Medical school is not supposed to prepare anyone for specialized care. It's only to help students gain enough knowledge and experience for residency.
Here's the breakdown (this is meant as an exaggeration and a joke, to illustrate the point):
- First 2 years of med school: mostly academic teaching so you don't kill anyone when you show up in an actual hospital.
- Third year of med school: (jokingly) you can look and touch, but even the nurses are keeping an eye on you. You just contaminated your hands by touching your beard, get out of the room!
- 4th year of med school: did you talk with the new patient? What do you think? Student: "He was a little odd, otherwise he's here for a checkup." Doctor: "He's autistic..." Student: "Oh...I had a feeling he was."
Residency: how to actually do something for patients in general.
Fellowship: how to actually do something for complex medical conditions.
Residency is what's supposed to prepare people to operate in their respective fields. And then comes fellowship for specialized care.
For anyone who wants to complain about what doctors should or should not learn during medical school: first go learn what the curriculum does teach, then ask yourself if you're even mildly qualified to make those judgements based on your understanding of healthcare, and then maybe you could comment on what would have to be left out of education to accommodate for X, because the curriculum is already super bloated and a firehose of information.
I'll finish up my fellowship this summer and it will have been a solid 10 years from when I started medical school. The vast majority of people have no idea what goes into medical training (even my own parents remain confused) - and that's okay, there's no need for everyone to know these ins-and-outs, but when we're passing judgment on the medical curriculum and adding additional things, it does become important.
You can talk about adding a class in medical school addressing neurodivergence and disability, but how do you really address that spectrum of diversity in a single class? And what aspects do you really retain a decade out when patients with neurodivergence can be relatively rare (depending on your specialty)?
In the end, I think the best learning comes from seeing patients (especially, again, as the spectrum of what these patients experience is so diverse and individual). I am always grateful to patients who provide guidance along with parents or caregivers and nurses who had often cared for that patient before for their advice on how to approach a specific patient, along with individual behavior plans if in place.
Not to diminish the difficulty of the existing curriculum, but it doesn't seem fair or sustainable to ask for patients to train and guide each physician they see in how to work with neurodivergent individuals. I'm sure there is much from formal education that new physicians don't retain, but that doesn't mean it is not worth teaching.
I see neurodivergent individuals (or at least, significantly neurodivergent that a more individualized approach is needed) relatively rarely in my field of work (adult oncology, where the average patient is much older and has often had significant exposure to the healthcare system). Every patient I've seen has been very different in terms of needs and their prior experiences and so I have difficulty imagining a "standardized" curriculum for these patients that is specific enough to add value but broad enough to apply to every medical student, but I'm happy to be corrected on this.
And, I mean, if we're talking about neurodivergence more broadly and including people who generally "pass" as neurotypical, then that's a huge chunk of the population. Really, any time you talk to a patient, you should be assessing where they're at, in terms of general understanding and preferences, and should always tailor your approach to an individual.
As an autistic person, it unfortunately does not work like that. Every single neurodiverse person has their own unique needs. There is no one size fits all technique, not even close. The best you can do is teach some general strategies and an awareness of the fact that these people have unique needs. And generally we do teach these things.
It unfortunately is up to the individual to work with their practitioner to come up with an individualized plan of care. It really can't be any other way. Any attempt you make to come up with a universal standard of care for neurodiverse patients will necessarily exclude and likely harm people on other parts of the spectrum.
Over-generalizing these things sounds like a good idea up front, but it ends up causing more harm overall. We get stuck with narrow and rigid standards of care that just don't work for more than a small subset of people. This has been a real problem with autism in particular: until very recently the diagnosis and treatments were only concerned with young white boys. There's a very serious problem with women, adults, and all other groups being drastically under-diagnosed and left untreated. More generally, there are very few resources for autistic adults because of this. It's very slowly changing though
Seems like the most obvious solution would be to have some sort of case manager/continuum of care type support for these types of individuals. I’m pretty sure this already exists for geriatric patients but maybe not widespread enough?
There’s too many particularities that can come up with individuals that are “non standard” for whatever reason. Any new physician for a particular patient could easily get up to speed on those particularities at the time it’s needed and not have to fumble through the friction it presents AND they don’t need any extra training to do so (probably?).
> For anyone who wants to complain about what doctors should or should not learn during medical school: first go learn what the curriculum does teach, then ask yourself if you're even mildly qualified to make those judgements based on your understanding of healthcare, and then maybe you could comment on what would have to be left out of education to accommodate for X, because the curriculum is already super bloated and a firehose of information.
I think this knee jerk reaction is unwarranted. The writer is a doctor herself, so she's well-versed with the breadth and depth of medical school curriculum, and everything that comes after that.
But I don't agree that your breakdown about medical school curriculum is accurate or correct, definitely not across different schools. For example, the Harvard Medical School curriculum offers classes for Sports or Rural medicine practice (subjects for highly specialized medical focus), so I don't understand why something for autistic or disabled patient care cannot be included in either those subjects, or separately. My guess is that it probably is to some degree, but not to the degree that this article writer would prefer. Source: http://tinyurl.com/mr8ncn2p
All specialized fields have "firehoses of information", and dismissing an opinion about improving the quality of care for patients who have different needs as "adding too much" is just lazy.
I’ve always wondered if a lot of the dismissive culture is an institutionalized mechanism to help people cope with the fact that some of what they learn and do is either very suboptimal or harmful. The history of
medicine is long. You can see some big differences if you work on stuff that touches different countries.
That's a complete dodge, and exhibits exactly the kind of arrogance people complain about when physicians ignore what patients have to say. People have valid opinions and expectations of their own healthcare or that of loved ones, no matter whether they can design or refine a medical school curriculum or not. It's silly to suggest that nothing they have to say is valid if they can't. People know when they or their family are receiving good care, and when they are not. To reject their experiences is, again, arrogance.
I know when my restaurant food tastes good and when it doesn't. But if I've never cooked the dish before, I don't know the first thing about how exactly to improve it.
Someone can know that their loved one was given substandard care, yet not know enough to know how to improve the system such that the care would have been better. Case in point: the family of the patient who died in the linked article, seem to think the systemic improvement that is needed is neurodivergence training. When in actuality, it was a failure to take into account the medical history of the patient which led to the malpractice that caused his death. It wasn't that the doctors didn't know what autism was or something.
Actually, most patients have no clue when they are receiving good care or not. For example, studies have shown that patient satisfaction after an office visit is highly correlated with whether they received a prescription. A lot of patients feel like they got their money's worth if the doctor hands them a script, regardless of whether they needed it.
No its not. Random people have no fucking clue what they're talking about, HN is a perfect example. As it turns out, looking at WebMD for 15 minutes is actually not a comprehensive medical education.
Both parents are doctors. They complain all the time how they get patients who have no idea what they are talking about come and assume they know better than them. Patients lie ALL THE TIME for no reason at all. Patients also expect long periods of 1:1 time with Doctors about dumb BS a Resident could handle by tossing handfuls of Motrin at the patients general direction and counting how many pills fall into their mouths.
I personally saw one patient scream many slurs at a Doctor for being bad at medicine after the doctor asked what drugs they may have taken (a innocuous question), and ripped out their IV and ran away.
This is the shit that Doctors/Nurses/Medical staff deal with. Hospitals are not a place to go to be pampered.
The 1949 Nobel Prize in Physiology or Medicine suggests the medical field can probably do a better job at building trust with the public. It’s a two-way street after all.
I had to deal with pediatricians and Neurologists for last couple of years. My general experience is that their training is severely deficient in the empathy. I don't think it should be hard to accommodate it in their training plan.
I can say that doctors in Ireland aren’t categorically worse than doctors in the US so maybe we should start training doctors alright after HS instead of requiring a 4 year degree
> Oliver McGowan was 18 years old when he was hospitalized in England with recurrent seizures and pneumonia. He was autistic, and he and his parents had one specific request for the medical team: no antipsychotic medications. When he had taken them in the past, they made his seizures worse and had devastating effects on his mood. Despite the family’s vehement protests, doctors gave him an antipsychotic. A few days later, Oliver suffered a lethal neurological side effect. A week later, he was taken off life support. An inquest into his death found that the drug had led to the rapid deterioration.
I don't see what this has to do with autism.
Also, I understand that receiving medical care can be alienating but I'm not sure there's a way to fix that. It's real hard (impossible?) to train people to be kind, patient, and empathetic. Being honest and not making medical errors are probably more important training targets for doctors, nurses, and other medical professionals (and more achievable).
People with more severe autism can be really tricky to deal with. According to [0] the medical staff gave him medication he was known to be allergic to in order to sedate him. [1] says he arrived at the hospital scared and agitated and was physically restrained. The staff decided to deal with this by pumping him full of sedatives rather than actually addressing the source of his anxiety.
If the staff had been given proper training into dealing with neuro-atypical patients, there would have been no need for sedation.
> rather than actually addressing the source of his anxiety.
> If the staff had been given proper training into dealing with neuro-atypical patients, there would have been no need for sedation.
You're making some serious assumptions here. 1. The source of anxiety could be dealt with at the time. 2. The training would be applicable at the time. 3. A different approach would require no sedation. 4. There was time for a calming approach given what had to be done at the time.
Sure, we should improve things, but also when you end up in the ICU, the priorities are a bit different than during a routine doctor visit - we don't know whether that situation could be dealt with without any kind of restraints/sedatives.
The hospital is one of the places where you can encounter above average rates of neurodivergent people. They need to be trained. If it works or not is a different thing for which I don't have any idea
> Police cant/won't be trained on how to deal the neordiversity and mental crisis, why do we think that the assembly line health care system can be?
Why are you using police (who have no legal or ethical duty to care for or protect anyone) as a baseline for what we would expect of healthcare providers (who have both a legal and ethical duty to their patients)?
The LAPD adopted the motto “To protect and to serve”, and it was subsequently widely copied across the U.S. Besides a general mandate to protect the public at large, police are responsible for the wellbeing of anyone in their custody.
Police don't have a mandate to protect the public. This has gone before the supreme court, multiple times. Even if they are present while you're being attacked, they can just stand and watch if they think it's not safe for them to engage. (And practically speaking, they can't do it anyways, they're not omnipresent - if you live in a big city your response time for being murdered is probably over 5 minutes (where I am, it's 7+ minutes). Lot can go wrong in 5 minutes)
They do have a responsibility to protect people in their custody.
> The LAPD adopted the motto “To protect and to serve”, and it was subsequently widely copied across the U.S. Besides a general mandate to protect the public at large, police are responsible for the wellbeing of anyone in their custody.
That is a PR slogan. That's like trying to say Google can't be evil because their motto is "Don't be evil."
The Supreme Court has explicitly ruled that police do not have a duty to protect citizens, and that ruling has been reinforced consistently at lower courts throughout the country.
No, that's not what they meant. The ruling itself is extremely explicit. And furthermore, that's how other courts have applied the ruling in the decades since.
It's simply factually incorrect to claim that the police have a legal duty to protect citizens simply because of a PR campaign that they launched, when there are volumes of case law that establish otherwise.
> The LAPD adopted the motto “To protect and to serve”, and it was subsequently widely copied across the U.S.
AFAIK. it hasn't been copied in that form very widely, instead, it was popularized by TV (Dragnet specifically, IIRC), and so is culturally attached to police in general, despite the vast majority of departments with any motto having different mottos.
>If the staff had been given proper training into dealing with neuro-atypical patients, there would have been no need for sedation.
If people are given anti violence courses would it certainly stop violence? Doesn't matter if they have autism or not, doctors in their panic with or without training may make medical misfortune occur.
It’s not about stopping violence it’s about managing and understanding situations that appear violent but are borne of anxiety or some other emotion. Violent rage or criminal violence is a lot different than anxiety, and can be dealt with through purely social mechanisms. Certainly resorting to heavy medication to cope with autism isn’t the right way to manage behavior induced through anxiety and fear, especially if they’re known and explicitly disclosed to be toxic to the individual.
When you get right down to it, aren't most examples of violence from neurotypical people also "situations that appear violent but are [born] of anxiety or some other emotion"? Like, if a man turns up in emergency high as a kite and is worried the hospital will call the police so he shoves a doctor over and runs away, or a new mother grabs the scrubs of a nurse because nobody will tell her where her child is, it's not a great outcome to jam those patients full of antipsychotics either.
Is that certain? It's not a good solution, but it's also not a good solution to say that nurses just have to deal with agitated and combative patients for however long it takes to find or rule out non-pharmaceutical solutions. I'd question whether long-term use of forcible physical restraint is even better for the patient.
There are situations where it’s unclear what is happening and where it is clear.
In situations like this where the family tells the hospital specifically what is going to happen and what to not do, it’s not alright to do the thing that’s known wrong.
For someone severely autistic all you have to do is reduce stimulation. Sedating them isn’t the right way to handle them. Putting them in a quiet room is the right way to handle them.
In situations where there’s no knowledge of what’s going on restraining them and getting a psychiatric nurse or doctor to evaluate them is probably a better outcome than sedating them. Sedation makes diagnosis impossible. The comeback is that there aren’t enough psych staff on hand to respond in emergencies. That’s just a pathetic state of things given the human mind is the most complex part of our being and illness of the mind is prevalent and largely untreated.
Being autistic is why he got given the anti-psychotic in the first place, despite it not being in his interest as a patient, when people hear a patient is autistic or see autistic behaviour they dehumanize and give them drugs for the sake of personal convenience.
Who is going to question it - they’re autistic and the person giving them the drug was a doctor - what right do people have to question such things? As such, there’s little disincentive for doctors to abuse their patients with anti-psychotics to shut them up.
It also makes it more likely that their chart will be ignored, as obviously the request against anti-psychotics might have been the personal request of somebody with a compromised mind. The person reading the chart is a doctor, they know they’re very intelligent, so they know better.
Great question. Here's my response. My thinking is, essentially, doctors aren't really at risk of being dehumanised by having a few people like me. I also don't see myself as dehumanising them, more portraying them as flawed humans pursuing their own self-interest.
Doctors are aware of several positive correlations in Autism, autistics kick ass at the Raven's Progressive Matrices test [1] for instance. Yet the DSM-V doesn't mention this, it just defines autism as a set of deficiencies and impairments [2]. Why is this? Well it's all because the medical system has little incentive to portray their patients as able and capable - this only implies they do not need their help, and thus there is no need for them to provide and be paid for services. So with no outside criticism, this sort of attitude will just be how things are.
There's other controversies I could name, like the genocide [3], the ongoing torture [4], the open eugenics [5], the suspected eugenics [6], the historical connection between the gold standard therapy for Autism and gay/trans conversion therapy [7][8], the stigma against mental illness amongst mental health professionals [9], or worse care through diagnostic overshadowing [10]
I think the point of my posting, is I believe the attitudes towards autistic people in medicine is not good, I believe this isn't some unfortunately inevitable tragedy, or that doctors are inhuman monsters. What I more want to point out is how medical students are introduced to autism as just another pathology in their reference materials like the DSM-V from day 1, and how their views are coloured by this in a way that makes them more callous, and also how this entire attitude helps colour the views of broader society. I find the entire situation very frustrating.
My understanding is doctors will reliably treat requests from autistic patients with more suspicion than they do neurotypical patients. Either because of how people on the spectrum often communicate or how they react to stress and discomfort. You're exactly correct that this kind of behavior is always unacceptable, but historically people have excused this unprofessional behavior because it's common to find autistic communication styles confusing. The reason to talk about it like this is because we should be past the era where people feel comfortable with medical professionals being ignorant about basic patterns in common behavioral communities.
I am not well versed on them either! I was thinking of things like people on the spectrum finding eye contact uncomfortable (as opposed to connecting), or perhaps a focus on sub-points of the conversation which others find difficult to follow? People who are on the spectrum can describe it better than I:
>The reason for this is that natural, honest and authentic autistic communication - like giving ample detail, avoiding eye contact, pausing before answering Qs and giving direct, literal answers - mirrors the style of communication neurotypical people tend to adopt when they lie.[1]
It sounds like hyperbole. I told a dentist I was allergic to ibuprofen and she prescribed it to me. Some doctors will never respect you and think they know better. Just avoid those that don't do nice things like listen to you but also not enablers thsr want a lot of money.
Just train more doctors. For some reason the Western hemisphere is extremely resistant to large scale training of healthcare workers. Train doctors like engineers and you won't have a shortage of good ones.
A big part of the basic problem in the US is the artificially limited residency system [1], which has gotten so bad that states are now explicitly letting foreign doctors skip residency requirements to work in the US [2].
You -might- have a slightly higher proportion of “bad ones,” but you would also have a system with less of a capacity shortage. In turn, the harms from lesser practitioners would likely be less, and you could more readily suspend for misconduct.
Some of those we consider bad ones might even be considerably better under a little less time pressure.
Not having sufficient care can do some pretty serious harm. It's not like all the new doctors we'll be adding will be worse than the existing set.
Taking your argument to the extreme: if we have no doctors, they can't do any harm. Is that best? Or, we could get rid of 20% of doctors and avoid getting rid of the best, which would improve the quality of the distribution. Would that be better?
You absolutely will. People should be extremely careful what they wish for. Simplistic solutions like "just train more doctors" can and will have disastrous unforeseen consequences.
It doesn't take above average intelligence to go through med school, so long as you have high discipline and motivation. Good memory helps the most, really.
There is a simple way to know that we could train more doctors - failure rates are very low, which means that either the MCAT is a better filter than the exams (unlikely!), or that it would be possible to train a lot more doctors.
The failure rate in all graduate education is low, because you’re only taking people who have already performed well for 4 years in undergrad.
For med school specifically, you’re only taking the top performers, then of those you’re filtering further based on MCAT scores.
If you’re that selective and you already have a 15-20% failure rate, I’m not sure that lowering the entry requirements is a great use of resources.
You don’t really want a 40% failure rate. That’s a lot of wasted time, effort, and money.
There are already many alternate career paths for medical practitioners who can’t make it into med school or just don’t want to spend as much time in training.
Obviously it would be possible to run more students through medical school but that wouldn't give us more practicing doctors. The real bottleneck is in residency slots at teaching hospitals. For peculiar historical reasons almost all graduate medical education is funded by the Federal government through the Medicare program and Congress has been unwilling to increase that.
And meanwhile we select by willingness to go through basically hazing on top of inteligence. And meanwhile we routinely have doctors to perform in severely sleep deprived state too for no reason at all.
That's enough for a minimum baseline of quality. Medical school in general is hellish enough to drive people to actual suicide and there's plenty that can be said about that but at least stupid people can't get into these schools.
It could always be worse. It could be a pointless system that inflicted hell on students and minted shitty doctors!
The "soviet doctor" thing you mentioned is just so amusing to me. I'm brazilian, our current president is a literal communist who fancies himself the creator of a south american soviet union, he has a populist "doctors for the poor" policy which essentially consists of flooding the market with doctors via huge numbers of shitty medical schools that don't even have a hospital for the students to practice in, he's directly quoted as saying things like "we must create a new generation of leftist doctors who accept working for less"...
And now there are doctors who do not know how to identify a possible myocardial infarction on an EKG. There are doctors out there who cannot spot an ST segment elevation or depression on an EKG. Hell I've seen one doctor send a patient presenting with classic myocardial infarction symptoms home with pain meds without even running a simple, cheap, fast, non-invasive and universally available EKG. I wish I was making this up, my own goddamn lawyer made an example of this last idiot because obviously the patient died and it's just impossible to defend that conduct. I'm actually afraid of being sick and not having trusted doctors to care for me.
But of course my comment above describing this terrible situation was flagged. Welp. People here would be horrified if I described the literal quackery and charlatanism I see in this country on a daily basis. Blow smoke up people's ass tier stuff and I mean that literally. Worst part is those doctors make metric fucktons of money while the good ones are hated because they don't swindle patients with easy solutions that don't actually work.
The parents are obviously and appropriately advocates for neurodivergence.
But honestly, to your point, this is more an example of shitty medicine, especially in the ED. My family had similar arguments when hospitalists refused to give me pain medication 3 hours out of a spinal fusion. Or when my wife was bleeding out from a ruptured ectopic pregnancy and the ER guy kept telling her she had food poisoning.
One of the problems is that front line medicine, especially in the US spends alot of time dealing with the poorest, sickest, and dumbest among us.
I qualified as a nurse - Registered Nurse Mental Handicap - RNMH - here in the UK in 1989.
Many of those I cared for needed regular blood tests. Esp those prescribed lithium and other anti-convulsants so that the drug regime was within therapeutic limits.
There is, for example, a patient called John. He needs a blood test. He comes into a room with a person he has never met, to be subjected to something he is unfamilar with and, unsurprisngly, get agitated and refuses.
This happened again and again and again.
We, as a group of nurses say "Hey, let us do the blood sampling, we know the person, we can time it right, we know this person"
This idea was opposed 100% because DOCTORS KNOW BEST.
That's weird to me, in the US, because I don't know a single doctor that draws blood for tests. And if a doctor ever tried to draw blood from me I would say "No thanks, let the nurse do it". The American equivalent of this is probably "Administration knows best!" Like at my wife's hospital where they said "having all of these part time nurses is difficult on the admin staff and is going to force us to hire a few more people. So the nurses can go full or quit." Well, they all quit, and now the hospital is paying 4x the normal nurse rate for locums.
Doctors get paid a lot less in the UK because the NHS has a monopoly over their employment (I’m oversimplifying but that’s the effect). There’s a lot less incentive to offload routine patient care to nurses but they’ve still got the air of superiority so patients get the worst of both worlds.
I'm not entirely sure what you're asking. In my wife's hospital's case, a lot of the nurses were part time due to family requirements. When the hospital demanded they go full time or quit, they simply quit and went part time at neighboring hospitals. You can't go making unreasonable demands of your employees when the demand for labor is larger than the supply.
I’ve told doctors countless times the medication’s they used to treat my Asperger’s and my bipolar disorder schizoaffective type, make me ill weak and caused me pain. But they never listen to me. So this is not even about people with serious mental handicaps. They don’t listen to patients in general. But that’s true for people with mental illness They think every pain or issue we have is solely our heads.
But I also recently had a friend mother who went to the doctor because her ankles were swelling and she had some other issues. They took a blood test and didn’t tell her. Her kidney function was with stage 3B kidney failure. It was two weeks until my friend showed me the labs and I told her to go back and force him to take more test.
I don’t know what’s going on in medicine if this is something new or is this something old but medical school shouldn’t cost as much as it does if they’re putting out doctors like these.
Profit and loss incentives make it so that if you are competent you get clients and you keep going, if you aren't you lose money and fail.
With central banking we have destroyed this system and in the case of medicine not only there is a lot of central banking interference but here is also a guild system that limits the supply of doctors, so bad doctors don't fail and with time you get more and more bad Doctors. Things will only get worse
Doctors being bad at their jobs predates central banking, take the long held obsession with blood letting as just one example. Fixing finance will not fix doctors.
If doctors want people to listen to them they need people to believe they’re very smart, and getting pulled into the mire of the specifics of people’s conditions would just result with both the patient and doctor finding out they don’t know enough and that’s bad for business.
Absolutely. Nowhere is the perversion of incentives more clear than in places where we hope people will act from their heart and their genuine concern, because they are out-competed by the economic forces of easy, cheap, fast money.
This phenomenon is also visible with regard to single-use plastics, as much a stretch as that may seem: why buy things that can be re-used indefinitely, and passed on to next generations, when money is such a hot potato? Better (rationally) to trade money for cheap plastic things from the other side of the world.
Fair question. The profit incentive in this case is not meant as a psychological incentive, but a purely economic one.
If I make money doing something, I can keep doing it. If I don't, I lose money and so I can't.
It's a natural selection mechanism that will always happen. We broke it (aka we don't like it) because we moved from the consumer choosing who profits to central banks.
So, doctors that are not liked by the consumer don't disappear as fast as they should. They also don't land where they could do good because we leave everything to arbitrary judgements of well meaning bureaucrats instead of the choices of people that have to be served.
No system is perfect but we are missing something important in healthcare and I think this is the main culprit.
They also don't teach them how to care for people with Type 1 diabetes. There are so many horror stories about how awful hospitalization is for T1Ds. So many doctors and nurses don't understand the complexity of treating the disease, or respect the patient's ability to treat it themselves while in the hospital. Not to mention how common misdiagnoses are: I was diagnosed as T2, when I was clearly T1. They didn't even do an antibody test, all because I was an adult. So many people (including doctors) still have the dangerous idea that T1D only manifests in kids.
I'm terrified of being hospitalized for that reason. I'll sign whatever paperwork needed in order to self treat with my CGM and pump. I've been doing this for 12 years, no doctor is going to be about to do it better.
This also scares me in terms of inpatient mental health facilities. They often don't even give you access to your own insulin and testing supplies. Which is a recipe for feeling much worse after leaving then entering.
> This also scares me in terms of inpatient mental health facilities. They often don't even give you access to your own insulin and testing supplies. Which is a recipe for feeling much worse after leaving then entering.
Also, many antipsychotic medications fuck with blood sugar regulation (to the point that "antipsychotic-induced weight gain and metabolic disturbances" have been an active area of research for 20+ years [1]), and "low appetite" is routinely interpreted as a mental illness symptom.
I've had a few really low points over the last couple years, where I almost checked myself into a mental health facility, but chose not to because of my T1D. It sort of forced me to come up with alternative coping mechanisms, which I'm kind of grateful for honestly.
> I was diagnosed as T2, when I was clearly T1. They didn't even do an antibody test, all because I was an adult.
Same. I was about 30, long distance runner and bike rider. Went from 170 pounds to 130 over about 4 months. Doctor shrugged and was like, “You must be addicted to carbs. It’s type 2 here’s metformin. Start eating better.”
I have since found 2 doctors who I like quite a bit. But I now know that I’m the only one on planet Earth who truly cares about my health. It should’ve been obvious from the start, but it wasn’t. Now I know. If I want to be healthy, it’s on me to get there.
> But I now know that I’m the only one on planet Earth who truly cares about my health. It should’ve been obvious from the start, but it wasn’t. Now I know. If I want to be healthy, it’s on me to get there.
This is especially true for T1D. You don't just go to the doctor twice a year and have them prescribe a set medication dosage you take every day. You have to constantly adjust and factor it into every decision, every hour, of every day, for the rest of your life.
The reality is that chronic diseases vary greatly from person to person, and a doctor just doesn't have the time/patience/first-hand experience to treat your disease optimally. That's why their best option in the 20 minutes they have with you is to just prescribe some hard core drug or procedure that is one-size-fits-all for your disease.
I've seen a dozen doctors about my own chronic disease and 90% of them are useless beyond prescribing the standard $30k/yr chemo drug (which I'm allergic to). The only doctor that has ever actually helped me in my recovery was a naturopath. She didn't have the ego of an MD and actually took the time to build and iterate on an individualized treatment plan.
Yes, I 100% agree. Constant decision making and second guessing and third guessing takes a huge toll. I’m definitely not a positive-all-the-time person but I am happy to get to use a Dexcom that gives much more useful information than finger sticks.
That’s fascinating that health care providers don’t trust the patients to care for themselves considering that if they couldn’t or didn’t, they would literally be dead.
What should the medical schools remove from the curriculum to accommodate this?
It is not like they have part of a semester that that is just waiting to be filled. It is already stuffed to the gills.
There are 100s probably 1000s of things that should be added in order for doctors to be better prepared for one scenario or another.
Being autistic I would like to see this added, but at the same time I have
no idea what they could remove.
They could keep adding semesters until they got it all covered by that is
probably not going to work either.
They have a set schedule.
You want to push something in, you gotta take something out.
> It is not like they have part of a semester that that is just waiting to be filled. It is already stuffed to the gills.
Oh, how I wish this were true.
I'm married to an MD. Went through the med school/residency journey with her. Soooooooooo much waste and BS in the process.
In direct response to your question, 4th year of med school is essentially a joke. During the first half of the year, everyone is distracted by residency interviews and applications. During the second half of the year, no one really cares because they're ready to peace out. My wife's entire 4th year could have been dropped and she would have lost absolutely nothing.
The reality is medical schools primary metric is percentage of students placed into residency. More prestigious schools care about more prestigious placements, but placement is a must. The primary, almost exclusive, means of ranking resident candidates is test scores.
For most med schools, that means they don't actually care about providing their students with any practical skills. They only care about succeeding on a handful of standardized exams.
In fact, I've seen schools kick students out with exams failures so they can artificially keep residency match rates high.
It depends per school, but 4th year students usually fill their own schedules with electives and rotations. You can definitely fill it in a way to make it as intense for the first three years, but it would likely cause students to start burning out before residency instead of during it.
I am currently on my 4th year rotations and I find them to be some of the most educational, important, and interesting ones. YMMV of course
They could have a specialist with extra training who is brought in to consult for situations like this. That seems to be what we do for other scenarios (e.g. we could train every doctor to administer general anesthesia, but instead we have a specialist for that).
> What should the medical schools remove from the curriculum to accommodate this?
I vote they remove the part of the curriculum that pointlessly makes residents work zillion-hour, sleep deprived shifts - one after the other, for years.
Countries that do that usually have med school programs that last longer than 4 years. US med schools would have to add in all the required classes from undergrad.
Then you have to take into account that you the US doesn’t have a national high school curriculum, so the first 2 years of undergrad are essentially just getting everyone in the same page.
You’d likely be looking at a 6-7 year program with a much higher failure rate. It’s not a clear cut win and it would take a huge amount of coordination and effort.
Nearly all countries I know about have some system where only the best
of the best from high school are admitted into the program.
The criteria can be different but usually some permutation of the
grade point average from high school.
Competition to make it into the program if fierce.
A couple of countries I know about¹ start off with a much larger set of
students expecting a large. number will drop out early.
You still need high points from high school, but it might be a better
solution than just the top of the top grades.
All else being equal I think it makes more sense to let people go through an undergraduate degree first as opposed to combining that with med school.
I think it’s better to have discrete units:
1. you have more people who just never make it into med school but still have an accredited undergraduate degree vs more people failing out of med school after taking out loans.
2. You don’t need to know you want to be a doctor at 16 or 17 years old.
3. Med school is much more expensive than undergrad on average, so even if it takes longer, it’s still likely going to be cheaper. Sure med schools could make the first few years cheaper, but they won’t unless forced.
4. It makes it more likely that doctors socialize with non-doctors and get a chance to pursue non-medical interests. One of the biggest complaints about doctors is that they lack empathy—taking people directly from high school and ensuring that they pretty much only socialize with other doctors for 8-10 years definitely isn’t going to help that.
There are countries with 7 year programs. 5 or 6 is more common. But some of those require an extra internship year before residency (which may be optional).
But you’re forgetting the part where the US doesn’t have a national high school curriculum. So a direct high school to medschool pipeline in the US would definitely include a year or 2 of general education.
The whole point would be to skip the "general education" part and teach directly useful parts. You can even have an entry test for what you expect students to know, that will create a common baseline.
We don't have a national curriculumn. If you start requiring college level general education from high school students, you're biasing selection against kids whose schools can't or won't provide those classes. There's no way to force local schools to change without a major overhaul of our entire system.
We don't do that in the United States for any other undergraduate professional degrees. Engineers, accountants, pharmacists, nurses, teachers etc... all require college level general education.
In the vast majority of high schools biology and chemistry aren’t remotely comparable to the college lab based classes.
High school English isn’t generally equivalent to college English. High school history isn’t equivalent etc…
General education for doctors also includes calc based physics, so you need calculus as well.
Do you think people want to go to a doctor that has a less broad education than their accountant so they can save 3% on their medical bills?
Why don’t we do an experiment? A new medical classification—MDWL (medical doctor without letters). MDWLs go directly out of high school to a 6 year med school where all the fluff has been cut out. No history, no general chemistry, biology, physics, calculus, English, art history, political science, literature, sociology, psychology, foreign language, business etc…
Then let people choose whether they want to save $10 on an office visit to go the MDWL.
Physicians salaries btw represent about 8% of medical costs. So even if we did manage to cut medical education from 8 to 6 years we’re talking maybe saving 2%. That 2% would be eaten up by rising administrative costs, and most of those the cost savings would likely be taken by private equity. Not passed on to the consumer.
why do you think general education is necessary? went to med school directly from high school in england, and loved the fact I didn't have to waste time and money on “general education” - I can read and I know what a library is, I don't need a university to spoon feed me “general education”
You could say the exact same about high school in general. Where you end general education is a tradeoff. You could say 12 year olds can read, so why not let them go be apprentice electricians or whatever.
However, what I or you think is irrelevant. America in general has decided that general education is a requirement for anyone who is college educated.
Every undergraduate professional degree requires general education. Pharmacists, accountants, engineers, teachers, actuaries etc...
The other ones are finished with their learning years faster and can move on into jobs.
With doctors, unnecessary additional years hurt them more then others and also it makes whole medical system more expensive. So yes, there is a difference. The situation is worst with doctors.
2 additional years of general education is 2 extra years whether total training time is 4 years or 10 years. There’s no non-linear effect that I’m aware of that makes a 33% increase from 6 to 8 years somehow much more expensive or more painful than a 100% increase from 2 to 4.
All of the other profession degrees provide public services and so pass the costs of general education directly to the public. In many cases like with pharmacists and physical therapists, it’s directly affecting the medical system.
Also take a look at the percentage of medical costs that go to doctors. It’s a small percentage. Speeding their training up by 2 years isn’t going to make much of a dent.
In fact if you move to 6 year med school it might actuality make their education more expensive overall because med school is much more expensive per year than an undergraduate degree.
My wife is autistic, and has hyper mobile Ehlers-Danlos syndrome. She's had nurses accuse her of pill seeking while one or more joints have been dislocated.
It seems as if a large part of the world's (professional) empathy was drained during the COVID-19 pandemic and I'm not sure it's ever coming back.
I assume you are in the USA. If you are not, I apologize.
If we changed the US Constitution so that every person has the individual right to import, purchase, own, redistribute, manufacture, and use anything that is vaguely medical without any taxation, restriction, or tracking from any source whatsoever...
Then we could just buy our meds from Cipla and be done with most of the corrupt American healthcare system.
She should find a doctor she likes and stick with that doctor - apparently, “if you like your doctor you can keep your doctor” (with obvious extension to that doctor’s nurses,techs, clerks etc)
If that statement is not true, perhaps we should consider what changes in the system might might make it more or less true over time?
I get the feeling that doctors aren’t really trained for more than half of the stuff they need to know. Trauma informed care is a joke, yet a huge proportion of people have a history of multiple adverse childhood experiences, and these have very real effects on health. And any chronic illness that doesn’t have an easy biomarker is a complete unknown to most doctors. They just throw up their hands and say the bloodwork is normal, you must be fine.
I don’t know how doctors can be trained for twelve years and have so little understanding of health. And yet they have such confidence in their abilities.
Part of the challenge of bringing mental health into physical health, I think, is that it introduces a vast number of non-verifiable variables into an already incredibly complex system. While it might be a good idea, it asks a tremendous amount from a practice which often can’t keep up with demands as it is.
I know a paradigm shift and rethinking could resolve that to a degree, but it’s quite antithetical to western medicine.
It’s like asking programmers to embrace non-deterministic programming languages when you’re already deploying to non-deterministic platforms. It would seem like total chaos, I think.
I don’t think it’s antithetical to Western medicine. It’s antithetical to mass produced, industrialized medicine. Those aren’t the same thing. I only want them to use the scientific method on each individual patient. That’s all. They don’t seem interested in it though. They don’t seem to be able to think for themselves and reason on their own. They like acute diseases and disorders. Here’s a virus, and we kill it with this medicine. Here's a bacteria and we kill it with this medicine. Here’s a tumor and we cut it out. Anything more complex and they don’t have any interest in it. If they want to treat the patients they actually have, they need to learn how to do this other work.
The other option is we just accept that they don’t have any interest in this type of complexity, and say OK, that’s fine, but they no longer have a monopoly on medicine. We find other ways of certifying other branches of science to treat people with these things. There are a lot of people who are already treating these things well. I go to a nutritionist who is amazing and has helped me more than any other doctor. She’s not anti-science or using crackpot theories. She’s still scientific. But my insurance won’t cover the because the MDs have a monopoly on that.
As you've said, the human body is complex. We don't always know what's wrong - of course we do our best with the tests we have, but often we're ruling things out and are left without a clear answer. When I try to tell patients that "I don't know", they're frustrated with me. And frequently, it's the patients that are mad that I don't have a pill or procedure that can fix it immediately.
You say that doctors like diseases that we can treat...well, of course we do. I want to help people! Why would I enjoy having to tell someone they're feeling badly but I can't figure out why with my current available tests and data? It doesn't mean that the symptoms aren't real, I just don't know what's causing them.
People think modern medicine means we have all the answers, but that's not the case by a long shot and the vast majority of human experience and condition is still unknown, and I do wish people understood that more.
(And, side note, insurances put up a fight with a ton of doctor-prescribed orders as well, it's a huge problem in the system. I'm sure all healthcare workers would love universal dietitian coverage.)
> When I try to tell patients that "I don't know", they're frustrated with me. And frequently, it's the patients that are mad that I don't have a pill or procedure that can fix it immediately.
One of my best experiences with a doctor was when he told me he believed my symptoms were real, but he didn’t know what caused them. After being told I was healthy repeatedly even though I had very real symptoms, just being believed was a relief.
Different patients want different things. Some want a quick fix. I don’t. I want to get to the bottom of it. Maybe try to ask some questions up front to gauge which type of person they are, so you can know how to give them bad news?
The other problem I was referring to was not that doctors like diseases that they can treat. That’s a misrepresentation of what I said. I was talking about how they seem to only like diseases with a VERY clear-cut diagnosis and standard treatment, where they can run one test, then write a prescription and solve the problem. Boom. Next! But anything that’s slightly more complex than that or has any grey area, and they don’t have the patience or mindset to troubleshoot the problem.
As a software engineer, I find doctors’ lack of curiosity very difficult to deal with. You get the strong sense that they’re just looking up a flow chart, but when things don’t fit the flow chart they have no method for dealing with that uncertainty, so they give up. I guess part of the problem is that easy fixes are the only thing that can fit into a twenty minute visit. Seems like there’s no time to be curious.
I don’t expect miracles. I know that modern medicine still doesn’t have anything close to all the answers. I suppose I just want doctors to get more comfortable with uncertainty and learn how to manage that uncertainty better. Don’t act certain about things they can’t be certain about, and be more curious when the patient in front of them doesn’t fit the diagnostic flow chart.
I understand that you’re all in a difficult situation though. Dealing with insurance B.S., difficult patients, legal risks, hundreds of thousands of dollars in school loans… I don’t envy you at all. But I can’t act like the current situation is working. It’s not.
What would it mean to use the scientific method on each individual patient? You can't run a valid RCT or even an observational study with an n=1 sample size.
You can form hypotheses and test them though. That is what they do when they run the "standard" tests, but once those tests are done most doctors don't seem to be good at and/or interested in coming up with further hypotheses.
You're mixing up unrelated issues. Anyone can call themselves a "nutritionist"; it's essentially a meaningless term.
MDs don't have a monopoly on receiving medical insurance payments. Insurers will pay for many non-medical allied health services including registered dieticians (RD) in cases where those meet coverage rules based on scientific evidence.
> Insurers will pay for many non-medical allied health services including registered dieticians (RD) in cases where those meet coverage rules based on scientific evidence.
Saying they will pay out in their brochure and actually paying out are two very different things. Anyone who has spent any time trying to get reimbursed for medical expenses knows the maze of dark patterns that insurance companies will use to avoid paying out. They wear you down with broken websites and “lost” form submissions until you give up. Medical insurance companies don’t make money by providing healthcare. They make money by collecting premiums and not providing healthcare. And actual scientific evidence has very little effect on what’s covered easily and what gets the runaround.
“so little understanding of health” - compared to, for example, you? Whats your method of developing this understanding and does the state and society in which you live recognize your tremendous ‘understanding of health” and allow you to prescribe medications or perform surgery on other humans? If not, why not?
Or are you just frustrated by how little we know about human health compared to what we wish we knew? (which I agree with but have made my peace with)
I think medical research has progressed far beyond what clinicians are capable of using. I won’t claim to have any great understanding of health myself. But I’ve had issues where qualified doctors told me there was nothing to be done about my health issues, yet with some research I was able to find evidence-based interventions that I tried on my own, that helped. A Google search by an engineer should not outperform twelve years of rigorous medical training, but it did on multiple occasions. And many people have these types of experiences. It’s not unusual at all for people with chronic health issues. There’s something very wrong with that.
But also, I agree that our understanding of health is still very limited, and I am ok with that. But MDs seem to think that their knowledge is much greater than it is. They tend to have a certainty in their assessments that is unwarranted. For example, instead of saying “Your bloodwork is within the normal range, so I’m not sure what’s causing your symptoms,” they will say “Your bloodwork is normal. You’re healthy.” Those are two very different statements. One shows empathy with their patient and allows for further investigation, and the other one says, “I did my job. You’re on your own now.”
While I don't know anything about medicine, I have some experience in curriculum design. My rule of thumb is that you can learn two things in a year. That doesn't mean people can't learn more. It means that you should describe the learning objectives you expect the students to meet at that level of granularity.
Anything that gets substantially less than half a year of full-time study is uncertain. Students may encounter it but fail to learn it, or they may learn it and later forget it.
12 years is enough time to learn 24 things. While there are more things you would like every doctor to know, you can't reasonably expect them to know all of that after just 12 years of training.
I don't dispute the headline but this article is a total mess. First referring to the US health system but then citing anecdotes from the english health system. It then mingles US healthcare and dentistry. The US health system is as different from the UK health system as different can be and in the US dentistry is a fundamentally separate industry and education tract that has absolutely no connection to healthcare whatsoever.
In the US I can speak first hand as a former hospital executive that a lot more can be done to improve treatment paths for people with a wide variety of mental health diseases. Medical school can play a role but residency programs are a much more important element, at least in terms of how US doctors are trained. From history the best way to do this is to create a specific health system focused on treating those patients and to lead by example. I am not aware of such an effort but there may be one.
Autism and ADHD are, by far, the most thoroughly studied mental disorders. They are also the most thoroughly undiagnosed, untreated, and ignored.
Sprinkle the hyper-politicization of stimulant medication on top, and you get what we have today: hell.
Imagine if the wheelchair store was at the top of a staircase. Imagine if the glasses flashed bright lights into your eyes every time you tried a frame on. Imagine you broke your leg, and your physician told you with a straight face, "I think it might be a sprain. I'm going to prescribe you a mild painkiller, and see if that helps." There's a shortage of crutches, and we don't want to risk getting you dependent on those anyway.
Think I'm being heavy-handed here? Just read any collection of first-hand ADHD diagnosis. If anything, it's worse.
Even with a diagnosis from an age of 12 (!!!), and testimonies from teachers and parents going even further back, I was still being stonewalled for months on getting medication as an adult.
This was after they took my diagnosis (demanded a redo, came to a conclusion after 2 appointments and discharged me) and i regained it at a neuropsychiatry clinic (ADHD and Autism specialist).
The only thing that broke through was outside help from a municipal caregiver, he prescribed it immediately when she called.
This shit is not incompetence, it is malice. It is on fucking purpose.
Medical schools do not prepare students for a lot of shit.
I have a rather rare metabolic disorder, a subtle one with a lot of complications. I had to fight to get the correct tests done, I had to fight people who got constellations of symptoms wrong, older people with MDs who didn't want to listen to some kid. The tests came back: they were wrong. (This was all prior to all of this information being available on the Intarwebz; I had to learn everything from books)
I still have to check the meds I am prescribed. I have to deal with doctors whose pupils visibly twitch when scanning my chart -- they mysteriously excuse themselves for a bit and return, "I see it says here you have ..." Others simply pass the buck on treatment. I had a hematologist client-dump me on the answering machine.
It's hard enough to treat the bulk of the boring patients. If you're on the edge, well, they simply don't have experience. Most doctors won't ever see someone like me. If doctors were some other species who lived to be a few hundred years old, they would have the experience. I'm reminded of that recent Slate Star Codex parable about the alchemists and the dying prince. It's just too much to ask from mere mortals.
The flip side of this is me recognizing doctors as mere mortals and not just going with everything like a lamb.
Honestly this has less to do with training and more about the catastrophically understaffed and overworked healthcare system.
There are not enough nurses on shift at any given time, and patients like this are difficult and require a lot of one-on-one care. Hospitals won't or can't bring on additional staff to care for these cases. It's already nearly impossible for a nurse to round on all their patients, so sometimes they use sedatives so that they can care for everyone else.
Which is clearly a very bad thing to do, but when your options are sit with one patient who only needs social/psychological support or caring for a dozen or three other people, it's a much more difficult call.
The problem is staffing and pay, not training. Nurses are trained to deal with difficult situations. Maybe not this specifically, but part of the job is recognizing an unusual situation and dealing with it rationally. But after being burnt out for so long, rationality gets lost.
And not to excuse these doctors, when family tells you not to use a particular drug, you DO NOT DO THAT. And this is why: you kill people.
A caveat to this would be that "caring for the autistic and/or disabled" is generally not viewed as "high status" in human society.
If you have a disabled child, a lot of the time, the other children don't wanna hang out.
If you're a disabled young adult, nobody probably wants to date you (or at least a very limited subset). You're already below 7-8 on hot or not for most.
If you're a disabled adult, a lot of time, people don't "really" wanna deal with your needs (work/home/businesses)
If you're a disabled elderly, you're probably in a home.
Plus, a lot of societies for (pretty much since humans existed) have shunned the disabled as untouchables / failures / curses / diseased / bad-genetics / unlucky
And in human society, "high status" often correlates with "expensive" or "high wealth". Also "pretty" or "desirable".
Easy big money right now is actually the techbro field.
Becoming a doctor just for the money would be the hard-mode way to do it. (Grueling pre-med weed-outs, med school applications, med school, residency competition, residency, specializations, etc.)
Doctors do have status/respect, deservedly.
Techbro stereotype is that of overpaid dimwit, from how we assume that big paychecks confer intellectual status, and confidently open our mouths on topics that other people actually know.
The tech bro stereotype has only emerged in the past couple of decades, and even so is mostly isolated to the United States. Doctors are still the go-to "money and status" profession for most of the world.
There needs to be more than one level of doctor. No decision should be left solely to one doctor: human health is too complex for our current level of technology.
At the patient level, there is the doctor that interacts directly with the patient.
There should be a doctor whose sole purpose is to observe and support;
to consult on patient cases, contact specialists, research cases, etc.
There should be a doctor who manages a patient's overall health - but like a teacher with students, there should be a limit to the number of patients they can manage at a time.
Then there should be a doctor who reviews this process.
Specialists should focus not on direct patient interactions, but on supporting general care doctors in the technicalities of their specialty and guiding them through cases.
These different types of doctors would have training based on the role they want to fill in patient care. Doctors who interact directly with patients could have focused training in collecting information and other subjects related to the article at hand.
Many important topics are competing for the limited teaching time available in med school. Special care isn't the professional duty of a medical doctor and therefore doesn't belong in the core curriculum.
Unless these medical students have some immersion exposure into the physically-challenged (including Deaf) or mentally-challenged communities, this trend of ignorance shall continue.
How is this different from giving a patient a drug that they say they are allergic to? Doesn’t seem to have anything to do with the patient being autistic
Do you mean just from a primary care prospective and avoiding OBGYN? Also, I wonder what the difference between male and female PCPs is in that regard.
Not even OB-Gyn practitioners are trained for a woman-centered point of view. See for example the "The Miracle of Birth" segment from Monty Python's The Meaning of Life.
No offense, but what do medical schools prepare you for? I know very few people who have ever said "yeah I have a really great doctor", and then it's only because they spent time searching and learning to navigate the system.
When I go to the mechanic (honest ones) will tell me everything wrong with my car. When I go to the doctor, unless I do outside research and proffer solutions, they just send me home.
On a related note, I think a big part of the anti-vax phenomenon is how many people end up seeking care outside of the medical system because it's so broken. People find holistic solutions like diet and exercise and end up falling down a conspiracy pipeline.
I've had two doctors that I considered great, both of them got fed up with the medical system and decided to switch careers. I don't think this is uncommon either.
I dropped out after my first year (an expensive lesson, public med schools or not).
Over the past two decades, several physicians have said to me (some form of) "that makes you smarter than me, then." I always remind them that there is no amount of money that can accommodate the sacrifices made just to diagnose somebody.
No amount of money/status would make me re-do/go-back.
You can read all of the medical school accreditation criteria which explains what students are expected to learn. The human body is several orders of magnitude more complex than a car.
I didn't mean to imply that medicine should be as easy as car maintenance, just that I'm typically satisfied with my mechanic, but not with my doctors. There is a disparity in customer satisfaction.
I mean, your body is slightly more complicated than your car. If your issue is highly specialized, assuming your PCP or family med doctor will be able to figure it out is like thinking your car mechanic can fix your airplane, just because an engine is an engine.
I’d also note that cost incentives in healthcare are badly misaligned (commercial and Medicare, and generally for most other single-payer systems). There’s a reason your doctor usually only spends a few minutes with you before running out to spend a few minutes with someone else.
I have wondered why we even need primary care doctors when it seems like if you really need treatment, you see a specialist. Not to be the "disruptive technology will fix X industry" guy, but wouldn't it make sense to have nurses and techs just run a diagnostic on you and feed it into a computer, which can spit out a list of possible causes, which you then take to a specialist?
I don't really know much about this stuff so I'm genuinely curious why our system seems to suck so bad from the outside.
I think 90% of everyone’s needs are handled by primary care (family med, IM, peds) - most people aren’t going for anything really complicated, and basic preventive care like a yearly physical can be really, really powerful. I think there’s a movement to move away from needing MDs for primary care, which should generally help with availability and costs, as well, but I do think the majority of people don’t need specialty care.
I think adding AI makes sense, though the biggest focus right now (for major providers, at least) is on admit prevention (and, specifically, readmit prevention) and reading imaging. I imagine eventually you could get to quality diagnosing/suggesting, but I think it’s further away than the tech sector thinks. That said, I who knows, if an AI stops hallucinating, maybe you can get closer faster.
The biggest issue in the US, in my opinion, is that fee-for-service models are absolutely, completely broken. They (and bad reimbursement rates) encourage doctors to see too many patients, sell too many non-medical services (see how many ads your dermatologist has for Botox, for instance), and suggest too many irrelevant tests (radiology for lower back pain, for instance). You really need a massive structural change to convince everyone to move to value-based models (which also aren’t perfect, but at least align incentives).
This is a long comment (leaving a lot of space for people to nitpick and/or disagree!), but I’d just end with: healthcare is really, really complicated. Anyone selling an Easy Solution is either a neophyte (I don’t say negatively), or a huckster. What might work in SF will probably work very differently in West Texas or Eastern Montana.
"Run a diagnostic on you" is a fair summary of what primary care doctors do. It's hard because the human body is complicated, often unintuitive, and most of us need coaching to explain even our own experiences with the required precision. (My PCP saved me from a misdiagnosis once because I incorrectly told her I'd been waking up "wheezing" - apparently that term refers to a specific whistling sound and not general breathing problems.)
That is completely unrealistic. There is no magic "diagnostic" which can gather all of the necessary data. And in most cases the diagnosis isn't even the hard part. The hard parts are coming up with a workable treatment plan that the patient will comply with, and in many cases directly performing procedures on the patient's body. Primary care physicians are cheaper than specialists and so in order to hold down costs and waiting times we should use specialists only when necessary. And for routine cases the trend is to have physician assistants or nurse practitioners handle those.
I once chatted with an older doctor while we were both waiting for an oil change, and his theory was that while at least 80% of people who wanted to become doctors stood a chance of having a reasonable bedside manner when they started med school, between med school and the residency they had it all beaten out of them until only 5% retained any semblance of it.
I got a California "recommendation" once, from a gentleman physician approaching his 80's. When I asked him why he chose this particular "pot doc" persona, he asked me:
>"Have you ever heard of `the elephant graveyard`?"
His defeated demeanor still haunts me, often (and this was 15+ years ago — he's likely deceased).
Of course, some students learn these skills better than others. And even doctors who have good communication skills are under so much pressure to see more patients that they may not have time to talk much. If they only have 8 minutes with a patient then they have to get right to the point instead of letting the patient ramble on.
In sweden they teach them to underestimate what people complain about, and when in doubt send them home and if they come back try to do something about it.
Here's the breakdown (this is meant as an exaggeration and a joke, to illustrate the point):
- First 2 years of med school: mostly academic teaching so you don't kill anyone when you show up in an actual hospital.
- Third year of med school: (jokingly) you can look and touch, but even the nurses are keeping an eye on you. You just contaminated your hands by touching your beard, get out of the room!
- 4th year of med school: did you talk with the new patient? What do you think? Student: "He was a little odd, otherwise he's here for a checkup." Doctor: "He's autistic..." Student: "Oh...I had a feeling he was."
Residency: how to actually do something for patients in general.
Fellowship: how to actually do something for complex medical conditions.
Residency is what's supposed to prepare people to operate in their respective fields. And then comes fellowship for specialized care.
For anyone who wants to complain about what doctors should or should not learn during medical school: first go learn what the curriculum does teach, then ask yourself if you're even mildly qualified to make those judgements based on your understanding of healthcare, and then maybe you could comment on what would have to be left out of education to accommodate for X, because the curriculum is already super bloated and a firehose of information.