let a bunch of weenies with MBAs put our lives and health in the kind of risk that the modern medical system puts us in. Every single story from a doctor or a nurse over the last decade involves being overworked, not having time to actually diagnose patience, lack of sleep, and rapid burnout. On the patient side, what we get for that level of hospital "efficiency" are medical bills that would bankrupt anyone below the top 3% if they don't have insurance, rapidly rising medical insurance costs, and what could charitably be described as prescription drug costs that are not based on the cost of the drug. The business side, though, is going swimmingly, so there's that, at least.

KRAKRISMOTT 2y ago
The doctors themselves have as much to blame for this too, not to mention most hospital administrators are MBAs with a healthcare background, they are not art students. Medicine perpetuates a hazing culture of overworking residents thanks to a jumped up medicine pioneer who took too much cocaine. They refuse to come up with a way to train doctors at scale and instead restrict it to physical residency spots, keeping their compensations high. Train doctors like engineers, break up the medical unions and lobby groups with the anti trust act and most of the problems will be solved.
- SoftTalker 2y ago
  Exactly, it's the AMA that's a big part of it. Doctors could stop this by just refusing to work that way. They are the ones with the knowledge and skills and licenses to do what they do, so they are ultimately in the driver's seat.
  - rscho 2y ago
    Refuse to work that way?? And how are we supposed to do that? Stop working until our requirements are met and leave everyone on their own during that time? Who do you think people would blame? The C-suite execs? The only choice you really have is to leave medicine. After dedicating ten years of your life to it's study, a fucking huge debt and no guarantee of finding a better life elsewhere.

bjornsing 2y ago

It seems to me that nobody teaches anybody how to think. Instead we teach people to do things that require thinking, and trust that they will develop an ability to think as a “byproduct”. Which is a bit strange to me, since there are definitely some general principles that can be taught.

smrtinsert 2y ago
Let's poke this, how would you teach how to think?
- daveydave 2y ago
  Breaking a problem down into smaller problems, solving those that are immediately obvious or known from experience, for harder or new problems: gathering evidence if available, coming up with a hypothesis, testing this against the available evidence, looking for reasons why the hypothesis must be wrong and abandoning it if reasons are found, iterating on the hypothesis until an adequate one is found (adequate being provably correct, or "sounding sensible" based on solutions to similar problems). My 2c is being ok with uncertainty and being wrong, and an awareness of cognitive biases can be helpful.
- eszed 2y ago
  Traditionally? Humanities. Those fields have the advantage of starting with common experience and a natural-language corpus, so there isn't as high a barrier to entry as STEM disciplines. But, you know... we don't do that anymore. (And yes, I know, some of the reasons are intrinsic to choices made by people within the Humanities.) We've abandoned that, but not found a better way.
- CleverLikeAnOx 2y ago
  I took a class psychology class on learning that was superb. It taught how to memorize stuff: spaced repetition and semantic encoding. Spaced repetition is reviewing the thing at increasingly spaced intervals of time. Semantic encoding is coming up with connections to the idea. The wilder the better as that tends to be memorable. The class taught some strategies for creativity such as use of analogies and trying to combine disparate ideas. The class also taught cognitive biased, like loss aversion. This class was life changing. It was also easy because the teacher applied the best practices she was teaching. I would say something like that class is the basis for teaching people how to think.

sn9 2y ago

This person fucking gets it. I want to force every software engineer and manager and MBA and anyone else to read this until they've internalized it.

ngcc_hk 2y ago

Wonder about Canada and nhs doctor training? Btw anyone knows what happen in Korea?

shkkmo 2y ago

> we often mistake the speed of initial understanding with a students’ capacity for mastery This is one of those assumptions that I didn't notice I was making till it was pointed out. It is hard to predict capacity for mastery. It seem natural to adopt initial understanding speed as a heuristic, but I think it is the kind of heuristic that while effective, also tends creates a significant overestimation of it's own effectiveness through confirmation bias.

at_a_remove 2y ago

I have what is a rather rare disease in the United States. I recognized it for what it was about a month in, purely by accident -- I recalled an interesting article I had read when I was about twelve. It took roughly a year to convince the appropriate doctors to run the tests, yes because they were fixated on the "hoofbeats, horses, not zebras" mantra, despite my symptoms aligning so perfectly you'd think a constellation had been traced on onionskin paper. Each specialist who drifted through behaved like a sage in the tale of the six blind sages and the elephant. Then you consider the overwork -- why? It's hazing, but we know that it causes people to underperform.