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Things I've noticed while visiting the ICU (trevorklee.substack.com)
339 points by exolymph 70 days ago | hide | past | favorite | 371 comments



I'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit.

There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it will certainly be lost as soon as you are off for a few days, or even as soon as a new nurse comes on. To think of a somewhat crude example, if you find out that it is much easier to obtain a blood sample from the veins on the left arm of a patients vs the right, many nurses will still stick the right arm countless times hoping to get something.

And you can leave a chart note about things like that or speak about it during report, but for the most part few people will think "hm, I wonder what everybody else had to deal with." They are probably too busy handling a thousand different things happening all at once. And, even if that is not the case, from what I observed it's simply not part of how things are done. And very often patients will get (justifiably) angry, saying "I've been complaining of x thing for days!" or some version of that. I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.


> I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.

I once had a week as a patient at the Mayo Clinic in Scottsdale AZ. There were many remarkable aspects of care there versus the impossible mess out here in the other world.

But the single most significant aspect of care at Mayo Clinic is that the doctors and nurses and techs get to read your chart before seeing you.

That's it. You write something in the chart, it doesn't get tossed. It might not get parsed completely, but the essential info is there. And the staff does not get penalized for reading it.

(The other big reveal for me at Mayo was the sheer scale and throughput of the system. Healthcare at Mayo did not cost more than healthcare in my small town. It. Cost. The. Same.

It took six months to get in, I had a week, then it was someone else's turn. I presume that the high paying "celebrity" customers can get seen more regularly. So it's not perfect. But holy cow I wish it were easier for healthcare professionals to do their job.)


In general for US healthcare providers there is little relationship between price and quality. They have to meet certain quality standards in order to operate at all, but outsides few limited areas they don't get paid more for delivering higher quality care. So quality (or lack thereof) tends to come down to organizational culture and management.


For someone that hasn’t heard of they Mayo Clinic other than through webite articles describing medical conditions, are they that desired/high-quality?


I'm not sure if you live in the United States, but Mayo Clinic is probably a top 5 hospital system in the US. It is legendary. Just read the opening paragraph from Wiki: https://en.wikipedia.org/wiki/Mayo_Clinic

    The Mayo Clinic (/ˈmeɪjoʊ/) is a nonprofit American academic medical center focused on integrated health care, education, and research.[6] It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, across three major campuses: Rochester, Minnesota; Jacksonville, Florida; and Phoenix/Scottsdale, Arizona.[7][8] The practice specializes in treating difficult cases through tertiary care and destination medicine. It is home to the top-15 ranked Mayo Clinic Alix School of Medicine in addition to many of the highest regarded residency education programs in the United States.[9][10][11] It spends over $660 million a year on research and has more than 3,000 full-time research personnel.[12][13]
A little deeper:

    Mayo Clinic has ranked number one in the United States for seven consecutive years in U.S. News & World Report's Best Hospitals Honor Roll,[19] maintaining a position at or near the top for more than 35 years.


IIRC, the Mayo Clinic invented the medical checklist. Like, people actually read the checklist and make sure that they tick off all the boxes they are required to tick off.

That's why they are number one. Because they actually use checklists.


"The unreasonable effectiveness of checklists"


My wife was diagnosed Devic's disease, a rare disease with a grim prognosis. Almost every paper we could find on it had the name of a doctor that worked at the Mayo Clinic in Scottsdale. We lived in Arizona at the time so we went there and found that doctor. He corrected her diagnosis as MS, not Devic's. They both suck but Devic's is much worse. We paid out of pocket and getting the correct diagnosis was worth every penny.


This is similar to problems that would often happen in car manufacturing. The person assembling the car the standard way finds a problem, but the problem doesn't get addressed, or information isn't disseminated correctly, so the cars go out with problems. Toyota developed a methodology whereby such problems are addressed immediately and fixes were disseminated immediately, and would not send a car out otherwise. That kind of obsessive attention to detail and "crazy" focus on quality is what made them the top automaker. But most businesses are led by management that refuse to believe that being slow or focusing on quality first will result in more profits. And none of their lower-level workers are trained on how to spot and fix quality issues, nor are they told to care.

Hospital systems are the same way. Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in, ignorant of the fact that more dough would roll in (in addition to better health outcomes, which of course is not their first priority) if they would just focus on quality.


This is my favourite ever episode of This American Life, about NUMMI, the shop floor level and individually fraternal miracle that was created by workers at Toyota and GM in a CA GM plant, until management shut them down:

https://www.thisamericanlife.org/561/nummi-2015


This episode is incredible! I also listened to it a few years ago. It provided so much insight into (a) Japanese vs American manufactoring and (b) the impact of poor labour union relations. (Please do not read [b] as me being personally anti-labour union. Some of the revelations from union members in that podcast were shocking to me -- drinking and drugging while on the manuf line!)


Very cool point. In my ideal world a whole nursing unit or facility would be a self-correcting operation. There are problems that a nurse on the floor can fix but it takes up time. If those problems were prevented to begin with, it would be much easier. I would like a system where the nurse notices a problem and simply sends it up to a manager / supervisor who 1) finds a way to handle the immediate problem and 2) always writes up and enforces a new guideline to prevent it from happening again.

Good managers probably already do this, but healthcare has a very short supply of such people. It would be great if this type of improvement were the standard across the board. Let's say, for example, that you have latex and non-latex foley catheters mixed in the same bin in a supply closet. Your patients with latex allergies have gotten a latex catheter put in more than once and it now becomes a problem. Well, someone notices the issue, sends it up to someone above and now there is a new guideline to place the different catheters at least 3 feet apart, or something to that effect. It almost sounds silly, but people would be surprised how many of these mistakes happen over and over again due to equally silly reasons / lack of basic prevention.


> Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in

That sounds like it’s the same in any sector? Especially IT.


Not lost, but I've had a lot of trouble with information being captured incorrectly.

Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.

I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...


I've noticed recently that there are people out there who simply can't accurately listen to others and repeat back what they say. It's not about being stressed for time, the skill is just not there. You say ABC, they write CBD, and they have no idea it's not the same thing.


Add to that the people who reply to an email or other message without providing any response to the questions it explicitly poses.


I’ve found numbered lists of short questions helps a lot.

But with some people definitely only ask 1 question per email.


This can be intentional rather than a misunderstanding.


OpenNotes can help a little with this, but only if the patient or one of their caregivers has the time and ability to do a detailed review of every chart note.

https://www.opennotes.org/


This comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the hours is that continuity of care is by far the factor most strongly correlated with good patient outcomes. So the argument goes that a change in caregiver is more detrimental to the patient than continued care from one doctor even if that doctor is sleep deprived.

I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.


As a physician, shift length is honestly a red herring.

As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover.

You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover.

You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help.

Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.


> As a physician, shift length is honestly a red herring.

This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!


It’s essentially unheard of to have someone die because a resident made a mistake on call.

On-call medicine is so rote as to not require much, if any, thinking. Ward medicine is far less intellectually challenging than teaching.

Patients who are active/critical are not managed by a single tired resident overnight.


We had a case a few years ago in Argentina, when a child got an overdose of Potassium Chloride. The nurse was new in the hospital and in the previous hospital they had a different concentration, so she prepared a wrong dilution. [1]. Anyway, it's a problem that is common enough that the English NHS added it to a list of recommendations [page 8] https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-N...

It looks like a random accident, but it's one of the silly mistakes that are more common when someone has worked 12 or 24 hours straight and has no checklists.

[1] I tried looking for the case, because the details matter, but most of the recent news are about a case where it apparently was intentional https://www-telam-com-ar.translate.goog/notas/202208/602435-...


Not sure what this has to do with resident/physician work hours.

Nursing errors (i.e. administering the wrong dose) can certainly kill people. They also don’t / shouldn’t work 24 hours shifts (infrequently a nurse might work a double due to emergent staffing requirements, this is a systems issue though and not by design).

There are both technological (EMR and ordering systems) and human safeguards (nurses and pharmacy) protecting against “silly mistakes” by physicians.

Once again, resident physicians’ roles overnights are no where near as mission critical as a nurse.

You also identified a key point in why 24 hour resident call shifts are safe - we have checklists.

If I order the wrong med on the wrong patient on an overnight call shift this will be flagged by the nurse who’s checklist includes verifying order accuracy. This is especially true of medications that can have life threatening complications (e.g. insulin, potassium, hypertonic saline).

Please also note I’m only talking about places I’ve trained (US and Canada) where all of these systems exist. I cannot comment on other countries where the infrastructure is different, perhaps this is more of an issue in Argentina than it is here.


Probably the system is not so difference, because here sometimes they just copy whatever the FDA says (or whoever is in charge of that).

It depends a lot on the hospital. There are good hospitals and bad hospitals.

There was a recent strike of the residents doctors in the capital of Argentina. https://www-lanacion-com-ar.translate.goog/sociedad/no-llega...

> By contract, [...], a resident has to serve eight hours a day, Monday through Friday, and do eight 24-hour shifts per month.

> “We work shifts of more than eight hours, which can reach 15 or more and with guards that are also on weekends. There are colleagues who work 40 hours straight,"

(The last one is a quote of one of the union leaders, so it may be a corner case.)

If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.


> If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.

Ward call for residents generally works like this:

I have an inpatient list of 15-20 patients I’m covering overnight, some of them I likely know as I’m often part of one of the relevant day teams (unless I’m flying in from another clinical service to help out).

I start by receiving handover from one of the day team members. We sit down together (or by phone) and go patient by patient on the list asking what their reason for admission is, any labs/results I need to follow up on from the day (e.g. patient A had a fever and a cough, we ordered a chest X-ray if it shows pneumonia start antibiotics), patient specific management plans (e.g. patient B may have a seizure overnight, he’s known for this and if it happens give drug Y.) and any patients that I specifically need to see (e.g. patient C was complaining of some belly pain this morning but has been fine the rest of the day, eyeball him in the evening and make sure nothing is brewing).

I then write these action items and notes down (either on paper or in an EMR patient list) for my shift and carry out the relevant actions from 5pm to ~10pm.

Between 5pm and ~10pm I’m following things up and seeing any patients I need to see. Depending on my service I may be taking ED/inpatient consults but that’s not the point here so I won’t get into that.

At 10pm I do what’s called “tuck in rounds” and call up to the nursing station and ask if any of the nurses have issues they want me to address. Often this is something like morning labs that haven’t been ordered, laxative orders, etc. If there are any patients I’m worried about (uncommon on routine inpatient wards) I will pop my head in the room to make sure everything is alright. Cumulatively, the evening usually represents 1-2 hours of active work (again disregarding consults because that workflow is very different).

After that, and until the next morning, I am either asleep in a call room bed or at home. I will only be practicing medicine if there is an overnight issue that needs addressing (e.g. a patient is short of breath, their heart rate is elevated, decreased level of consciousness). These acute ward issues are beaten into every physician from the beginning of medical school and we follow very routine diagnostic workups (i.e. CBC, lytes, glucose, VBG), many of which are codified in algorithms such as ACLS.

If a patient is really unstable I call the RACE/code team (an in-house service to deal with unstable issues staffed by an ICU trainee, RT, and ICU nurse with advanced training) who assume care while I provide support and context as the home service/MRP resident.

This is a very safe system. It is really hard to kill an inpatient with a medical error in an acute setting.

Now let’s pretend I handed over to a night resident starting at 11pm. Two potential sources for error arise:

1. We would go over the same process of “running the list” and discussing patients, except now it’s second hand information I’m relating (versus my initial handover was from the primary team/MRP who knows the patient intimately). Broken telephone / forgotten action items becomes more likely.

2. An acute situation happens overnight and the 3rd shift person alerts the RACE service, except now the resident from the home team/MRP has never actually met the patient (you don’t go round and familiarize yourself with sleeping patients) and has no idea what they’ve been like all day except from what I’ve told them. This creates a huge problem because now they’re reading through the chart/notes to make sure this is a new symptom and not something I forgot to tell them about, they’re also reading the chart to see if there were any action items I addressed in my evening shift that didn’t merit handover but may be related to the acute concern. Whereas with the same resident on a 16-24 hour shift you have a much better understanding of the patients and their unique circumstances.

Many, many, many studies have shown medical errors happen a lot more due to handover than physician fatigue. You can argue that we should have better systems/IT in place to make handover safer, but we do not. Even places with systems like Epic/Cerner, it takes too much effort to maintain the handover list with accuracy and direct verbal communication remains the mainstay.

Furthermore, it’s important to keep in mind that dealing with ward issues between 12am and 7am is also pretty uncommon unless there is a late admission or someone that’s active, but that’s atypical. On-call is for emergency coverage not active medical practice.


Thanks for sharing!

Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.

This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.

I had some exposure to formalized incident management[1] at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.

1. https://en.wikipedia.org/wiki/Incident_management


I liked the way you framed this as something universal. Is there any field where one can quickly reference knowledge from your peers to just as quickly solve a problem in practice? Maybe it's asking too much. Though I suppose it wouldn't be necessary to get everyone on board with such an idea if you have that single coordinator who everyone knows as the reference point. Although, if you think about it, even then that person would have to be available 24/7, which isn't feasible.

With patient documentation specifically, what I would really love to have is a simple search mechanism for patient notes. This still wouldn’t solve the problem of getting everyone to capture the right information. But assuming the information is there, and I'm having a real hard time sticking that right arm, I would love to be able to search for "arm", "blood draw," "stick" and see what pops up. I hope it's not something I missed entirely, but I have never used an EMR with such a feature.


Indeed, seemingly simple functionality like you describe should be bare-minimum requirement for just about any kind of information system, and yet it's almost always omitted or implemented so terribly as to negate any practical benefit to users.


> a single coordinator to be responsible for continuity of information and coordination

Years ago I saw a talk by a VA (US veteran's health care) thoracic surgeon, who was trying to entice tech folk to address the following problem. A surgeon is both team manager and skilled technician. When heads down in the technician role, the management role suffers for lack of attention. Especially severely at the VA, which did randomized staffing of operating teams, so you don't get the "group mind" and practiced gap filling of team which stays together. So surgeons would say "do X", and being distracted, not notice the order was dropped, and then proceed assuming X had happened, with regrettable results. The VA surgeon envisioned a voice system which noted the request, waited, and then whispered a nudge in someone's ear "did we do X?".


I think this is a symptom of hospitals being understaffed, whether that's from a deliberate lack of hiring or an actual labor shortage. I feel like many of the problems in this aspect of healthcare could be solved if doctors, nurses, etc weren't run ragged with insanely long shifts and expected to care for a ton of patients.


I don't know how to respond to your post. I'll try: Money. Skilled people cost money, a lot of money. I disagree with both of these: <<deliberate lack of hiring or an actual labor shortage>> They are making do with the amount of money that is available. It would be wiser to focus on why healthcare is so expensive in the United States compared to other highly advanced countries -- France, Germany, Netherlands, Finland, Japan, etc.


I wonder if part of the issue is having to remember a bunch of random things about a bunch of different people so that you can apply the information at the relevant time. E.g. the left arm is easier to find a vein, but this information is only useful for 30 seconds a day during a blood draw, so it's hard for people to remember or even retrieve (how much notes do you have to read through to find this info?)

If the info were somehow magically there when needed, it would be used, right?


Like, google glasses but for ICU workers?


I was gonna say augmented reality, but there are probably low-tech options that could do the trick.

I would start with "sticky note on the relevant machine" type interventions first.


Your comment made me think about this for a bit. It is almost fun imagining something like seeing a short little warning floating up in the air above a patient's arm, saying "blood draws from here". It would be pretty darn cool. If this were possible, it would be worth seeing how much it helps with continuity of care.

To let my imagination run a little wilder, I tried to think of what a system like that would be in practice, and how it relates to the problems that we currently face with the systems we already have. As much as it would be interesting to have all that information available through some sort of AR, there are really three important things that I would like to see about a patient: code status, vital signs and how they get up from bed.

It's really crazy to me how even the simplest of stuff is buried in a chart or EMR. Most do show the patients code status easily, but quite often it is in a small little font beside not-quite-as-relevant stuff like their marital status and what type of insurance they have. Why isn't this in big bold red letters in every room and in every chart as soon as you open up a document? Even for vital signs you have to click through two or three different things to get the information you need (but thank goodness I get to see some stuff right away, like that ICD-10 code for unspecified follow up for dietary counseling!)

One thing I think a lot of people may also not realize is how little information a nurse often has to go off of when walking into a room. If I am answering a call light for a patient who is not one my assigned ones, and they are screaming that they need to go to the bathroom yesterday, and you see them with both feet planted on the floor ready to get up, you have a quick second to think about a few different things. 1) How alert is this patient? 2) How mobile are they, do we need two people in the room? 3) Is this someone with a massive diabetic ulcer who wasn't supposed to be putting any pressure on that heel at all and they are about to do just that? Of course, you can look at the whiteboard, but you better pray that it's updated haha.

So, going back to the AR stuff. If I could have a snapshot of all this information as soon as I walked into a room, it would be a life saver, especially for situations like the above.


I have great respect for what people like you do. I've lived all over Europe and a have some first hand experience with care in different countries. Universally, nurses are heroes and it's just a very hard and often thankless job. Not to mention under paid in many places. But there's a big difference in what I would label as institutional stupidity between different countries. Some countries feature a lot of mismanaged health care facilities where things are bureaucratic, slow, etc. For example, Germany is hopeless on this front. Being in the health care system here means an endless sequence of forms that need to be filled in with the exact same data points over and over again and over worked nurses dealing with all that crap on top of their normal job. It's beyond stupid. Nobody shares any data. And it's inefficient and dangerous for patients because no doctor or nurse can possibly have the full picture.

My home country the Netherlands is very different. My father had a stroke quite recently and spent some time in a very modern hospital where they are applying some of the latest insights for patient care. So, he was obviously hooked up to lots of equipment and intensely monitored. However, this hospital has separate rooms for all patients. Reason: it's best for the patients and helps them recover more quickly. Basically, more privacy for the patients and less restless nights. There are no TVs in these rooms. Instead patients are issued ipads with entertainment options and access to various things like indicating dietary preferences. Nurses carry ipads as well. Everything is digital. There are no paper charts in sight anywhere.

The rooms were modern, clean, and clearly optimized for making patient handling easy and straightforward. What struck me was the attention to detail and level of pragmatism in this. For example, my father's room had wall mounted hangers for folding chairs. These are for visitors. And when they are folded they are not in the way. The room had a whiteboard and a locked cabinet for medication and supplies. The doors are sliding. So, it's easy to move things in and out. Like beds, wheel chairs, equipment, trolleys. Etc. And so on. Just a really well designed and thought through design and architecture. Well managed and efficient.

BTW. This is not a private hospital: my country has a mandatory private insurance system: they can't reject people, people must be insured, and they can switch insurer. So, insurers mainly compete on quality care. Miserable patients and inefficient hospitals are bad for business and they are working to fix any issues there with hospitals. Which is why everyone, rich or poor, gets the same quality treatment in this hospital. It's way better than the private insurance I pay for in Germany. Way cheaper too. My German insurance is about 5x the price. I've been in a hospital here a few times and they can learn a thing or two about efficiency there.


The only bad thing about Dutch healthcare is that, if you are not acutely in need, it can take months to get a spot.


I have heard similar complaints about UK and Canada. From a cost perspective, it makes sense to me. I also wonder: If you make people wait months, how many people skip/cancel the appointment? Probably many.

I have lived in two countries with very unfair healthcare systems. High income people get "health insurance" (whatever that term really means!) from their employer. They use it a LOT. Way too much. And their "health insurance" covers most of the cost. The number of times that I have seen high income people see a medical doctor for a runny nose (light head cold) stuns me. What an incredible waste of medical resources! As someone fortunate enough to have this "health insurance" at various times in my life, I am constantly saying "no" when doctors try to over-prescribe all manner of medicines. Obviously, they know my insurance will pay 100%!

The #1 duty of a public healthcare system absolutely must be "acute need". Everything else is second priority, else they go bankrupt. It's rough. I don't know a better solution.

Crazy idea: What if there was a kind of public auction system where people in the queue could set a price to sell their position? As long as it was fair and transparent, I might be OK with it.


I'd say that's universal across many countries. The flip side is that Dutch insurers do allow their patients to shop around for care. E.g. getting treated in Belgium or Germany for routine procedures is fairly common. Mostly these just are shortages of staff, equipment, etc. and being efficient sometimes also means that available care is fully utilized. Which just means people have to wait for non critical things sometimes.


That makes sense. When I worked shiftwork (8 hr days), you'd get good info from the people before you, but not about the people before them (after you), so you'd often have the same problem in that rhythm. But we would stay on shift for months on end, and obviously that helped with all the knowledge walking away all the time.


I noticed a lot of the same things when my dad was in the ICU. Some additional thoughts:

1. "Almost every patient has delusions and nightmares" I personally felt "off" when visiting my father. The sounds, smells, lights and constant buzz of activity all contributed to a feeling of being in a surreal dreamworld. Lack of sleep contributes. I can't imagine what my father experiencing.

2. Food was HORRIBLE. One meal was a low quality hamburger on a plain, white bread bun with a slice of "american cheese", fries, iceberg lettuce salad with a couple of slices of cucumber and a single slice of tomato, a container of apple sauce and glass of milk. Lots of salad dressing and ketchup. They wouldn't let us bring better food into the ICU and my dad didn't want to "make waves".

3. Family is critical. My father got better care because I, or my brother, was there to act on his behalf. Having obnoxious family members is worse than having none from what I saw.


I had a family member who wasn't even in ICU, and still experienced delusions simply from being sick and being in the hospital for a few days. He thought there was a group of family members around the corner waiting to jump out and surprise him and was insistent that I tell them not to disturb the other patients. I had to argue with him to get him to accept that, no, there is not a random group of family members waiting to jump out. He insisted he heard them talking and stuff. It was pretty disconcerting for me actually because he has always been a psychologically-bulletproof person. Definitely an eye-opening moment for me.


Now thinking about how this applies to the acute mental health wing.


Yes - my wife is a physician and she routinely describes how well meaning family members make care harder for their loved ones by trying too hard in the wrong ways. Requesting more care doesn’t get you better care - “squeaky wheel gets the grease” doesn’t really apply in many situations.


I certainly saw that. The issue we had was my sister grilling everyone who came into the room, or even walked by, often the same questions that she already asked that person earlier. I could see everyone starting to dread seeing her. The “squeaky wheel gets the grease” doesn't apply if people are avoiding the patients room.

My father's cardiologist was explaining the procedure he was about to perform and my sister and mother were so upset they just flooded him with irrelevant questions and questions that he had already answered. I kept trying to get them to stop talking over top the surgeon and actually listen to the answers he was giving. He finally asked me if I could "socialize this with your family" so he could return to the operating room.


I have heard an equal number of stories that are exactly opposite. Only through aggressive, pushy "squeaky wheel" behaviour was someone able to get the correct care.


My dad definitely got better care because both my brother and were assertive in our advocacy, but my sister’s aggressive, undirected badgering didn’t help at all.


As someone who has spent much more than my fair share of time in ICU and on "the floor" I can honestly say that being in the hospital is similar to being in prison in one respect. Having someone on the outside working for you is critical. Medical staff will almost immediately try to establish a power dynamic over you to keep you cooperative and docile. Having people from outside who are polite but inquisitive and questioning is key. I've also noticed that people who have frequent and varied family visitors get more attentive care than those who never have visitors such as the elderly whose family may all be gone and friends can't really travel.


> There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though. It’s all shooting in the dark, and most of the time I felt like I could have done just as good a job on these longterm issues...

This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...

    if(return_value == 5):
        return_value = 4
...to fix it, and being satisfied. What I want is something like in the television show House. The main character is unhinged and anti-social and takes extreme risks, but at least he demonstrates curiosity to really figure out and understand the root of what's going on. To be fair, I don't actually think that doctors lack curiosity or are incapable of doing this, the medical system as it's set up just doesn't allow it. For chronic issues, I've usually figured them out for myself, as a layperson, by persistently keeping track of things, searching the web, reading, and experimenting over months and years.


The main thing that House MD has, that no other doctor in the world has, is not so much his superior intellect. It's that he and five other doctors spend 100% of their time on a single case, and can sit around all day discussing it, trying different things. If real world doctors had even a fraction of that luxury, you would see a lot more of what you describe.


Yeah, that's what I mean by the medical system just not being set up to allow this. I generally see a different doctor every time I make an appointment, because I'm assigned to a team in a clinic with constant turnover, the appointments are 20 minutes long, and the doctor easily spends more time on boiler plate stuff in the computer system than examining and listening to me. I don't even think they have time to look over the basic medical history, let alone have a whiteboard session to consider all the pieces of the puzzle and brainstorm possible explanations.


Jeez, no kidding. I imagine if they made a realistic doctor show they'd be constantly showing the doctor at the bar (on days off) trying to make money on side gigs like health startups.

Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".

It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.

Also I'm not kidding but I would LOVE such a show.


You should check out The Resident. The first several seasons are about the doctor invested in a device that is a fraud, a private equity group buying the hospital, it eventually failing.

Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.

New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.


Are all of these well-written shows? They all look terrible in the descriptions but I’m hoping I’m wrong.


I rank New Amsterdam and the Resident better for the hospital politics; Chicago MD is more short episode drama (though does touch on mental health and social services more.


Back when ER was a hit show, there was survey among medical professionals and hospital staff asking for their favorite medical drama series and the reasons for it. Grey's Anatomy, and similar series, constantly beat ER. The reason was that medical staff considered ER way too realistic. Makes sense, why would I entertain myself during my off hours with what is basically a documentary about my on-duty hours.


I’m half convinced the ER diagnoses everyone with no apparent issues with dehydration so they don’t feel stupid about coming in for no reason.


You would not. 5 doctors talking about your case wouldn't help much.

People really don't understand the dire and primitive state of current medicine.

We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.

If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.


Also, the cases are usually in desperate enough straits that “here, swallow this seagull poop!” doesn’t get hints thrown out of the hospital.


I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers.

What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.

You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...


Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again.

Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.

I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.


Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do


You still have the problem of writing a sufficiently detailed tree. I had a blood test last year and when I discussed the result with the doc, he asked me the clinic location where the blood was taken, because then he could estimate time between blood draw and lab test and interpret the result accordingly.


It’s your blood usually tested immediately? At least my hospital gives me results right away (well, say within 30 minutes).


It might be different where you live, but where I am, the vast majority of blood tests are not done at the hospital. Family doctors and lab test centres do it.


I think you just made my point about a sufficiently detailed tree.

GP orders test. I go to a test center to get the blood drawn. They have couriers taking samples to labs a few times per day.


> Any educated layperson can figure out and follow a clinical decision tree.

12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.


What I meant is that I can follow it for myself, not do it for others. I don't have the training to know every medical decision tree by heart, but I can look up ones for problems I have and apply them.

I am a bit biased because I have several medical professionals in my family, but a common refrain is definitely that most doctors/nurses aren't going to be that engaged and helpful, and are more of a input/output device to navigate rather than someone you want to completely defer to.


Are all doctors working these hours? I thought these were the hours for residency, not the average general practitioner or specialist working outside of a hospital. If they’re working 15 hours a day, why are they only open 8?


Yes, it's so tiresome and frustrating. I once had a period of a few months where my sleep was down to around 5 hours/night (normally I would get 8-9), I was exhausted and my body just wouldn't sleep more than that. Went to a doctor who offered a couple of thoughts "some people only need that much sleep" and "there's only one thing it could be, but that's not what it is". He wasn't even going to test the "one thing" until I asked if he would. Turns out he was correct that that wasn't what it was, but obviously there was at least one other thing. My sleep ended up returning to normal though I still have similar periods where I can't get enough sleep.

The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).


The fact that they’re more open to believing that anything might work cuts both ways :)


I think when dealing with chronic issues, it might be better to optimize for luck. [0] A little ridiculousness like homeopathy might be worth it to find the thing that actually works.

[0] https://www.lesswrong.com/posts/fFY2HeC9i2Tx8FEnK/luck-based...


Thank you for this link. Well written and mirrors a lot of my experiences though I am still looking for my 'miracle cure'. I think this could be helpful for sharing with other people in my life who don't understand why someone would stray from an empirically/scientifically sanctioned approach.


>

Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.

For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.


not all of us live in the US


I don’t either but fully agree GP’s assessment, you chose a strange character to use there.


It's the default on my keyboard, and the commonly accepted symbol in my language. Next time, I'll choose something else.


I was not familiar with keyboard layouts including DEGREE SIGN handily, so I though there was at least a decent chance you had deliberately gone fancy. (I double-checked that it was ° and not º U+00BA MASCULINE ORDINAL INDICATOR, which I would expect to see on some keyboards, and “Nº” is incidentally distinctly better than “N°”, since it’s the shape of an o rather than a circle.)

To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n.

Looking through <https://en.wikipedia.org/wiki/Numero_sign#Usages>… hmm, French AZERTY? I see now that it does have ° readily accessible.

I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.)

P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.


I appreciate your perspective as a professional in this area.

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


Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him.

Creativity also has a role for non-critical conditions when standard treatments aren’t working.


I guess this is why the hospital asks me to list historical surgeries.


So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.


Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised.

I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.


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


Medical treatment is obviously not fully-solved, or anywhere close.

But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.

I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.


I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful.

As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.


General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners.

> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).

https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/


More tests isn’t a good things. The doctor was significantly quicker and could see 3 patients for every two the nurse saw.

I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.


Yes talking about scientific method and citing a TV show. Logic


House is not real, it falls under "arguing from fictional evidence"; House's patients are written by a writing team to have obscure and surprising - yet easy to fix - ailments. They are generally young with acute short term symptoms leading to a race against time and a boolean toggle outcome healed/dead. They are rarely the 70+ year old ICU inhabitant with age related complications who is mentioned in the blog post with long periods of 'boring' illness to keep track of and treatment rotating between many doctors.

House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.

House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.

House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.

Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".

In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.


Author of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc...

One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry that is close and double to triple most other nations we are typically compared against like the UK and Canada.

ICU beds are extremely expensive to both build and operate. Also for the lay person the term "bed" has a specific regulatory meaning and does not refer to just the physical existence of the room and bed but means that it is operational with highly regulated amounts of staffing, services and equipment. Each "bed" has costs in the millions to build and equip and operating costs are typically in the neighbood of $10k to $40k per "bed" per day, occupied or not, a large portion being labor.


I am going to repeat myself here.

Quick Google search for "icu beds per capita" finds: https://www.oecd.org/coronavirus/en/data-insights/intensive-...

US: 25.8 / 100K population

Germany: 33.9 / 100K


My impression as a Canadian resident was the bar seemed a lot lower to get into the ICU in the US. Unless they needed a tube to secure an airway, pressors, or CRRT we managed COPD with BiPAP, pretty profound hyponatremia, cirrhosis with& bleeds, DKA/HHS on the ward pretty regularly just as examples of repatriated patients I remember. I always figured it was due to an overly litigious culture and a money maker for the hospital. To be clear I didn't practice in the US.


It’s probably because we don’t have enough ICU (or step down beds) in Canadian hospitals than the fear of litigation in the US. Canada’s capacity is amongst the least in G20 nations.

A lot of patients we manage on the ward or step downs (i.e. pressors on step down, I’m unaware of any ward that will let you run these, very few tolerate central lines) really should be in a full ICU, or at least a high level step down unit like D4ICU at KGH (rather than the hilariously awful AMA units at TOH).


I am going to repeat myself here. You wrote: <<Canada’s capacity is amongst the least in G20 nations.>>

Not even close.

Quick Google search for "icu beds per capita" finds: https://www.oecd.org/coronavirus/en/data-insights/intensive-...

Canada: 12.9 / 100K population (slightly higher than OECD average)

For the record, it is usually better to quote "OECD" than "G20". G20 just means total GDP is large, but GDP per capita can be very low, like India, Indonesia, and China. OECD is always (democratic and) high-income -- high GDP per capita. For example: Nederlands, Norway, and Switzerland are all OECD, but none G20. All are very high income and high human development.


This number includes level 2/step-down ICUs inclusive of regional/community hospital.

This is not the bed count of units capable of having cardiac support or prolonged ventilation.

I can’t readily find the OECD figure but if you look at ventilator capable beds in Canada the number drops to ~9.7, again inclusive of community/regional hospitals mostly staffed by non-ICU trained physicians which are only equipped for short term ventilation.

Which center in Canada have you trained at where there isn’t constant pressure to offload ICU patients to the ward due to a lack of beds?


Can you explain why one ICU room costs millions, and why they cost 10k a day even if no one is in them? Neither makes sense to me. I can imagine say 100k in monitoring equipment in a room.

Maybe it's the hospital inflation applied to equipment?


An ICU unit isn't exactly a single room. There are different configurations but they typically involve some sort of centralized monitoring station and 5-20 ICU "beds". Total cost of that / number of beds. Everything in hospital construction is expensive, ICUs are at the extreme end of that. Huge power requirements, medical gas lines, fixturing and surfaces needs to be able to be disinfected, special air, special water, on and on. It has requirements very similar to an operating theatre.

The reason they cost so much even if no one is in them is because of what a "bed" means. It isn't the literal bed, it is a unit a treatable/treating capacity. Requiements vary somewhat by jurisdiction but it's going to mean 24/7/365 nursing and attending doctor staff. You can't just call them in when a patient shows up, they need to be scheduled and available. Then ICUs will also need a large cadre of oncall specialists, neurologists, cardiac, laboratory testing staff, and on an on to cover a huge range of possible patient needs. Stocked blood units, stocked medicine units. All those things have costs whether a patient in in the bed or not. Hospitals to a large extent spend an incredible amount of money on capacity. No wants wants to end up in a hospital to have them say, "oops, we didn't expect your spleen to rupture today, Dr. Bob won't be in till next tuesday so you are out of luck, sorry"


To add to this, the costs the one area I understand are huge.

Radiology generally needs to have a CT ready to go when there is an ICU. It likely needs an MR too, and staff for running after hours. Portable X-ray and ultrasound, a PACS, a RIS, services contracts and a load of other smaller costs.

That’s several million in hardware costs.

The running cost is huge with MR service contracts alone into the hundreds of thousands per year.

Staffing utterly dwarfs that expense and getting skilled people to work out of hours requires a lot of money, and additional cover for when they sleep.

Staff need to be kept competent with courses and training, certificates and leave to get to these sessions. More money.

The consumables are silly expensive and expire fairly rapidly. Everything needs to be available and a few spares should be present.

Radiology can be a cash cow for day to day operations in a private clinic. But having staffing and equipment that can run 24 hours a day with 100% uptime is a massive cost multiplier.


So, they're complicated, they're expensive, they're necessary... why don't we have the state pay for them? We spend 720 Billion dollars on the military. Would it be useful to send a couple of those billion to make ICUs less expensive?


Where do you think state money comes from? Even if it’s the government that foots the bill for ICUs, in the end it will still be paid collectively by all of us regular people.


Well good thing regular people don't ever need to use ICUs.


Did you reply to the wrong comment?


No.

In case it was unclear, I was being sarcastic in my reply and pointing out the hypocrisy of being offended that "regular people" would have to foot the bill for ICUs - as if they weren't the ones relying on their existence.


I am not offended that regular people would foot the bill for ICUs if state decides to pay for those. My point is that I do not see why it would be an improvement in any way over the status quo. It will not make them cheaper or more available, most likely quite the opposite.


Where do you think the for-profit money goes? (HINT: it’s in the name.)


Most hospitals in the US actually are non-profits, but that’s really beside the point. Just because something is for profit or non profit does not allow you to immediately conclude anything about its cost. For example, the government in my city built a 3 stall public restroom at a cost of $638,000. At this price, if I wanted to have a restroom built on my behalf, I’d rather hire a for-profit contractor to do it instead of the putatively non profit state.


Yes it would, but in the US we have a for profit medical system so this is a natural result of that.


Most of the cost is people. It’s not much use calling it an ICU room unless there are doctors and nurses and anesthesiologists and other specialists on call to actually care for people intensively. Plus a janitor or two.


For one American medical workers earn absolute insane wages compared to their European counterparts.


This is a practical reality of the "we keep old people alive too long" category.


I'm not old but I have an Advance Directive on my file that essentially says if I'm fucked then they should let me go. (And I'm in the UK where treatment is free at point of use).


Wow, this is a great post. I never knew about this NHS programme. I wish I had the same where I live.

https://www.nhs.uk/conditions/end-of-life-care/advance-decis...

https://www.nhs.uk/conditions/end-of-life-care/advance-state...

At the risk of sharing some PII, are you willing to share some of the conditions that you set?


Compassion in Dying have some advice about advance decision making.

https://compassionindying.org.uk/making-decisions-and-planni...

It's important to get the right balance around specificity. You need to include some


It's not an NHS programme as such, just that the law recognizes these documents. It would work with a private GP too.

I used a template document but don't recall where I got it.


I’m old and statements like this are… interesting


We all will be old one day, if lucky. My comment was not about you because you happen to be old right now. But are you unfamiliar with typical end of life care in the US? Where the last few years is a constant stream of hospitalizations, rehabilitation, etc with no quality of life and no tangible benefit but a very substantial cost? I find that concept… interesting… as in, I don’t like paying the cost and I don’t intend on participating in it when my time comes. I think this feeling is growing with younger generations because we’ve witnessed what older generations are subjecting themselves and their families to.


I’m familiar with all those issues and have been for years. Have taken both parents through agonizing deaths. Doesn’t make comments like yours less unsettling.


Probably no productive discourse to be had. We fundamentally have different views and I respect that.


I didn't express any views, only emotions. What disturbs me is that our views appear to be very similar. It's just at my age it is not exactly comforting.


Sorry I must have assumed you were dissenting with my stated views. But I now see you're actually not saying much at all so I'm having difficulty understanding what views are behind the statements regarding the feelings you've expressed.


How old should people be allowed to get? Why are the old less valuable to you? A life is a life, is it not?


Well traditionally, nobody allowed old people anything, except what their own family or checkbook could provide.


It had never been this simple. A child dying is pretty universally seen as worse than an 85 year old dying.


I feel like the greatest tragedy of them all is a 53 year old person dying.

Why 53?

No reason. No reason at all. I may change my view on this in a few months however.


When you turn 54?


It’s more about health and quality of life vs our capabilities to delay the inevitable. If you’re unfamiliar with the topic there’s plenty of information out there about how much money is spent and now low quality of life is commonly enough in the final few years.


Interesting take.

I was in a paediatric cardiac ICU when my daughter battled with heart disease for 7 of her 8 month life. Another dad who we got close to in the ICU said the phrase "practising medicine says it all...".

My experience is same same but different. It was during COVID, so we welcomed the nurse change, sad/happy to see one go and welcome another. Paediatric ICUs and their staff, I'd say are top tier in most respects. Parents are involved with most/all decisions, and nurses/drs respect most wishes, don't like your child being disturbed at night for non-100%-necessary stuff? Ask social services (etc) to print out a sign with your wishes and stick it on your room door. May not 100% work, but worth a shot. It did in ours.

Sleep is somewhat respected as this is when babies develop/heal best, unfortunately it's an ICU, and these are sick kids who need 24/7 complex care, so there's sometimes little wiggle room. I attended a conference in Chicago on heart disease and it's outcomes (npcqic.org), and sleep and proper nutrition (not just feeding TPN) are definitely hot topics. I know the NICUs are extra hard on any additional sleep/disturbance other than 100% necessary.

But shoutout to nurses, drs, any medical staff, ICUs are sterile, haunting, traumatic places. I witnessed things I can never forget. They do the same, and have to do it again, and again.


I'm a cynic to some degree. I think suffering doesn't ennoble people for the most part - it just makes them bitter and angry.

I realize this wasn't your point - and who knows maybe I'm misreading you - but this comment makes me reconsider my view on that. I have a child and having to go through something like what you describe makes me feel sick. Doing that and then having any degree of empathy - sympathy even - for the people involved is a credit to you.


Cried a little reading that. What agony, losing a child in slow motion. My best to you and yours.


> What agony, losing a child in slow motion.

These words are both poetic and heart-wrenching.


There should be a name for this, "medical theatre", analogous to security theatre. A brilliant performance art, with all its buzzing machines, expensive insurance, bright lights, pretty graphic logos, well-dressed specialists and doctors that aren't able to apply their knowledge correctly because they can't get simple things right, like letting patients sleep properly or recording and passing on information specific to a patient. All of this because the emphasis is on the "system" rather than the patient, and the solution is "more system". There is no amount of procedure that can replace genuine care and concern for a human being -- this man's father was lucky to have someone who was spending time with him observing these things, and presumably helping the staff avoid mistakes, and probably helping with the feelings of paranoia and hallucinations as well.


I suspect part of what causes the hallucinations is withdrawal from alcohol combined with opiates. When you need emergency care nobody asks or seems to care if you are dependent on alcohol, they simply put you in the ICU and wait for you to wake up, going cold turkey. Maybe there is nothing they can do about it, but it seems like they should at least be aware of it and perhaps working on a solution. That they have not seems to be due to moral judgements (you shouldn't have been drinking so much in the first place.) Perhaps small intraveneous doses of alcohol would help (although the opiates would make that complicated since they interact with alcohol.) Maybe some type of blood cleaning would help. Ignoring it seems like the worst choice, particularly since it can cause physical effects besides hallucinations. This is one of a number of areas that medicine ignores. Another is environmental causes of diseases; when was the last time your doctor asked for air, water, soil, and food samples from your home as part of your regular checkup?


For context see my comment here https://news.ycombinator.com/item?id=33625584#33647770

One thing that this article touches on, but I think needs to be emphasized even more is that the stark reality is that the only advocate for the patient is the patient themselves, or perhaps a caretaker.

The burden is on me to ask questions about fertility and sperm banking because my oncologist is well... an oncologist not a fertility expert. I have to ensure that every department is communicating with every other department.

Hospitals and physicians are fantastic at solving discrete issues, but the bigger picture is often lost in the chaos. I can do it as a technically adept 34 year old, it's horrifying to think about how someone closer to 80 goes about it.


I was in an ICU for a week after a cardiac arrest. I don't remember much of it other than a lot of hallicunations.

I had family there to advocate for me, but there's no way in hell I would have been able to advocate for myself. I was literally seeing things around me in the ICU room that didn't exist. My family were probably the only ones that realized that that wasn't the real me.

The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery, and I have full working memory of that normal patient room.


> The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery

To be fair (and this is also true for the article itself), it might be difficult to distinguish cause and effect here. Being moved into less intensive care means that you are more stable which might lead to other issues becoming better in the following days regardless of whether you are in the ICU or not.


Hallucinations are one of the most common symptoms of sleep deprivation.


I don't have much personal experience with hospitals, but there's a trend I've noticed across several articles now where the medical system is characterized by an unpredictable and frequent alternation between extreme competence and extreme incompetence.

The author's dad was being seen by a variety of highly trained specialists all working to treat him, but "people need to sleep" seems to be a recent discovery in the ICU world, and if his family hadn't been there to help, every new nurse would have tried to give him the same medication that gave him a bad reaction, over and over, just because there wasn't an established place to write that (obviously important) information down.

I've read that food with better nutrition than regular hospital food may reduce mortality rates by as much as half [0]. That's such a huge effect that it's shocking that hospital food is just expected to be bad. Everyone says nutrition is vital for health, but hospitals don't seem to care.

I think the root problem is cost-cutting. Management cuts costs until the brink of disaster, and tries to hold it there for as long as possible. This is not a system that strives for the best outcome for patients within reasonable limits of the resources available; this is a system that attempts to extract as much value as possible from the patients, and patient death is only prevented as a means to that ends.

[0] https://www.sciencedirect.com/science/article/pii/S073510972...


From reading the abstract you are completely mischaracterizing this study.

For the average person healthy food usually means food with fewer calories and more micro-nutrients, like eating more broccoli and less white bread.

This study is about malnourished patients who need more calories than they can even digest from an average meal so they need specialized high-calorie foods that are customized for their own metabolism. It's essentially exactly the opposite of what "healthy food" means in any other context.

So it has nothing to do with any narrative about cost cutting and the quality of ingredients used in hospital cafeterias.


A closer reading of the intervention shows that it wasn't _just_ "more calories".

But I think that is missing the forest for the trees, what this study showed is that when a patient is left on their own, they consume an inadequate diet that _puts their health at risk_ in a hospital. By a big margin!

I would imagine, though the study didn't show this, that the primary factor in recovery here was having a human (dietician) actually paying attention to your recovery. On intake they put together a plan, and followed up routinely to ensure that the patient has consuming their diet.

The GP's point is valid, hospitals are missing out on a 50% increase in health outcomes because they're letting patients fend for themselves with regard to nutrition. You're right that it isn't as easy as spending $6 per meal vs $3 to buy "better" food. But what it means is that hospitals are failing their patients because they aren't thinking and acting with a holistic eye towards patient outcomes.


I don’t think the problem is cost cutting. I think the problem is just the same problem that every human enterprise has.

Most people just don’t give a shit outside thier immediate responsibility.

Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task.

Many people who do give a shit get this crushed out of them early in their career by the negativity you will face if you try.

Much easier to just accept the status quo.

Occasionally you get a group of people who really care and come together determined not to let things be crappy and they can form an organisation that is significantly more effective for a time. But once the rot of “We can’t fix things” sets in, it’s really really hard to turn things around.


I work in a hospital, and occasionally in ICUs. You're wrong. Most workers are very much jaded, but they do care. Problem is, the system crushes you to death if you don't set pretty harsh limits to protect yourself. In a lot of cases, that means de-humanizing your work, put your feelings aside and work like a machine. Good little machines are just what management wants, right? Now higher management... wow, those people really don't give a hoot about anything that's not themselves!

A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!


What percent of patients have a medical need to be woken up every few hours then?


pretty much every patient in the intensive care unit - that’s kind of what the “intensive” is referring to.

If nothing else, you either take the blood pressure the normal way with a pressure cuff, which is going to wake you up. Or you put an intra arterial catheter, which reads continuously without bothering the patient, but has a small risk of damage to the vessel, infection etc


Based on my knowledge of US based urban (downtown) / suburban metro hospitals - vast majority of beds / patients aren't in ICU/CCU beds. I would say only 30% are in a critical state under observation - ICU/CCU/post-op/etc.


You'd be surprised to see what happens to staff going against waking up patients all night. You get the "dangerous sloth" sticker on your forehead real quick on the morning grand rounds.


With all the focus on EHR and billing, they can't have all the machines taking vitals hooked up and in a ready only state thats sent to the nursing station?

This is the type of stuff I have a gripe with. Sinecure and fiefdoms of power.


Silencing monitors is actually forbidden by law in many places. Staff is supposed to be near the patient at all times => monitors beeping. That's certainly a bad state of things, but not a "fiefdom of power". It's so ingrained in our education that most staff don't even think about it but would certainly agree if asked whether the patient would sleep better without it.


I’m not sure where you’re getting this from. I / my nurses silence alarms at literally every hospital I’ve ever worked at (granted they’re temporary silences by design so you have to hit silence q1h/q30mins depending on the alarm).

Stanford Healthcare recently installed a system where all alarms/notifications get sent to a hospital assigned device the nurse carries rather blasting in the sleeping patients room as 90%+ are false alarms (aka IV or SpO2 sensors).

The real issue is that hospital technology is outdated and most places don’t have the option for this level of telemetry.

I’ve never been told / instructed my staff to “be near the patient at all times”.

In fact, most places have 1:8 nursing coverage on the ward…


You're right that silencing alarms is strictly forbidden in anesthetic territory only, not ICU. I'm biased bc I'm in Switzerland, and here the coverage ratio is usually 1:1. The country is so rich, that many things are different here... they really are near the patient at all times. To give you an idea: the day COVID really hit, we received 180 shiny new Hamilton respirators complete with additional staff overnight, in an ICU that's usually ~30 beds. And you can't order "your nurses" around, because they've got a lot more power. Yes, in most places it's different and I should have mentioned that.


I want to clarify two points given the language used in your response:

1. I used the possessive “my” in reference to nursing staff for simplicity in writing and clarity to the reader rather than to indicate ownership, we are on a team. This is akin to saying “my goalkeeper wears Nike soccer cleats”.

2. I do not “order nurses around.” I verbally communicate and leave medical orders in the chart that nurses act on. It is not about a power struggle, we are all trying to do our jobs and do what’s right by the patient. I’m grateful when nurses question my medical orders (as long as it’s a positive/educational discussion, which it is 99% of the time) as they catch my mistakes and we all learn together.

If you are concerned that you can’t order nurses around, I strongly suggest reflecting on whether this leadership style is the most conducive to providing quality patient care as this can increase barriers and hostilities in the workplace resulting in communication breakdown and adverse events.


Thanks for the lesson, mate. I'll be strongly reflecting over the past 15 years of clinical practice and see the errors in my ways.


Any doctor who says they treat nurses as valued professional colleagues should be presumed to be lying unless you have seen it yourself, in person. Doctors treating nurses like shit is the norm, not the exception. How badly varies a lot.


Not saying monitors should be silenced. You can monitor someone without waking them up.

Fiefdoms of power - nursing union not wanting to give up the night shift premium pay when the job description changes to monitoring a screen and half the physical workload vs. day shift.


Cost cutting is definitely to blame for how understaffed hospitals are. Then Covid happened and it got even worse. It's definitely not all due to Covid though. Even the "not-for-profit" medical group in my area has been pushing doctors and PAs to take more and more patients, well past what they're comfortable with. Nursing staff has been cut down to nothing compared to 10 years ago. Wages haven't gone up to match the increase in workload.

Again, this started before Covid, the pandemic just highlighted how much these cuts screwed over both healthcare professionals and patients.


Everything you said is spot-on, but, brining things full circle, the lack of “shit giving” could be due to cost cutting. People don’t have an incentive to care. The end result, vis-a-vis their personal situation, is unchanged whether or not they go the extra mile. Part of this is because they exist in a rigid corporate structure hyper-focused on value extraction and not at all focused on the development of human capital.


>"people need to sleep"

Sleep is almost impossible with regular check-ups... 30 min or 60 min, don't remember. Excepting the comatose and most medicated(maybe not?), a person's sleep cycle is unable to reach REM when a stranger approaches and fiddles on regular intervals. I would think monitoring from afar(sensors, cameras) would be more beneficial, but I was informed the liability factors preclude such remote monitoring.

edit: to add context, I slept in the room on separate occasions with 2 family members. While tests were not performed, the regular checks were mandated. I was exhausted after my shifts ended.


Last time I was in the hospital (in 2016 with a broken arm) it was very difficult to sleep because the bed had some device that pokes you every so often to make sure you don't develop bedsores from lying too still.

This makes sense for someone who might be in there for weeks, but I was barely there overnight!


Nightmarish yet darkly comical. Sort of torture adjacent…


More than 10 years ago now, I was in the ICU for myocarditis, leading to bradycardia, a very slow heart rate.

During the night, it would drop to 40 (which is still fine), but sometimes below 30, at which point my heart monitor would blare an alarm, waking me up and scaring the absolute bejesus out of me, raising my heart rate immensely. A nurse would walk in, see that I was fine, and leave again.

This occurred nightly for a few days.


I don't understand this post. It reads like "have your cake and eat it too". The the heart monitor did not blare an alarm, maybe you died. Which one do you want?


The alarm to go off in the nurses' station so they could investigate.


I don’t know why the haldol reaction didn’t go in his chart, but the whiteboard in the room (which is present in every high level hospital room I’ve been in) is exactly where the TV information and other patient preferences should be, and is the second best place after the chart to put a drug reaction. Cost cutting has nothing to do with “nobody wrote it on the place for writing it”.


>The author's dad was being seen by a variety of highly trained specialists all working to treat him

The training doesn't really matter. Context is very important as is caring about doing a good job. You'll find a severe lack of both in hospitals. You eventually have to stand up and defend yourself against bad healthcare... or search endlessly for good healthcare which is terribly difficult to find.


Great, well written article, I wish your father a speedy recovery.

Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.


>Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.

After ACL reconstruction surgery many (~30) years ago, I was required to stay overnight due to both the general anaesthesia and the lateness (late afternoon) of the procedure.

I had a similar experience with the nurse coming in every two (2) hours to take my vitals. I was trying to sleep, but she kept waking me up. I groused about wanting to rest, but was informed (direct quote) "this isn't a hotel!"

And it's not. Rather it's a money printing facility for the owners of the health care system that runs the hospital.


There was an interesting article that showed "state of the art delivery rooms" from the 1950s - and they were ALL oriented around the doctor and nurse's convenience.

Now we've moved back toward "birthing centers" which focus on the mother and the baby; perhaps it is time for something similar to grow across all aspects of care.


> There was an interesting article that showed "state of the art delivery rooms" from the 1950s - and they were ALL oriented around the doctor and nurse's convenience.

And women are still giving birth lying down, fighting gravity, for the doctor’s convenience.


These threads always have lots of people jumping on doctors and their decisions/callousness/lack-of-reason/etc.etc.etc. My wife is a physician (OBGYN) at a major city hospital that primarily serves a very poor population. I'd like to share her schedule, and see if you think what kind of care you could perform under these circumstances:

Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to start rounding on patients - Sometimes work inpatient all day sometimes clinic thrown in, but usually not done working until 7 PM, without even a 15 min break or a chance to eat a meal (15 hour day) - Come home and do about an hour of notes - At least once per week, wake up in the middle of the night to deliver a patient who asked for that kind of continuity of care.

Saturday: - Wake up around 5am to be in by 6am to start the day - Work inpatient, usually without time for a 15min break for food, until 10AM SUNDAY (28 hours shift)

Repeat 49 weeks/year (days of 24/hr shift can vary and she usually gets one weekend off/month). Her average time at the hospital last year was 96 hours/week.

How much confidence do you have that you'd be able to take care of a complicated pregnancy at the end of a 28 hour shift, having not eaten for more than 24 hours, having 10 other patients on your mind, and having had only a couple of hours sleep the night before? It's no wonder to me anymore to me birth outcomes are so bad in understaffed hospitals in poor areas...


It's kind of amazing anyone chooses to go into healthcare having to work like this. It's the absolute last field I would ever want to go into, even as an engineer who wouldn't need to actually practice medicine. Seems like you need to practically give up your life to save countless others. Your wife, and those like her, are truly performing an innately critical job at an absurd cost to themselves - God bless.


It depends a lot on the specialty. Obgyn is particularly hellish.

But yeah, there's a good reason why suicide rates are so high for doctors...


The AAMC should increase the number of students they admit. The average medical school is turning away 95% of applicants. The top 10 schools in America are excepting <2.5%.


Doing this would make the problem worse by increasing the amount of unemployable newly graduated doctors that can't practice because they can't match into a residency program. Medical schools have exploded in number the past few decades compared to the actual amount of residency spots that have been opened.

The limiting factor isn't medical school admissions, it's residency spots. We'd need to increase medicare funding if we want more residency spots.


Why does medicare alone have to fund residency spots?


Conceptually, I'd agree with you. I don't think medicare alone needs to fund residency spots (its just currently tied to the amount of spots last I checked). I'm more concerned about the total number of residency spots.


excepting?


Goofed that one up...

Accepting


That is insane. For some reason, airplane pilots have very strict rules about how long they can be in the cabin, how much they must rest, and similar stuff. (Also, they have checklists, plenty of checklist, but medical doctors don't like checklists.)

Even bus and truck drivers have a more sane maximal shifts restrictions.


That sounds illegal.


Nope, not where we live.

I have seen administration do some blatantly illegal shit around physicians with COVID, but I don't want to write that up here.


Doctors answer: yes. And?


And she is not a resident or in a training/certification program?


Not anymore, but she’s only two years out. Her hours are actually worse than most of residency these last two years.


Wow, that first paragraph is as cynical as it gets: " The ICU is filled with old people." It ends with people now knowing why it tales so long to get doctors appointments, and saying the author is not sure whether ir nit this is a good thing, that we (the articlee is about the US but is pretty much the same everywhere) spend so much of our health care resources on the old. While his dad, also not in his twenties, was cared for in the same ICU. Maybe he should visit an ICU for infants and babies next time...

Staffing. Well, what can I say. Patients are there 24/7, staff is obviously not. That staff works in shifts, great realization. I am almost surprised that the author wasn't surprised ICU staff has vacation and sick days.

And finally "The ICU is a good place to not die, but a bad place to recover.". No shit, Sherlock, tgat is basically what an ICU does, stabilizing patients enough to transfer them to a "normal" station for recovery, or, worst case, to a paliative unit if death is the only possible outcome.

Oh, not to forget: "It really makes me think about how the hospital might be organized differently. If the hospital focused less on pure survival, might their patients recover faster?" What makes a emotionally involved amateur think that the people running ICUs, after sometimes years if nit decades of training in that exact field, don't think about this question constantly? And tgat the current state of ICU care represents the current optimal solution?

I am so fed up with articles from people judging things by looking at them from the outside. Mind you, the articke in question here is one of the better ones.


What's cynical about stating the truth? Are you disagreeing with his observations, or just hoping he'd have the good taste to keep them to himself?


Saying ICU are overproportionally occupied by the lederly, abd very young also if this a different ICU, is a fact. Continuing to say that is reason "you" have to wait for getting a slot and asking whether or not the observed sotuation is actually hood is cynical.


I’m a layman with no knowledge of how ICUs work, because (thank God), I’ve never had to visit one.

I found this article informative, and not cynical at all. No system is perfect, and so with all of the significant benefits they provide, ICUs have some things they aren’t best for.

> Continuing to say that is reason "you" have to wait for getting a slot and asking whether or not the observed sotuation is actually hood is cynical.

I see you bashing the author, but you haven’t made a coherent argument at all. In fact, I’m not sure if this is even English.

If there’s something op got wrong, help us understand and make it a teaching moment. Just bashing them isn’t productive.


Exactly my thoughts. I don't know anything about medicine, so my ultimate opinion is "I don't know". If I were to guess, the article just describes a well functioning medical structure and the author has some problem with people paying taxes.


I really wished "I don't know" would be the default position of otherwise smart, educated and exeperienced people once they step out of their fileds of expertiece. There is only so much that easily transfers from one domain to another, or from one industry to another.


Related, interesting anecdote: I was recently talking to a co-worker. We are both "third-country", so we can compare and contrast our current healthcare system versus "home". My co-worker made an interesting point: In their home country, patients are much more involved in their care, and doctors are willing to engage with well-prepared, intelligent patients. As a point of comparison: Our current country, not at all.

My point of this anecdote vis-a-vis high-agency healthcare systems: I like when I can ask questions to a doctor about their diagnosis and proposed treatment. Yes, I understand they are busy and there is a reasonable limit. I am equally annoyed when this is viewed (in the extreme) as an assault on their authority!


The observations of the comment about old people does however match the demographic data, and it shouldn't be simply dismissed this context is important and was not made clear during the COVID-19 pandemic.


The solution to difficulty booking doctors isn't to pontificate on how to allocate their time, the solution to difficulty booking doctors is to make more doctors.

There's lots of levers that could be pulled in the US. Cut down on undergraduate requirements, incentivize large health systems to fund more training (people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything).

Medical care suffers under the bizarre idea that central planning and capacity management will control costs. Meanwhile, costs are spiraling up and up and up. Train more doctors and all the stupid games being played to optimize their utilization start to go away, because it is less worth it when demand is less than supply.



Although I agree with you on a distaste for the foolishness of central planning, lLet me provide an alternative perspective.

A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.


> Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.

The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.


"But I want my doc to have a degree from medical school not some 3 month anatomy bootcamp..."


Not making American doctors do 4-years of an undergraduate "premed" degree will not meaningfully lower standards. Nor will creating more residency slots.

We don't need better outcomes. We will happily take the existing outcomes but cheaper.


Is the point you're making here that removing the "premed" undergraduate degree (which doesn't exist) will somehow lead to reduced healthcare costs?


> the "premed" undergraduate degree (which doesn't exist)

Yes there's no undergraduate major named "premed". There's no need to be pedantic. But US medical schools generally require a 4-year undergraduate degree (BA or BS) and certain coursework (biology and chemistry, among others). [1][2]

> will somehow lead to reduced healthcare costs

And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.

1. https://www.shemmassianconsulting.com/blog/medical-school-re...

2. https://www.hopkinsmedicine.org/som/education-programs/md-pr...


> And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.

It's "controversial" because you are conflating two issues.

Shortening the path will at most lead to a very minor supply increase at the time it is implemented; the gains don't compound. Without increasing the total number of admission spots (or more critically, residency slots), the overall supply will not be meaningfully increased.

Removing a prerequisite (bachelor's degree; which I point out in another comment is not actually required at many schools) is generally unrelated to the supply of US physicians and this is why you're getting pushback.


Yes you have to remove the other bottlenecks in the system too (I talked about residency spots in another comment). This seems like an easy win without any accusations of lowering standards.

> the gains don't compound

You give doctors, on average, an additional 2 years of their life to practice medicine instead of spending them in college on a pointless degree (not to mention, slightly lower college debt when starting out). Multiply that over however many doctors we graduate every year, and it'll add up over time. It's not "compounding" in the mathematical sense of the word, obviously. If you assume that a medical career is about 35 years, that's like an 8% increase in available doctor-years over 35 years (or something like that - the math is a bit handwavy). Without doing literally anything else.

I saw your other comment about degree requirements and I'll respond here. In addition to the consulting website, I also looked at Johns Hopkins and they do have a degree requirement. Thanks for providing that counter-example. I wasn't aware and I'll update my understanding of this.

However, your own source said "a baccalaureate degree...is strongly preferred". So it has to be asked - how many non bachelor's degree holders actually get into med school?

Every US-trained doctor I've had has gotten a bachelor's degree (I read bios when they're available). The ones that don't were foreign-trained. If the number of med school applicants greatly exceeds the spots, I'd imagine nearly all serious applicants are going to get a bachelor's degree to improve their chances. It sounds like you're a doctor - what proportion of people in your class got in without a bachelor's degree?


It’s unclear to me how removing the requirement for an undergraduate degree (side note, it is not actually required at many or most US medical schools) will lower healthcare costs.


> it is not actually required at many or most US medical schools

Source for this? That's surprising to me and a brief Google search tells me the exact opposite.[1]

You really don't understand how reducing the number of years it takes to train a doctor, after they complete high school, will lower healthcare costs? Are you unfamiliar with supply and demand, or the relationship between the cost of production and pricing?

1. https://www.shemmassianconsulting.com/blog/medical-school-re...


The link you posted says this:

> Every U.S. medical school requires the completion of a four-year degree from an accredited college or university.

However, if we look at the University of Chicago's Pritzker School of Medicine as just a single example [1] we see the following:

> "A baccalaureate degree is not required but is strongly preferred by the Admissions Committee."

Given that your reference, "Shemmassian Consulting", appears to be low-quality given that it makes categorically false statements, I won't bother to search for other schools. Suffice it to say that I am aware of quite a few, including my own, that do not require 4-year bachelor's degrees.

Finally, I understand supply-and-demand quite well, and I agree that increasing the supply of licensed US physicians may decrease healthcare costs (but it may not, as excess dollars in the system likely will be vacuumed up by administrators). However, this discussion is about decreasing entrance requirements to medical school, which is completely orthogonal.

[1] https://pritzker.uchicago.edu/admissions/entrance-requiremen...


> people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything

Agreed, but I would go further and say that if demand by students for the training provided by residency exceeds the demand by hospitals for the work provided by residents, I don't see why residents couldn't pay for their training just as they do for medical school. The whole "residency funding" thing seems like a red herring as an explanation.

To be clear, I'm not saying that medical graduates should have to take on more debt to pay for residency, but rather that the reason this doesn't happen is not obvious according to typical economic reasoning.


If you've spent on average ~200K for medical school, how willing will you be to pay to work for 3 to 8 more years before you get a paycheck? Resident doctors already make less than nurses with 4 year undergraduate degrees.


So? People really, really want the prestige that goes with being a doctor. If they could pay for it they would. Physician compensation is heavily weighted towards middle and late career as it is and that hasn’t stopped people beating down the doors to get into medical school. Half the people who currently apply to medical school could look at how crap it is and decide not to and there would still be intense competition.

The below article on how awful medicine and medical school are was written a decade ago and nothing has gotten better. People really like social status.

https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...


I know a lot of doctors and medical students, for the vast majority prestige is not a primary motivator, not sure why you think its the prestige motivating everyone.

Knowing these people, I also get the feeling that if pay were worse / debt was higher they would have pursued alternate careers. If your goal is to make more physicians you don't want to make the job less desirable. There are already paid residency positions that go unfilled every year (not because there arent enough students, but because the students dont want them). I don't know why you think people would pursue positions that they have to pay for.

To your other point on the intense competition: If half the people currently applying to medical school quit applying the quality of your average future doctor would drop.


Just getting accepted to a medical school is pretty hard unless you’re amazing/very good at the tests.

Had a cousin and a friend (both I would characterize as smart and hard working) take several years after undergrad and eventually “settle” for physicians assistant schools.


I personally want my doctors to be amazing and very good. For now tests are a fair proxy, it's the 8 years that seem ridiculous, esp when looking at non US countries.


I would argue that having onerous tests are not a great proxy. Not only do they not necessarily measure how good a physician a student would be, but it also encourages undergraduates to intentionally enter easier/less rigorous coursework to focus more on the exam aspect (though GPA plays a large role as well). I'm sure a psych major may make a fine physician, but I don't want doctors to only be educated in a rather dubious field. If undergraduate education is only a stepping stone towards medicine, then just integrate medical education with undergraduate studies, rather than adding a ritualized acquisition of a bachelor's degree.


Everyone takes the same premed courses though, and you need to be able to teach yourself any MCAT content that wasn't covered by coursework. Sure people will game it, but it's your science GPA that counts, and having people from a diversity of backgrounds is a good thing.


Nah, doesn't matter. There are still the pre-med requirements (organic chem etc -- recall recent bruhaha about that at ?NYU) that can't be sidestepped for easier courses


> For now tests a a fair proxy for that

Is it? Is there a study demonstrating the correlation to pre med test scores to patient outcomes?


Personal intuition, feel free to dismiss.


Makes sense, and seems like a sensible prior.

It just strikes me as something that wouldn’t be particularly hard to answer with a detailed study, and probably is a pretty high value question to answer, so I wouldn’t be surprised if there was a study.

Maybe I’ll poke around this weekend


I agree with your sentiment however it reminds me a lot of the leet code style interviews and all their downsides.


I get what you're saying, but I don't think more doctors is the answer. Hospitals will only hire the absolute minimum number of doctors they can possibly get away with, other than the ones who actually bring in new business.

This is the reason: as soon as the medical industry has established a consensus price for some procedure or other item of care, the hospital administration starts to work on figuring out how to do it for the least possible cost. The price has been set in stone, no need for further justification. Medicare or whoever WILL pay that much. The price is fixed so the only knob left to turn is cost, and cost will be reduced all the way down, until service is just above a level so poor that patients would decide to stay home.


Possibly part of the problem then is having a for profit medical system?


Totally agree. Also, let people open more medical care facilities. Right now "Certificate of Need" legislation is killing lots of viable options for care _outside_ hospitals.


.


It's not illegal for other entities to fund residencies!

I anticipated your argument in my other comment...


My wife is a physician who works in a critical care setting. She did not read or approve this post; these are my thoughts as someone who hears a lot about the other side of this environment:

For the most part this seems like a sensible and reasonable article communicating what must have been an extremely difficult situation for the author. In case the author reads this: I'm really glad your dad got better and I know everybody working in the hospital appreciated the amount of patience and restraint it seems like you showed in helping him without being that patient family member who goes off the handle about everything. (There are so many of those.)

Many of the issues the author points out are very real - constantly-rotating doctors, attending disregarding consults once the consult leaves the room, the ICU not being set up for anything but bare survival - all of that is totally true from what I understand. I think, if anything, the author fails to understand how systematic and critical those issues are when he says things like this:

> So, digestive issues, hormonal issues, and mental issues all get short shrift. Basically, if there’s an obvious symptom, a consult will come in to try to treat the symptom. Then they’ll take another test in a day or so, see what happens, and go from there. There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though.

I don't think this is giving the medical practitioners a fair shake here. Doctors do a huge amount of this kind of reasoning and research, even in the ICU. The trouble is often not a lack of reasoning, but a matter of, as with everything else you note, resources. Like you realized, the goal of the ICU is "keep patients alive at all costs, and worry about their comfort once they're able to be alive without our help for a while." Judgments are made with that in mind. It's not that they can't do reasoning about complex problems, it's that spending time on a complex but non-fatal problem means somebody with a potentially fatal problem won't get that time, and that's not what the ICU is for. Anything that can be solved later... will be solved later.

So the real question is not "Why didn't they help this patient with his digestive issues?", it's "Why didn't they move this patient out of the ICU once he reached the point where non-life-threatening digestive issues were relatively of any importance?"


It’s also impossible to infer the logical process from a superficial observation of the tests being done - that would be like inferring the code architecture from what’s displayed on an output device, in rare cases it might be possible, but usually not


The author even mentions that a long term stay like their father’s is rare. A lot of the criticisms are about what is, and I apologize for the expression, an edge case.


My wife just gave birth and it was my first multi-night hospital stay. The midnight pokes and checks were infuriating. It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed. Constant nurse changes were difficult too.

On the plus side, I was surprised at the decent quality of food given to my wife. Steamed vegetables and mid grade proteins with every meal.

After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early. Best decision we made and my wife recovered great. With the built in iOS medication reminder app and a blood pressure monitor I was able to manage her just fine.


> After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early.

In my country you don't even stay a single night if everything goes fine. There is no medical need for parents and child to stay at any hospital if there were no complications


Congratulations! We just went through the same thing and decided to leave after one night in post-partum. It's much better to be at home if there's nothing concerning that needs medical attention.

Side note: it was surprising how well the "dad chair" served as a place to sleep after being awake for 24 hours.


Father of four here, had one two months ago.

> It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed.

Yes, and? You're free to go to the cafeteria and buy food or leave and go buy food. And there's usually at least a chair. What do you expect, a Marriott?


The father is the wife (and baby's) advocate in the hospital, and should leave as little as possible. You need to be there for every test and consultation.

So yah, they should be bringing the father food, and there should be a bed for him because the father is critical in having good care for the wife.


I made do, so can you (and all the other dads).


I spent 2 weeks in an ICU due to an appendectomy gone wrong followed by growing open wound and infection. Horrible time from a mental health perspective with visual and auditory hallucinations, feeling of paranoia concerning the medical team and nightmares. Hallucinations and paranoia stopped before I was discharged, but it took a couple of years for the nightmares to subside.

Post-intensive care syndrome is something that happens that hardly anyone who hasn't been in an ICU knows about. Even when I was in the ICU the medical team never discussed it with me. My running joke to deal with what happened is that I aged 10 years the 2 weeks I spent there.


> 1. The ICU is filled with old people... Pretty much all these patients are on Medicare, which means your taxpayers dollars are making this happen.

This ignores the (I think) very strong possibility that the old people are preferentially selected by the system because, thanks to Medicare, they can _afford_ the ICU. Many people aged less than 65 cannot. Consider the idea that if we had something like "Medicare for all", the population of the ICU would better reflect normal demographics.

That said, as a beneficiary of Medicare I can only be grateful. I had several days in a top-quality hospital and a procedure by a top-quality surgeon, and after all the EOBs had come in, I ended paying out of pocket... nothing at all.


Old people having more health issues is not really a crazy observation to make. I would be blown away if medical care needed was equal across all ages.


It wouldn't be. Clearly age brings medical problems. However, I'm saying that the cheap access to hospital care afforded by Medicare, could be skewing the distribution of ICU patients. If we had universal medical insurance comparable to Medicare, the ICU population might be closer to the demographic norm.


Having experience from emergency departments in two different countries with "Medicare for all", it seems pretty much the same everywhere. There are two cohorts that make up the frequent flyers: the old and the drunk/addicts. The former get sick often and when they get sick they don't recover well; the latter end up in problematic situations like falling asleep outside in winter, getting in fights, overdosing or similar.


ability to afford the ICU is not relevant at all when the docs decide to put someone there or not, based on my 14 years practicing in the US. Do you have any experience to the contrary? I’m pretty sure that would be illegal in the US


A very quick DDG search turns up stories from reputable outlets:

"Americans dying because they can't afford medical care"[1],

"66% of Americans fear they won’t be able to afford health care this year"[2],

"Nearly 46m Americans would be unable to afford quality healthcare in an emergency"[3],

"Nearly 1 in 4 Americans are skipping medical care because of the cost"[4],

and more are easily found. If this doesn't reflect people avoiding hospitals, or leaving early AMA, and thus reducing the number of pre-Medicare patients by some amount, I'd be very surprised.

[1] https://www.theguardian.com/us-news/2020/jan/07/americans-he...

[2] https://www.cnbc.com/2021/01/05/americans-fear-they-wont-be-...

[3] https://www.theguardian.com/us-news/2021/mar/31/us-affordabl...

[4] https://www.cnbc.com/2020/03/11/nearly-1-in-4-americans-are-...


That’s the patient choosing not to go to the doctor - how is that the ICU doctor’s responsibility? Are they meant to scour the streets looking for people who need intensive care?


What he wrote about delusions and nightmares in the ICU really hits close to home. When I was younger I ended up in the ICU for an accidental poisoning. Initially I went in and out of consciousness, having horrific nightmares fed by the morbid happenings around me. We had many interesting patients come through the ICU. One person was there for a suicide attempt on prescription drugs. Another person had been in a car accident. At one point we even had a prisoner who had been stock-piling drugs to kill himself on. They had him hooked up to a dialysis machine which apparently works well when the drugs aren't fat soluble? It was like a real life episode of House.

Meanwhile I wasn't mentally doing that great. When I was finally conscious I started hallucinating and hearing voices. I was hearing insults from the staff that weren't there and felt like everything was done with malicious intent. It was quite traumatic. I actually remembered these delusions for years afterwards and had trouble accepting that it wasn't real. It's only been a recent thing that I've even been able to speak about such experiences without shutting down emotionally. The work that doctors and staff do at ICUs is extremely valuable. But it's definitely not a great place for a vulnerable mind.

I feel like there is more that could be done in such a situation. e.g. where someone is profoundly hallucinating. I was over-stimulated and noise was making everything worse. If I just had of had a dark room to recover in I probably wouldn't have been traumatized. Maybe even ear plugs or a mask. But I didn't even have that. I'm also kind of surprised by the OPs story because the ICU I was in was like this closed surgical ward filled with medical staff. ICUs don't really seem like a place to have visitors. I get the feeling many people there aren't even going to be conscious. OPs dad is lucky to have had such good family support.


> So, when it comes to prescribing (...) Giving psychiatric medicine “as needed”? Go wild.

This implies a lack of duty of care which is painfully unfair.

As a counter story to this I have a friend of mine who is a _former_ ICU nurse with a gigantic scar on her forearm.

I much later in our relation found out that the scar is from a patient who basically ripped her forearm biting down on it while she was trying to stop him from tearing out a central line in his own neck.

It's ironic that in trying to stop a patient from having a massive central line bleeding she ended up bleeding herself.

Outside hospitals we fail to realize how disoriented and irrational patients can get when coming out of anesthesia or with certain diseases.

So yeah 'as needed' is absolutely right because everyone is entitled to work in a safe environment.


his "go wild" sounds like it's blaming the nurses, which it is partly, but I think moreso he's trying to point that this situation is just pretty awful. Or at least he should be trying to focus on the bigger picture. I certainly don't blame the nurses for showing up to work and trying. But I think we can all see how the 'path of least resistance' and financial incentives also leads us to this 'medical factory' type of treatment of people. And that's not the nurses' problem, that's just all our problem.


It’s worth noting that the patient’s condition is not an independent variable with respect to the level of care - the author’s father got moved to step down because they got better…and I’m glad to see that they continued to get better in step down.

A UK judge once talked about balancing the “benefits and burdens of treatment” when making medical decisions, I think that’s a good way to think about it. The benefit of ICU care is less chance of deterioration and death - the burden is the pain, medication effects, discomfort, noise, confusion and many other things described in the article.

It would also be less confusing for the family if the doctors could explain their thought process well, but a) not everybody is good at this, b) not every family member can necessarily even understand or remember this when they are distraught and sleep-deprived, and c) the health system (and patients) don’t want to pay for the time - if they paid double, the doc could spend twice as long with them, as happens with boutique / concierge doctors.

Regarding the ICU doc disregarding the consult recommendations- the ICU described sounds like a “closed “ ICU where the intensivist makes the final decision, vs an “open” icu where a hospitalist will often be the one making the final decision regarding care. Either way, it seems obvious that someone has to coordinate the care and decide what’s important right now and what’s not - there are many tests that a consultant may recommend that won’t improve the chances of the patient improving right now, and can be done later on the med-surg floor of the patient survives that long. Many of the consultant recommendations may also be contradictory, someone has to take responsibility for picking and choosing a course of action

[edit: fixed typo]


For older patients and those with significant co-morbidities, we often advise against intubation and ICU admission in the UK. Usually if the disease process can't be reversed on the ward with current therapy, it is often unlikely in this group of patients for it to reverse on ICU. However, it does depend on the context. There was an interesting article that talks about doctor's choices as an end-of-life patient [1] - they often choose not to opt for aggressive life-prolonging treatments because they know how it is like. I think that doctors need to improve the way we talk about death with patients, and doctors can be just as guilty as everyone else at ignoring the inevitability of death.

[1] https://www.zocalopublicsquare.org/2011/11/30/how-doctors-di...


From personal experience, one of the most frustrating things about the ICU (if you're there for any anything beyond a day) is dealing with the variability in the availability, skills, and temperaments of the nurses on duty. The 'right' nurse can make a huge difference in how fast the patient recovers and how difficult the stay is.


It's politically toxic to discuss but a ton of money goes to keeping people not dead (not really alive either). You could give a lot more people medicare/medicaid if we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.


Yes, certainly people in medicine are aware.

> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.

Often it's a 4 week old baby.

For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.


Could you please stop creating accounts for every few comments you post? We ban accounts that do that. This is in the site guidelines: https://news.ycombinator.com/newsguidelines.html.

You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...


> Often it's a 4 week old baby.

You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.


Your human dignity is not predicated on how much pain you're in, how awake you are, or how able you are.


You mean yours.

My human dignity does depend on whether I have to endure the rest of my life pooping my pants, not remembering my own name, and hooked up to some noisy machine telling my lungs to breathe and my heart to beat.


Uhh, yes it is to all three of those things.

If I'm in pain, am delirious, and am unable to operate in the world. I've lost my dignity.


Just because you feel undignified, or humiliated, or useless, does not mean that you are. Don't swallow the lies.


It's pretty well know and often discussed that up to 1/3 of Medicare spending is wasted. Being fee for service doesn't help but neither does spending 13-25% of all medicare dollars on end of life care[1].

What's worse is how much of Medicare's wasted spending goes to harmful treatments.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:tex....


Many of the top causes of death, per the CDC, are from diseases that can be prevented or naturally mitigated. We're all going to get old. We're all going to die. But carrying two or more "pre-existing conditions" into your later years is going to decrease your quality of life, as well as your use of healthcare.

My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.

Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.

It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.


> My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy.

The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.


I think the root of it is recognition that mental health is as important as physical health, and that losing weight isn’t as easy as many people assume, and shouldn’t be done the way many people try - so actively shaming and criticizing fat people for being fat is of negative health utility overall.


> o actively shaming and criticizing fat people for being fat is of negative health utility overall.

Fair enough. But then what do you suggest we do as an alternative to normalizing diabetes and obesity?

To your point - kinda - about losing weight. Changing behavior isn't any easier when there are too few environmental signals to nudge behavior in a more healthy direction. As humans, we are wired to assume the norm we see around us. How do we reverse the tide when abnormal (and unhealthy) has been normalized? When everywhere you look, there are people just like you?

I do agree. Mental health is important. But a component of that is (dealing with) adversity. I'm certainly not condoning repetitive malicious bullying, but the current climate has outlawed any/all references to traits connected with being unhealthy. At this point there are no social deterrents, are we really better off?

Have we robbed Peter to over-feed Paul?


I think that it's also important to realize that maximizing "health" is not some kind of absolute goal. Not every aspect of life needs to be optimized to the highest level.

Of course, obesity is a huge issue (especially in the U.S. compared to many other "developed" countries) that can affect people's lives negatively and causes further medical issues such as diabetes, and ultimately can prevent people from leading a life that is as fulfilling and meaningful as they would have liked.

But we are still dealing with people here, not rats in a laboratory experiment, and I think the issues that directly follow from being obese are already bad enough that it does not help to pile on more shame by treating those people as being "weak-willed" or something of the sort, or denying them basic human dignity and respect for being outside the sacred norm. Do we really have to add artificial negative consequences for being overweight? Does that help those people have a more fulfilling and meaningful life?

I don't think people will just forget the direct negative physical/social consequences of being overweight by not being reminded of them all the time in a moralistic tone (and even just reminding people of such information can be moralizing, depending on the context in which the information is provided).


Any form of euthanasia runs into the legal and moral problem of who decides? And why?

You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.

Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.


I don't think its politically toxic, but rather, extremely humane that we care for our elderly. The real unfortunate part is that we, in the working class, have to make due with sharing slices of the pie so more money can go to our exploiters and owners - especially in the US, we are such a wealthy nation, and yet here we are bickering around who deserves care based on age. Sad.


> I don't think its politically toxic

Ever hear of the Obamacare death panels? The ones where doctors would decide if your loved one was too old and shouldn’t get treatment?

Yeah. That’s this.

What it really was that Medicare would pay for consultation with doctors (?) to discuss end of life care and setup living wills and DNRs and such if the person wanted.

That way if something happened and they were taken to the hospital they could be treated the way they wanted to be and not stuck in a coma on a vent for the rest of their life if that was against their wishes.

But the Republicans branded then “death panels” (which for political purposes was brilliant). So the choice of having help making those decisions was removed.


We don't care for our elderly. We fear death.

If our society really cared for the elderly, they would be integrated and respected, not segregated and shunned. We do the latter because we fear age, sickness, and death. Fear isn't caring.


> We fear death

In the US. It's perhaps the most striking difference that hit me during my stay overseas. In the Old World we occasionally get people completely panicking about their own death. In the US, seemingly _everyone_ is like that.


I'd like to hear how elders are treated in these societies that don't fear death as much.


I'd wager: not very differently. But not out of fear. The social isolation of old age is the same everywhere. Young people have their own lives to live.


> The social isolation of old age is the same everywhere

That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.


Well, yes I see what you mean. What I meant was: it's the same in the US and western Europe. But certainly if you go to more "old fashioned" places, the elderly usually live with the family and are taken care of. To be fair, this still happens even in "advanced" western societies. I seem to recall this also goes together with a lot of elderly abuse.


I wonder if elder abuse is correlated with younger people "having their lives to live".


I disagree, spending on these things is growing at 2x GDP growth so yes more of the pie is going to this. What I'm suggesting is that at some point the pie isn't big enough for this. No matter what happens eventually standard of care will roll back/fewer people will be covered etc. Ideally we can innovate out of this situation but after spending 8 years working in healthcare I've gotten cynical about it.


Where do you draw the line? At what age, what illness do you refuse to treat a patient even though he may not want to die?

You could give a lot of people medical treatment with a proper healthcare and tax system. Why don't we try that first?


I assume we start by getting more information from patients about their wishes, and then following them accordingly. A large number of elderly people don't want hopeless and unpleasant medical interventions, but end up having them anyway because no one asked them.


> Where do you draw the line? At what age

30? or 21, if you prefer the book ;p


At some QALY/$.


QALYs are hardly non-controversial.


The original comment by questime literally said we should discuss the general topic even though it's controversial.


Canada is actually moving in that direction with their medical assistance in dying laws.


Is it the same dilemma if we can kill one to save more?


This is an oft-repeated piece of received wisdom that is empirically untrue.

https://www.statnews.com/2018/06/28/end-of-life-health-spend...


Wow: just sample bias! We need to also look at the old people who had expensive care and survived (95% of costs in that article). Money does gets spent on hospital care just before death (5%), but predicting how to avoid “wasting” that money is hard.


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