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Complications
Complications is a look at the medical profession from the inside -- written by surgical resident Atul Gawande, it is a frank, thought-provoking commentary on what happens when fallible human beings do a job that requires infallibility. In its chapters, he reveals that doctors make mistakes more often than most of us think -- and that while there are bad doctors, the more usual case is the good doctor having a bad day, or the problem for which all the training in the world would not have been enough.
Gawande is refreshingly honest about the limitations of medicine and of how much doctors, despite years of training, do not know. Witness the titles of the three sections of the book: "Fallibility," "Mystery," and "Uncertainty." He shows us myriad facts and stories that seem designed to make us lose confidence in our physicians. The study that showed that a doctor's confidence in her diagnosis was not related to whether the diagnosis was correct. The colleagues who chose to remain silent when a well-known surgeon began to show signs of incompetence, choosing instead to quietly redirect patients to other doctors when possible. The studies that show that autopsies reveal misdiagnoses in between thirty and forty percent of cases. Yet Gawande suggests physicians are doing the best they can: given the complexity of the human body, the short amount of time they often have to make decisions, and a host of diseases, injuries, and conditions that mimic each other, it is a titanic task we ask of them. Often a doctor has little more than her intuition to go on; sometimes that intuition can result in messy complications, but just as often it results in a spectacular save.
Complications tackles other issues as well: How do we reconcile the needs of patients to have experienced hands performing procedures to the needs of physicians who must teach the procedure to residents so that a new generation of doctors will be able to perform it? What does a doctor do with a patient whose symptoms show no discernible cause? How much say should a patient have in his or her medical treatment? As Gawande describes, until quite recently, the answer was "none -- doctor knows best." But whose body is it, anyway? While the reader might find himself, as I did, indignantly reacting with, "Of course I should be able to decide what happens to me!" Gawande raises an important point. Sometimes a patient really is not in the best position to decide, as when a patient in pain demands the treatment that will alleviate her pain now but cause her serious trouble down the road, unable to consider anything but how much it hurts now. The doctor's dilemma of when to step in is one I do not envy, and one Gawande describes poignantly.
While you will pick up Complications for the ideas and questions it raises, it is the stories Gawande tells, and the polished magazine writer's style with which he tells them, that will make you unable to put it down. Whether it's the television anchorwoman who couldn't stop blushing, the star orthopedic surgeon who inexplicably began doing shoddy work that hurt more than it helped, or the beautiful young event planner who was saved from a deadly infection by Gawande's lucky guess, the stories are about fascinating human beings, and Gawande tells them with riveting language.
If Complications has a weakness, it is that the chapters sometimes seem disjointed, without adequate transition between them. In the acknowledgments, the reader learns that the book originated from several essays Gawande wrote for The New Yorker. When the book is considered as a collection of essays rather than a unified whole, the lack of continuity is not a problem, and even without knowing this, it is still a more than worthwhile read.
Complications is about, as its subtitle says, an imperfect science, but not just any imperfect science. Arguably more than any other field, medicine's failures are held under a microscope and second-guessed ad nauseam; we expect our doctors to be perfect, and when they are not, our disapproval can be severe indeed. While Complications may shock you with its admissions of how deep the errors run, in the end it will give you a better understanding of what it is to be a human being doing an inhumanly difficult job.
You can purchase Complications from bn.com. Slashdot welcomes readers' book reviews -- to see your own review here, read the book review guidelines, then visit the submission page.
No man is perfect, and therefore, no doctor is perfect. Seek a second (or third) opinion.
Just my two cents
What is truely disturbing is that in this current litigious mentality of the US, doctors are more likely to address the symptoms rather than the source. Gives new meaning to 'take two asprin and call me in the morning'.
If we don't fight for ourselves no one will.
Ask a lawyer if you should sue; the responce will be "Most Definitly".
Ask a doctor to operate; the responce will be "Most Definitly".
You can't judge a book by the way it wears its hair.
That's what doctors are, plain and simple. The day-to-day responsibility for not fucking your body up belongs to you. Decisions about your well-being and best interests are your responsibility. When it's time to have major work done, ask around, find someone who won't rip you off or "replace your muffler bearings" and who is at least minimally competent, and cross your fingers, knowing you're gonna get screwed anyway.
You don't have to be a doctor to have your life screwed up over one bad decision, btw. All you need are two fingerprints and a SS number.
Back when I was in patient care, I really liked working with third- and fourth-year residents. They have a tremendous amount of knowledge but most of them haven't developed the arrogance and/or cynicism that a lot of docs get after a few years. I'd say an experience resident is in a better position to critique the medical field than just about anyone else, to tell the truth. The same is true in other biological fields (medicine is applied biology.) I'm in research these days, and let me tell you, it's the senior postdocs who really know what the hell is going on.
The correlation between ignorance of statistics and using "correlation is not causation" as an argument is close to 1.
The prestige, money, respect and social status that come with being a doctor comes with a commensurate price -- that price being an extremely high expectation of capability. I don't have a problem with this. If you aren't damned sure that you can handle the complications of an illness with a rate of success that is expected for that same illness or complication, then you shouldn't be a doctor.
I'm not advocating open season on doctors without a good cause. Some things just can't be fixed. My father had a heart attack (first and last) at the age of 38 and died in front of a 30 year old doctor who I'm told was seriously rattled by losing so young a patient. I don't blame him in any way whatsoever, my father treated his body like crap. But if a good, sincere, well-meaning doctor does fumble the ball then I don't have a problem with stripping them of the fruits of their 8 years of college.
I'm not sure that we should view a doctors credentials as any more sacred than that doctor views their patients life.
My
Limekiller
WFT are you talking about? This isn't about "shit happens", this is about some doctor giving me or a member of my family a misdiagnosis that almost kills us, or giving me powerful drugs with horrible side-effects that I didn't need in the first place. For fucks sake man we had a doctor amputee the WRONG FUCING LEG on somebody a few years back. I'd like to see him use the "human beings are deterministic" excuse in a court. You amputet my GOOD leg and the realize you still need to amputet my bad leg, I'm going to fucking sue you into the next dimension. Hell, it's the worst thing I can think of, I'd probably want to just kill you.
Finally, math books without any of that base 6 crap in them.
"we still regard the doctors of the world as, perhaps, something more than human."
No, we do not. More and more people are realizing that doctors are people, not robots.
It seems older generations (I'm speaking from personal experience here) are the ones that accept everything a doctor tells them without questioning. The later generations seem to be more involved in diagnosing (sometimes correctly, sometimes wrongly) their own ailments.
Sent from your iPad.
I hear that medical doctors have to get really good insurance in case they get a malpractice suit against them. Apparently the ability to smear a doctor's name by simply engaging in litigation is too easy. So they must maintain expensive insurance to prevent lossing their assets in the event of a lost court case, and to simply pay the lawyers. I belive it is the insurance companies that allow this to continue. They play both sides of the field. They take money from doctors when patients sue them, and they take money from patients to pay the doctors.
It isn't a lie if you belive it.
The same things that make humans fallible, also make us efficient and effective. The same "intuition" that may lead a doctor to be wrong, will many times lead them to be right. I would not want a computer diagnosing me. That human intuition may be able to quickly identify my problem, and fix it.
Think about this, if every person could write their own prescriptions (I'm NOT advocating this, just a thought experiment) they could probably treat their known illnesses well (assuming they are responsible, and a bit intelligent). It's not hard to find research data on different drugs. The information is relatively easy to come by. I could compare the different drugs used to treat my condition, evaluate the effectiveness with the risk, and make the decision. I realize that this is a huge oversimplification, but my point is that the biggest reason I go to the doctor is for his/her intuition in my diagnosis (and because I can't write my own preciptions).
Black Knight:
Oh. Oh, I see. Running away, eh? You yellow bastards! Come back here and take what's coming to you! I'll bite your legs off!
...maybe because they are serial killers?
Why Some Doctors Kill
Demon Doctors - Physicians as Serial Killers
Medical Serial Killers
Britain plans wide probe of serial killer doctor
How to Download YouTube Videos
Because it is the patient who is experiencing the pain involved, unless the physician can provide alternative pain management measures, and as long as the treatment desired is valid (no "Hit me on the head with that skillet" or "I demand you sacrifice a goat to Baal"), a patients wishes should be honored even if there are forseeable side effects to the treatment. Since the most oft used reasoning on limiting pain management is the possibility of addiction (which is not as great a risk as is currently taught in most institutions), the patients wishes should definitely be respected and the pain should be treated.
Probably the biggest problem in medicine today is lack of sleep of interns, nurses, and doctors. No joke. So many of these people lack sleep and it is killing us all.
Long Hours, Little Sleep
Sleep Deprived Medical Residents Ask for Limited Work Hours
Fatigue, Sleepiness, and Medical Errors
Doctors Are The Third Leading Cause of Death in the US, Causing 250,000 Deaths Every Year
How to Download YouTube Videos
I work in the medical industry, and my father has been a family practitioner for over 30 years. I have no doubt I've met and interacted with more doctors than the average person, and probably more than the average resident. With that disclaimer out of the way...
In my experience, there are two rather large things wrong with physicians that could be improved. Both of these would have a positive effect on outcomes. Neither are discussed much. It sounds like neither of these are touched on in the book.
First is a lack of scientific background. Now, I don't mean that some doc didn't have a BS in biology or whatever. They don't think like scientists. Far too often, physicians build up a mental table of symptoms. When a new patient presents with a condition, the table is consulted. This works fine in general, but falls apart miserably in corner cases. To solve those corner cases, some deductive (and inductive:) reasoning is called for. It is staggering the number of physicians who lack these skills. In some ways, newly minted MD's are better in this respect. They haven't had the time to develop a catalog, so they are reasoning through EVERYTHING. Sure, it makes them slower, but everything will be reasoned through. Docs with 5, 10, 20 years of experience have built a corpus of knowledge that they refuse to look beyond.
But all is not well with new docs. All physicians suffer from hubris. No kidding that this is one of the seven deadly sins. Most doctors are convinced of their own godhood. Check out Alec Baldwin's character in "Malice". Yes, it is a caricature. But there is also a grain of truth in his portrayal. For most doctors, questioning a diagnosis or treatment plan is a surefire way to piss them off. Being correct when they are wrong will drive them to either apoplepsy or catatonia. Is this something they come out of med school with? I think so. Older physicians seem to be better in this regard. There are two possible explanations that immediately come to mind. First is that they have experience to show their human failings. The other explanation is the makeup of the teachers and instructors in most universities today. Thirty years ago, they were staffed by former physicians, those who had had private practices, large patient caseloads, etc. Today, like much of academia, they are staffed by professional instructors. If you can't see the problem with this, I can't help you.
What's the solution? I really have no idea. Once the hubris disappears or is mitigated, it should be possible to learn the thought processes necessary to do good medicine. But how do you convince someone that they have too much pride? This is a real world problem for me, as my practice has several new doctors. They have potential. They can be great. But can they get past their own thoughts of superiority to recognize their weaknesses in certain areas?
Jesus was all right but his disciples were thick and ordinary. -John Lennon
There was a story on /. a while ago about the
PKI system. It's a computerized diagnosis system
that most doctors are reluctant to use because
it does a large part of their job. They absolutely
refuse to admit that the PKI system can diagnose
a patient better than they can, or even be
considered a useful tool. I can draw parallels with
certain UNIX Guru's I've had the displeasure of
working with that absolutely refuse to embrace new
technology, then go ahead and blow deadlines because
they "Know the right way to do something, and that's
their way". Figure out a way to force medical
professionals to embrace life saving technology
like the PKI, make the use of a computer a
mandatory skill for the degree program, and you
might see a lessening of misdiagnosis.
The most important thing any republican needs to know.
I have not read the book. I'm planning on it, when finances permit me to spend something on myself again that isn't required for my profession (we've all just come through the annual gift-giving frenzy).
There's a saying: You can find "sympathy" in the dictionary between "shit" and "syphilis". That pretty well sums up my feelings about sympathy in general. Unfortunately, it also sums up my feelings about the medical industry, of which, like it or not, doctors are a part.
Now, Americans live in a country where crisis medicine (medical procedures used to treat catastrophic and sudden bodily failures, like injuries due to vehicular accidents or sudden onset of acute illnesses, like appendicitis) is king, and is very well developed. Why? Several reasons.
Unfortunately, the very nature of quick fixes is that they are prone to mistake. So, we see doctors make mistakes. No reasonable person would fail to cut someone slack for making an honest mistake. Of course, that's the rub. Most people aren't all that reasonable, period, much less so when they're in pain.
But the flip-side to that is what I'm going to focus on, and it's a point alluded to in the review above. When doctors make mistakes that aren't honest. Maybe they were being sloppy. Maybe they were in too much of a hurry, not for good reasons, but for a golf game. Or maybe he just had to get to the bank. In the cases of the most notorious failings, like Dr. David C. Arndt (mentioned in the linked story), national coverage guarantees that he won't work in this, or any, town again. But what about the ones who don't make the headlines?
In 1994, I had surgery to repair a hernia. It was a dime-sized hole in my left lower abdominal wall. The surgeon that my GP sent me to declined to do the surgery laproscopically, even though it was acknowledged as a method of reducing the recovery time. "We've had problems with the procedure," he told me. So I had the old method used, an anterior incision that was 4.5" long and had a piece of nylon mesh sewn in to close the hole. The surgeon prescribed codeine for the pain. Not co-tylenol, just codeine. When my wife went to the pharmacy, the clerk told her that no one had prescribed that alone in over 15 years. I later found out that the surgeon definitely had had trouble with the laproscopic procedure: he had been the surgeon working the procedure when he clipped the artery of a patient, nearly killing him on the table. Of course, I was never told that. I was never offered that information, and if I had asked, the surgeon, the hospital, the medical community as a whole would have zipped their lips to protect one of their own.
There is where the doctors fail in a way that could be avoided. Be honest! Be open! Educate me in the why's and wherefore's of your past mistake, and I'll be much more likely to give you credence in the future. But if you keep it quiet, and I find out later, then you're toast. I'll sing like a bird to anyone who will listen, and that's when the power of "word of mouth" advertising really shines.
Sympathy for their mistakes? Sure, if it's warranted. I'll cut that much slack for anyone. But if you hide it all from me, I'm going to assume you don't want me to know, and I'm by nature a very suspicious person...
Believe nothing, not even if I say it, if it violates your sense of reason -- Buddha
Unlike doctors, lawyers don't take a hippocratic oath: "Do no harm."
"And like that
I'd LOVE an all encompasing view of the Healthcare/Insurance industry. I'd suspect there's a lot more there than meets the eye.
From a Doctor's standpoint, they often have to make a determination even when the patient refuses to believe they have what the doctor claims. Bro-in-law just got treated for stage two syphilis - he swore up and down that he'd been celebate for the last four years...Even after we reminded him of the 'evidence' we found after he house sit for us (for the last time.) So add signal-to-noise ratio from patient.
OTOH, I've got two brand new Twin boys. They were born almost five week prematurely. They've spent the last 9 days in the Neonatal ICU while their systems catch up with their birthdate. The insurance company has been charged $5k per day, per kid for the 'hotel stay'. Nearly $100k so far, and that doesn't include the C-section, the two OBGYN's, the endocrinologist or the geneticist. I have no clue what the final tab will be, only that the insurance company will cover it, and we're out about $200 in co-pays.
I'm curious if there's an additional negotiation AFTER that bill, perhaps there's an additional 80% 'hospital to insurance carrier' discount we don't hear about...If not, I can't possibly see how my $400 a month in insurance premiums could HOPE to cover the medical expenses (20 years at $400 a month is only $96000, heaven forbid I got sick AND had twins.)
"Draco dormiens nunquam titillandus."
You need to think of doctors as garage mechanics that specialize in specific areas of the car (hi, I'm a fuel-injectionologist but this surgery will require a sparkplugologist).
He/she does not have a complete manual of the 'car'. Constant updates to the 'manual' are occurring but they are often contradictory and not settled upon as fact. Also, due to the heavy specialization diagnosis can often be off because the mechanic/doctor has never seen the problem before and will try to fit the condition into the wrong pigeonhole.
Under these conditions, are you going to accept the word of the first doctor you see? You shouldn't. Depending on the seriousness of the condition, getting second and third opinions are lifesavers.
The fix is going to have to be a revolution in diagnostics, where vast comparative databases are at the doctor's fingertips, and the whole weight of medical wisdom is brought to bear on each person's case.
We will need doctor success rates for the purpose of identifying doctor mistakes quickly for correction not punishment, means to make sure people are not turned away because they will likely lower the doctor's 'batting average', truly incompetent dangerous doctors are weeded out less expensively, and an understanding by the general populace of the risky nature of any medical care.
________________________________________ History Must Not Fall Into The Wrong Hands ___________________________________
I expect a doctor to follow a similar process, maybe even more rigorously -- ater all, no one dies if my database does down in flames. However, there is the additional constraint of time, which may require parts of the process to be sacrificed. In my mind, competence is following this process and making sound judgements. Incompetence is hurrying so he can make his tee time.
Unfortunately, determining competence is complicated by the fact that it is fairly subjective. Someone has to look at all the facts and decide, did this guy screw up negligently? And that's the jury. Not that I think our court system is very good at getting to the truth and assigning proper damages.
I think that if something went wrong while in a doctor's care, if the doctor went to the patient, honestly explained the situation, and apologized sincerely, many (I won't say most) people would accept that. But hospitals are so terrified of lawsuits that they would never allow a doctor to do that, because it would be a huge liability, tantamount to a "confession" that could be used in court. And many doctors, I think, don't feel enough compassion for their patients to want to make that kind of gesture (maybe not, but that's my impression, given that doctors spend very little time with each patient).
So we're left with a situation that if anything goes wrong, we don't work it out mano a mano, but we go to court.
I nearly had a root canal explode when it was capped and fluid collected.
You can't judge a book by the way it wears its hair.
A resident is the equivalent of a senior postdoc, not a grad student. One year of internship plus several years of residency for most fields -- even general surgery requires a four-year residency in most cases, IIRC. And I can almost guarantee he's not a first-year resident, because there's no way in hell he had time to write a book during internship. He's probably not a second-year either. If he's a third- or fourth-year, then he is eminently qualified to write such a book.
I think the original point still applies. Yes, a postdoc or a resident is more familiar with academia but it IS THEIR LIFE. So in my opinion when I read something negative from them about it, to me it smacks of using controversy to gain notoriety (we all know that fame or infamy are both self serving in todays society) the more known you are the better your odds in life.
1. The psychiatrists are often idiots. It is amazing to discover the number of psychiatrists who went to med-school in the third world. Rough estimate: 75%. After three psychiatrists I couldn't understand, I ran into one who did speak English. Of course, he was also a wacko running what appeared to be a cult out of his office.
2. The psychiatrists are often wrong. The first psychiatrist I went to (for ADHD that had been thoroughly diagnosed by two separate psychologists before I was willing to pursue medication) decided after 15 minutes that I was bipolar. He then prescribed a mood stabiliser that made for the worst month of my life. I would sit there, all day, unable to feel anything. I was calm - but I was miserable, couldn't sleep, and developed carpal tunnel from the water retention that was a documented side effect of the drug he gave me. Turns out this drug was brand new, very expensive, and heavily advertised.
3. Let's say I am mis-medicated and develop manic tendencies, and go on a rampage. (A distinct possibility with some of the meds used.) Who goes to jail?
The doctor?
Hardly. I go to jail. The p-docs want total authority, but it is hilarious to watch the way they dodge responsibility.
The bottom line is, I refuse to surrender my control to any idiot with an MD. I now have a doctor who has finally figured out that (a) I have done my homework, (b) I am more aware of what's going on in my head than ANYONE else, and (c) he can prescribe medication, but he can't make me take it -- I'm adhd, not psychotic and not committable. I can be fairly functional with no meds at all so long as I don't go to school. So he has to convince me that the med he proposes is the best course of action. He is okay with this, and he has to be if he wants to continue getting my money.
The sad part is that, if I weren't so stinkin' stubborn and didn't read so much, I would have either roled over and played dead or given up on the whole process. The point of all this is not that all psychotropic meds are bad - in fact, getting the ADHD medicated has made a tremendous contribution to my welfare and the welfare of my family - but that you shouldn't trust someone just because he's a licensed physician.
"He who would learn astronomy, and other recondite arts, let him go elsewhere. " -- John Calvin, commenting on Genesis 1
Ok, you can give me a -5 for this, and I sincerely am not trying to be mean here, but...
They got lung cancer from cigarettes. Yes, the manufacturers lied about the complications, and they should pay for that. The fact of the matter is your grandparents chose to smoke, and it is very obvious that inhaling smoke is bad for you, even without a warning. I do not need a warnig label telling me that drinking gasoline is going to kill me, and I didn't need a warning on cigarettes to tell me that they weren't good for me either.
I'm sorry if I offended you, that was not my purpose. I understand your plight, but I do not think that was the point of this book.
Great Linux Site
Yes but...
The system is currently set up so that if you're brave and forthright and honest and decent and take the high road and say 'Yes, our product is intrinsically dangerous, but people are adults and can make their own choices.' you will be CRUCIFIED in court.
The lawyers on the other side will take the low road and say 'SEE??? HE *ADMITS* IT!!'
That's because people are not adults but babies in the eyes of the State. The State is intrinsically motivated to see people like that because it gives the State an excuse to slap a few more bars on everyone's cage 'for their own good, of course! Not because we are lusting after power at all!'
Because of this behavior corporations must also take the low road and do things like lie about cigarettes so they can shrug in court and go 'We had no idea, your Honour!' and calculate the cost benefits of fixing the Pinto against paying the estimated law suits, etc.
People deride this as soulless capitalism but they are the first in line to put the diapers on when it looks like a payday at the expense of the suits.
It's Christmas everyday with BitTorrent.
I have stayed away from them for several years now with no problems, but the last 3 times a dentist operated on me I had bad experiences.
A capped root canal almost exploded. While removing the root canal another dentist caused me to vomit. None of the @#$@#$ing morons believe that novocain has no effect beyond a slight tingle on me and I feel every @#$@#$ing moment of it!
My Automotive Mechanics teacher told us on the first day not to screw anyone over. The previous experiences of his customers caused them to be wary around all mechanics, even those such as himself that ran an honest business. I apologize to all nobel doctors, mechanics, dentists, lawyers, and (if they exist) M$ programmers. Nah, just the first four.
You can't judge a book by the way it wears its hair.
ummm, you would lose the law suit anyway....you wouldn't have a leg to stand on!
Being correct when they are wrong will drive them to either apoplepsy or catatonia. Is this something they come out of med school with? I think so. Older physicians seem to be better in this regard. There are two possible explanations that immediately come to mind. First is that they have experience to show their human failings. The other explanation is the makeup of the teachers and instructors in most universities today.
My mother came out of residency (as a psychiatrist) about 6 years ago. From what she has said, your first explanation is plenty on its own. Being in medicine constantly teaches you how human you are. You start out thinking you will be the perfect doc, and then you make a mistake. You decide you will never make a life-threatening mistake -- and then you do. You revise this and decide you will never make mistakes because of tiredness, or ignorance, or sheer gutwrenching stupidity -- and then you do all of these. Then, well, you will certainly never make the same mistake twice, right?
Eventually, if you're honest, you have to recognize that you're human, and sometimes you're going to screw up. I wonder if this is a process that psychiatrists navigate more easily than surgeons?
This is the modern over-reactionary, ambulance chasing culture of America. If you can't blame God, then its obviously the doctor's fault...
There are doctors in certain states who are retiring early or leaving because of malpractice lawsuits. For example, many states of shortages of OB-Gyns b/c everytime a baby comes out retarded its blamed on the doctor, rather than their pot-smoking, alchohol drinking, stale sperm or old age of the parents. Its sick! Its hard enough for a doctor to pay their student loans AND make a nickle off the HMO's, but now they get rejected for malpractice insurance applications as well.
Hey Asshole, whose going to be a Doctor if all doctor's are human and all humans make mistakes, and we burn every f'ing doctor that messes up? We're not talking about a doctor who leaves a surgical tool in somebody's stomach. There's paying for negligence and then there's paying for society's bullshit reasoning. When one doctor can't get malpractice insurance it's because he/she is negligent. When an entire county/state of Doctor's can't get malpractice insurance its because the litigation is so rampant and fraudulent that insurance companies know they will only lose money by insuring the doctor.
Your attitude is the cause of this.
that there are times when a corporation deserves to be sued for their outright lies.
With surgical robots appearing more frequently, how long before M$ convinces a manufacturer to run windows on it? They are also guilty of lieing to consumers about side effects; how long before similar consequences insue?
I never met my grandparents; I can live with that. It's much harder to see the pain behind your father's eyes when he mentions them. It's much harder to know that such pain was caused by an industry's greed.
You can't judge a book by the way it wears its hair.
No, its not the insurance companies that are the problem. An enormous number of OB-Gyns in the country can't even get malpractice insurance anymore because nobody will insure their business! Its not the Insurance Companies, its the Lawyers
Imagine a programmer trying to fix a huge piece of software that has been developed over a long time with little modularity. The programmer has only a marginal understanding of how it work. The programmer is kept awake by Jolt and deadlines. I think it's a fair guess that they are going to be making lots of avoidable mistakes. Well, welcome to the world of medicine.
Ok, it's time for a physician to open his yap. There's plenty of hubris, and doctors are just mechanics and get paid too much/too little. Doctors should pay, blah, blah. And the like already spewed onto this thread. Here's my take.
First, I ran through the numbers a few weeks ago. Financially, if one became an RN (Registered Nurse) instead of a Physician Family Practitioner, you would be financially ahead of the physician by the time you account for deferred earnings and accrued educational debt until that physician had been out of residency for 10 years. That means that the nurse who began a career on graduation with a BS at 23 would be 41 before their counterpart that did premed and went to medical school would be financially even with them. Smart investing and good use of shift differentials as well as perhaps a masters degree in nursing could put them ahead indefinitely.
Further, medicine isn't recession proof. In the metro Seattle area, over 40 primary care doctors have become unemployed because the closure of a couple of large groups and layoffs by the big local HMO. Those guys don't just bounce into new jobs overnight.
The money in medicine is going elsewhere (lookup Tenet (NYSE: THC)). It's funneling into giant management corporations and insurance houses. Those of us out working with patients see very little of the money that comes in. Most family practices have overheads in the 50-60% range would greatly cuts the amount to the physician paid by the insurance. That combined with the endless gameplaying where insurance companies pay only a fraction of billed amounts.
As for the implication that doctors would rather operate than anything else is silly. I do office procedures, yes, but those are time consuming and pay relatively poorly. Besides, it's still possible to do the right thing without constantly thinking about the bottom line. I'm sure there are unscrupulous doctors out there, and frankly I've seen some questionable things done over the years but it's hardly the rule.
Most docs are out there humping it just ot make the debt service for their student loans. The days of fat cat doctors who made millions is long since over. I'd recommend getting ahold of a recent copy of Medical Economics to anyone who'd like to get a sense of what primary care physicians are up against. For those who intentionally decided on engineering instead of medicine, you made the right choice. A decent engineer makes as much or more than a family doc and has no call and minimal liability.
Actually, it's amputate, not apmutate. If you're going to correct someone on their spelling, make damn sure you proof-read that shit a few dozen times to avoid looking like a jackass.
Finally, math books without any of that base 6 crap in them.
this is what happens. People have high expectations because they pay a good deal of money to doctors to provide them with health care. Doctors feel they're entitled to exorbitant fees because of the years of training they've had to endure, and the extremely high cost of medical school.
The healthcare system in general, is out of control. We've got managed care facilities who attempt to minimize costs, rushing patients through the process whether or not they've accurately diagnosed or treated the patient's illness. We've got hospitals that charge whatever they can get away with for a given treatment regimen. We've got a growing population that thinks it's everyone else's responsibility to look after their medical needs after years of abusing their health. What does this have to do with doctors and their ability to practice medicine? One might reason that it's just one more facet of the same problem- a large disconnect between the medical community, the people they serve, and the individuals that ignore the responsibility they have toward their own physical well-being. In short, if we took better care of ourselves, it's likely that we'd spend less time in the doctor's office, thereby lessening the potential for any of the anomalies cited by the author.
The amount of medical literature doubles every 8 years.
By the time I finish my residency,the information available when I started medical school will have doubled.
A writer of a textbook put it best when, to paraphrase, he said "If one were to read for an hour a day every day for a year, he'll be 8 years behind at the end of that year alone."
Linux - Because Mommy taught me to Share.
...he works at the same facility as my wife (who is also a doctor, but with a different specialty), and his book really does tell it like it is.
For those of you calling for doctors to be punished when they screw up : grow up, please. Life is never that simple. There are some bad doctors, but even the very best make mistakes, often for reasons beyond their control. If you read the book you'd understand a bit more about how seriously screwed up our medical system is.
Take the Residency system, for example. Simply, the Federal Government pays for a certain number of Residents (recently graduated MDs seeking speciality training in their chosen field) for each hospital. They are essentially 'free' labor for that hospital, so they are worked the hardest. The janitors earn more than they do, on an hourly basis (and even with the new hour restrictions coming in, $40K a year for an 80 hour week where you could kill people through tiredness isn't all that swell).
As the cheapest labor in the hospital, Residents spend a lot of time doing 'scut' work that should be done by porters or nurses, rather than doing what they're trained to do - you could do a lot of good if you spent that entire 80 hours a week being a doctor, but you'll be lucky if you spend half of that time actually using what you learned from med school. It's grossly inefficient, and since the alternative would cost hospitals money (they'd have to hire, and pay for, more porters or nurses) there's no incentive to change. That's just one of the many, many things that makes the delivery of medical services in this country so damn expensive and inefficient.
And that's not even mentioning the patients on State medical insurance who call out an *ambulance* in the middle of a *blizzard* because they have a freaking *sore throat*. My tax dollars at work. Gah.
That's what they are. Flesh mechanics. No miracles, no Dr. Welbyisms, no last minute screaming in the ER, no poignant weepy nosed chick medicine.
Flesh mechanics. Some of them know WTF they are doing and some of them, like we used to say of all obstetricians, only need to know how to 'Catch!'.
And you are a bucket of loosely organized uncooperative parts.
rnicey is spot on the money.
I believe Atul is in his fifth year of his seven year surgical residency (I'll have to check on that, though - my memory is unclear). That's five years of floor surgery experience, cutting people open to fix things at one of the best hospitals in the nation.
:-)
Bear in mind that he works about 100 hour weeks (there's a big fuss going on now trying to get them down to 80 hours a week, averaged over four weeks). So really it's the equivilent of TEN years of 'regular' work experience. Plus he's surrounded by some of the best people in his chosen profession.
He is not an 'academic' by any stretch of the imagination. Frankly, I'm surprised he found the time to write for the New Yorker - I think he just doesn't sleep. But then, surgeons are weird.
Finally I visited one doctor who told me I needed to drink more water, have a humidifier in my room, and change my diet to largely plant based. In a few days my kidney problems ceased without any drug or surgical interventions.
Over the years since then, I've read, and noticed that the majority of health problems can be easily solved by the patient themselves. Just a little research from your local bookstore, or even the net can go a long way.
Doctors should really only be used to help diagnose your symptoms, and to treat those problems that you cannot yourself.
Instead, many of us see the latest drugs on TV and rush in to the doctor wanting him/her to prescribe them. All drugs are toxic and most have unintended side effects and consequences. If you dont believe me, check out side effects for a few popularly prescribed drugs that patients could easily be solving in more natural ways:
Zocor - http://www.medications.com/index.php?act=se&drug=Z ocor
Yasmin - http://www.medications.com/index.php?act=se&drug=Y asmin
Paxil - http://www.medications.com/index.php?act=se&drug=P axil
Levaquin - http://www.medications.com/index.php?act=se&drug=L evaquin
Sure, drugs have their place in certain circumstances, but doctors being in thrall of the pharmaceutical industry really set themselves up for lawsuits from uninformed patients who sometimes pressure them, and many times, medications are seen as the easy way out to shup-up a complaining patient and move on to the other one.
Fellow slashdotters who are ill, should talk to their doctors, and research natural alternatives from a variety of sources before submitting to surgery and medications. And if surgery and medications are unavoidable, get second and third opinions for convention and alternative physicians. You can save your life that way. Check out sites that expose certain health myths, such as The Physicians Committee for Responsible Medicine for more information.
Newsfollow.com
He is not an 'academic' by any stretch of the imagination. Frankly, I'm surprised he found the time to write for the New Yorker - I think he just doesn't sleep. But then, surgeons are weird. :-)
If you understood me to be calling him an academic, then I miscommunicated. I was agreeing with another poster who compared a surgeon writing about the med. profession to an academic writing about academia. I was stating that I did (and do) agree with the comparison.Sorry for the mix up.
Ok, here is how I feel on this subject. These are true facts from my own life.
:-)
1. My father was killed by a doctor. He had an aneurism behind his right knee he did not know about. He went to change a tire on my mom's car and when he squatted down his entire leg from the knee down turned white. He stood back up immediate, went inside, got my mom, and they went to the hospital. The surgeon on duty said he knew exactly where the problem was, didn't wait for x-rays, and operated in the groin section. First indication of a bad doctor. My mom, like my dad, believed doctors were gods. When the aneurism was not found they put my dad in Intensive Care (IC or ICU) and did the x-rays. Then the doctor botched the job by sewing my dad's main artery almost shut. He got gangrene and a blood clot detached. He had a stroke and died. My mom never sued. This is why I do not trust doctors and I always get three or four opinions. It is expensive but it is worth it. I don't want to wind up like my dad.
2. I have phlebitis. Major phlebitis. I, luckily, found a competent doctor who put me in the hospital. My blood was so thick they couldn't get any out to test how quickly it would coagulate. They thought I was going to die but I didn't. This was after seeing three other doctors.
3. A while later I was put on something called hydrochlorothiazide or HCT. It is a diuretic and has some other side effects. If you go to the Food and Drug Administration's website you can read up on just how bad this drug is if you get on it's bad side. One of those is that it makes you a bit dizzy as well as complacent. My great doctor I'd found turned out to like to fondle his male patients. I found another doctor.
4. The new doctor decided that since I am fairly well read and can think for myself that she would rather I just died - and told me to my face. She is no longer with the clinic I go to.
5. The next doctor I had I'd gone to twice when my leg with the phlebitis swelled back up. This was great cause for alarm with me. The doctor sent me to get a Venogram (sp?) done. The tests were inconclusive so he said "Take two aspirin and call me in the morning." (Honest to god! He actually said this to me!) I reminded him that I could not take aspirin since I am on Coumadin (a blood thinner) and I would die of internal bleeding (which he should have known about). He changed it to Tylenol. He's not working at the clinic any longer either.
My current doctor has been my doctor for the past two years and we have gotten along well.
Enough stories - here are my thoughts:
1. Doctors should have access to several databases. These should have diseases, muscle, nerve, bone, viruses, medicines, and other categories which I am probably leaving out.
1a. The databases should have symptoms, causes, effects, treatments, and most importantly, side effects, problems, reactions, and any other bad things that can happen from doing whatever it takes to fix the problem.
2. A drug interaction database. So doctors can know exactly what might interact with what and how to treat the problems that occur. (With hyperlinks to relevant information so they can verify the information for themselves if they need to do so.)
3. A database with methodologies on how to improve the human body so they don't have to just push pills on everyone. This should be open to the public as well (readonly status of course) so people can get on-line and find out how to keep themselves healthy.
4. Now, the important part: Make this available via wireless PDA to the doctor no matter where he is. So they can just plug in what is wrong and the AI breaks things down into percent chances (%c) of what is the matter. The reason this is so important is because I have seen (and I am sure so many others have) that your doctor only kind of knows you. If they are seeing over a hundred people a month they can not keep straight who's problems belong to whom. But a computer can. And it can recall that information and it can help the doctor to make the decisions he/she needs to make in order to help you out.
And that is the real problem here. Doctors become overwhelmed. Open your eyes and look at them. They are still doing everything with paper and pencil. Many times they can't even read their own writing. And charts? Do they have a nice bar chart that shows them how you are improving? No. They have to look at a bunch of separate papers, correlate all of that information into something useful, and then make a decision based on that information. If you think that's easy to do then have someone take twenty sheets of paper, write random numbers on them, shuffle them together, read each sheet of paper and add the numbers together in your head as you are going from one page to the next. Guaranteed that around pages eleven or twelve you will begin loosing what the number was because you also have to turn the pages, do the math, and continue going. But a PDA could do it in a few milli-seconds. Now try doing it with blood pressure, chloresterol, and other vital statistics. It's not possible. So they generalize. So long as you are up and breathing then you must be doing well. Here's a few pills, talk to you later.
It needs to stop. People cry "No! No! No! I don't want my personal information in a database!" Too bad - it already is there. What you should be crying about is the lack of proper security. We have credit cards - why not medical cards which have all of your information on the card? Can someone say flexible-CDs? Even if the card is only used as a key so only you can unlock the information - that would still be a great leap forwards for everyone. You go in, give them your card, your information is downloaded to their system, and your current information is available to the doctor. No more paying $50.00 or more to have your records transferred from place to place. Just so long as it is secure I'm all for it. Or put my information on a CD, have a good container for it (aluminum maybe?) and allow me to carry it from one place to the other. Or maybe we could go to memory sticks? These 256mb or more secure digital cards may just be the answer. Again - you carry it with you and the label says it all. "Medical Information"
Something to think about.
Someone put a black hole in my pocket and now I'm broke.
My mate is currently attending a four year university with a direction in biology and chemistry. She has considered directions such as pharmaceutical industry work, chemistry related product development, research, and anywhere in related fields of biology and chemistry.
One thing that she has said that she would like to do, but will not do, is be any sort of general practitioner of medicine -- that is, be a doctor. She references her previous experiences when following around a doctor at work in a hospital. While the idea of helping people and practicing upon the human system, which she likes a lot, is positive, the surrounding circumstances that doctors are put under are totally negative.
This negativity comes from the long hours of required work (don't work 12+ hours a day = get fired), the average pay in comparison with the work output required, the possibility of being sued out of existence (unless you practice in California), and most of all, the treatment decision making process is put into the hands of "Heath Medical Operators" (HMO) and other individuals who have no medical qualification to be making such decisions.
You get to work with the patient, make a decision about their condition, make a recommendation for treatment, and then someone out of state by means of fax, eMail, or phone (who was probably selling insurance or flipping burgers in their previous job) gets to tell you what to do -- with an absolute underlying interest in their own companies's profits rather than the patient's health.
The system of government and corporate intervention in it's attempt to force down costs for those who need medical attention has had the exact effect that one would expect it to -- pay less, get less. The quality of care that a doctor can give is greatly diminished because of the terrible American health system.
The result is that she has no intentions of going into the field of being a doctor. This perspective that she has is not a rare one, and individuals in the general populous are also understanding that being a doctor is a bad job because of the insane work requirements and terrible politics involved.
Who would want to be a doctor in the United States?
Nobody.
I suspect this is going to be a problem for a long time.
There seems to be a lot of assumptions towards physician salaries, intentions, etc.
Salaries
The average physician makes about $150,000 per year. I know that seems like a lot. But think about this. The average physician has $150,000 in educational debt after they finish residency.....that's when they turn 30! So, you're thirty, have tons of debt, no savings, and you are just starting.
How does one determine how much a person should earn anyway? It seems to me there are 4 factors that SHOULD govern this process.
1. Physical exertion
2. Level of training/education
3. Level of responsibility
4. Contribution to society
It seems to me that for a physician 2-4 are very high.
Lastly, I can't stress this enough. PHYSICIANS ARE NOT INTO MEDICINE FOR THE MONEY!!!!! I couldn't have made it through medical school and residency if money was my motivation. Almost all physicians due this for some higher/noble purpose of helping others. It was that reason that let me get through not seeing my wife and new daughter in residency. It was that higher purpose that allowed me to be worked like a slave.
Responsibility
Bad things happend....that's life. I know that everyone has a story about a relative or friend that had a bad experience in medicine. Why do people automatically start looking for someone to blame? Doctors are able to predict a lot of things with the human body. There are a lot of things they cannot. There is a saying in medicine:it's half preventing fires and half putting them out. Unexpected things crop up all the time....it's unavoidable. Yes, sentinnel type of events like amputating the wrong leg have blame, but most bad things that happen could not have been predicted by anyone.
Flesh Mechanics
I hate this comparison. Why? Because it implies that the human body is just as simple as a car engine. It implies that every body is the same. Imagine you are a mechanic. You know that the car you are working on has an engine, electrical system, and exhaust. Now imagine that you kind of know how everything is connected but aren't sure because no 2 cars are the same. That's the way people are. EVERYONE is different. Reactions to medications are different....both good and bad. Reactions to surgery are different....both good and bad. All physicians have are statistics on how these things affect MOST people....not all. Ever hear of the uncertainty principle? Well, it's present in every aspect of medicine and no amount of research, knowledge or training will change that.
Many people have a problem with personal responsibility. It's your God given right to smoke, drink and do drugs. It's your God given right to drive without a seatbelt and participate in unprotected sex. But how do these behaviors magically become the doctors fault? A good example is the lawsuit against the tobacco industry. Yes, they hid research that suggested nicotine was addictive. Yes, they did not tell the public that tobacco was bad for you. There is one person that did.....the Surgeon General of the United States.....back in the 70's. So, it seems to me that if you started smoking after the 1970's, you knew the facts and CHOSE to ignore them. Why should you be entitled to any of that settlement. Yes, THEY were wrong but YOU made the choice and now have to live with that choice.
Physician Intentions
I know I touched on this earlier, but I cannot emphasize this enough. Every single doctor that I know (including myself) is in this field for the most noble reason I can think of....to help people. Most of us try to educate our patients so they can make informed decisions.....and they are YOUR decision. The "paternalistic model"(doing what the doctor says) of physician interaction ended in the 70's. We now live in a world where medical information is easily accessible by the public...and this is a good thing. What is frustrating is when the doctors information conflicts with the patient. I know many people feel this is just the doctor being arrogant because they "know best." Medicine rarely changes the way it treats a patient based on one study. Not all studies are good ones. All studies have limitations. Physicians know this and merely want to better educate you.
Litigation
This is a difficult topic....simply because I don't know the answer. Suing a doctor into oblivion isn't the answer. What does that get you? You have then successfully punished a doctor for all eternity and ruined his/her career and livelyhood (docs have families too) despite all the good he/she has done because of something he/she may not have done wrong. That hardly seems fair.
I have made mistakes.....none of which hurt anyone...but mistakes that I lost sleep over...not because I might get sued, but because something bad might have happend to a fellow human being.
I would also like to flip the coin here. Let's assume that I see you as a patient. Let's assume that you see me over the course of your life, follow my advice, and I treat appropriately your diseases appropriately. Let's say that all of that care EXTENDS your life by 10 years (I'm being conservative). How much is 10 years of your life worth? It seems to me that if you can sue me for taking 10 years of your life away for millions of dollars, why wouldn't giving you 10 years of life be worth millions of dollars? I am not trying to suggest that I bill that amount....that would be ridiculous.....I merely want to illustrate the point that legal action settlement are a little over the top.
Thanks for reading.....I just want everyone to know that the great majority of physicians care about you and about what you think.
-A
Say you had an allergic reaction to Novacaine. Then they'll use something else.
Physicians take the hypocratic oath.
Surgeons do not. The hypocratic oath contains
the phrases 'I will not cut, not even for stone.'
So those folks doing surgery can't take it or they're out of business
___
It's the end of my comment as I know it and I feel fine.
Surgeons do dumb things, and all the surgeons get together in conferences about the dumb things and critique each other in a kind of Quality Circle, and nothing changes -- the advice is "Don't do dumb things." Nothing changes.
This engineer dude looks at how anesthesiologists kill patients. Well, they get the tube down the "wrong throat" -- not much we can do about that, but if we can monitor blood O2 level (see if fingernails are turning blue with a photocell), we can warn of this condition. We can also put a limit on the O2 dial that it gives at least some O2 at minimum; we can standardize the dials to min O2 and max O2 is the same on all machines (so much for all this whining in the Linux world about the need to "customize" every last UI).
Turns out anesthesia is killing only a 10th the patients it did 10 years ago. All from looking at where the fsckups are taking place and standardizing the "user interface" to anesthesia machines. All of the critiquing and peer evals the surgeons are doing is pissing in the wind by comparison.
In Soviet Russia, accusations take responsibility for you!
You can't judge a book by the way it wears its hair.
I have a friend who works in medical billing (including a long stint at Mount Sinai in NYC).
Screwups in the paperwork costs an amazing amount for both hospitals and insurance companies. Patient theft is another big loss.
Patients changing insurance companies every year or more just adds to the screwups.
It starts when a patient is admitted, and the poorly trained (Thankx Anderson Consulting!) receptionist gets the forms wrong, usually by sins of ommission, or glitches with the insurance company's pre-approval process. Then the correct medical billing code (very thick books with the standard codes are updated every year) needs to be used. While the billing systems have fields for extensive notes, since they aren't required to be entered, allmost no one does. Nor do they bother to read them.
Hospitals have contracts with insurance companies which are similar to Microsofts OEM contracts, details are hidden by an NDA. These provide substantial incentives *PROVIDED* claims are submitted on time, if not, then the hospital doesn't get 100% re-imbursment. Even if the hospital makes the deadline, the insurance company will claim it didn't. Since often neather side's peons has a copy of the contract, and the hospital's peon has more incentive to simply clear another case rather than save the hospital $20K or $30K, the point isn't argued.
At this point, the insurance company now has a payment deadline, unless there is a mistake found in the claim. Or the patient's chap 11 dot com "forgot" to send in their insurance payments. Or a claims reviewer is using an old copy of the codes. Or the pre-approval code doesn't match the final code because the code number changed during the process. Or......... (Hmnn, what's the intrest on $50K for 6 months?)
The real fun starts when a patient gets the re-imbursment check. Lets see, on one hand a terminally ill person can use the $100K on trips and quack treatments, or he can just send it into the hospital where maybe an underpayment mistake will be found. Or the patient can just "forget" they ever had a procedure done. (true story, patient needed to be reminded that a 6'5" 260# doctor shoved a 2 foot tube up her ass before she acknowledged that there was a reason she owed the hospital money. Makes me wonder what she usually shoves in there since the experiance hadn't been memorable)
HMO's and hospital love the pointy-haired logic that a surgeon can be paid a fraction of his standard rate since he can "make it up in volume". And if a surgery goes over the esimated time, he doesn't get paid extra since he can just work faster on the next one.
To sum it up, hospitals are effectivly giving insurance companies discounts by screwing up their claims and collections, and cutting doctor's fees.