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Comment by lsc | Hacker News Reader

Yeah, I'm personally not too concerned with the "stuff" end of things. This is America; in spite of rhetoric to the contrary, we remain a manufacturing powerhouse. Apply enough money and we'll get whatever "stuff" we need on pretty short order.

I think the big problem is medical technicians and doctors. My feeling is that we should be focusing on training up medical people on a massive scale, as that's something that the USA is notoriously bad at. Perhaps the military could provide medical technicians the fastest? lots of healthy young people who are trained in the use of serious PPE? (I wonder how the procedures differ between nuclear, chemical and biological threats like these?)

People talk about beds... but the problem isn't physical beds. I could make you a physical bed. the problem is doctor and medical technician labor to make the bed useful.

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The problem is threefold. We need: 1. ventilators 2. PPE 3. healthcare personnel (respiratory therapists). In the short term we should train existing doctors, physician assistants, and nurse practitioners in respiratory therapy ASAP. But without PPE they put themselves at risk, and without ventilators the patient may die anyway.

We need all three, and there's a worldwide shortage. That is the bottleneck.

I'm not questioning the need. I'm just saying that it seems to me a lot more realistic that we'll be able to short-term ramp-up production of 1 and 2 than it is to think we'll be able to adequately ramp up 3.

The stories I hear from medical people I know (and this is just anecdotal) is that they are only given serious PPE when they know there is an infection, but it's less clear if that's just standard policy or if that is due to limited supply.

I do agree that if PPE isn't used early and often here, we're going to be short medical personnel, and I think getting those back online is probably going to take longer than throwing money at manufacturers to build more PAPRs.

It’s not that we’re bad at training medical personnel. It’s that the AMA acts as a cartel to limit the number of physicians train to keep income high. We just need to allow more people into medical schools and make more residencies available.

Yeah, remove the limiter, and how long does it take to make a doctor? I mean, sure, some people are saying that this thing is still gonna be here in four years (I am not a medical person, but that's what some of them say. something about the type of virus this is that will make a vaccine difficult) so that might not be a bad idea, but... I think we probably need to be focusing on how we can increase medical capacity four weeks from now more than four years from now.

Hell, we'll make it so med students can get a proper night's sleep during their residencies while we're at it.

the disrespect for sleep the medical profession has is insane.

If someone is gonna be cutting on me, I want them to have a good night's rest. They tell me to sleep consistently and well quite often. seems like if it's good for me it would be good for them, too.

it's a hazing ritual

if too many make it to be doctors, the pay won't be as good.

We should cut about $50-100B out of the military budget and make it for training medical personnel without raising tuition because it doesn't matter if there's no population to defend or recruit from.

Two weeks...

> Yeah, remove the limiter, and how long does it take to make a doctor?

Undergraduate entry medical degrees in Ireland are either five or six years with summers off and ample other holidays. Post graduate is four years like the US but pre-med doesn’t exist. You have to learn the necessary content yourself ahead of time and if you fail the exams that’s your problem. You can get in with a degree with no science content whatsoever as long as you have high enough grades in your Bachelor’s. I believe during WWII the US ran some schools at three semesters a year so people were done in two years, eight months. A newly graduated doctor then has residency, a year of 60-100 hour weeks of on the job training. If some of the generalist training was cut you might be able to get someone able to do routine medical care in their specialty, like a nurse practitioner in three years.

It's easy if we are willing to cut red tape and willing to prioritize people over pets. Veterinarians need almost no training to do the job. Test runs done for emergency preparation have proven that veterinarians do a better job than all medical professionals who aren't already specialized in respiratory care.

>Test runs done for emergency preparation have proven that veterinarians do a better job than all medical professionals who aren't already specialized in respiratory care.

That's amazing.

We need to do whatever we can to increase capacity, and that involves breaking up the AMA cartel. This isn’t a two weeks and gone crisis, sorry.

The problem with this is that until we have better means to train people without exposing them to real situations, increasing the number without lowering the overall skill level is an incredibly hard problem.

Well there are about to be a lot of real situations.

For one specific type of illness. But we do not need staff that knows how to handle only rare exceptions, and that is the problem.

Training people to respond to this one situation so that they can respond to this one situation is fine. After covid19 is resolved they wont be needed anyway.

There's no shortage of people with ailments... A lot just go untreated or are queuing for a long time.

No, but there is a sufficiently large number of problems that relatively few people suffer from that even with people specialising there are plenty of problems where getting people to a point where they are competent enough to participate in operations on real people, and then get them enough experience to be able to do it unsupervised is a challenge.

We can specialize more, but that has its own problems in terms of e.g. availability to deal with urgent cases. And ultimately we do not get away from the fact that giving enough people enough experience even with relatively rare situations is a big challenge.

Eventually we will be able to simulate the situations well enough, and this problem will go away, but it simply is not as simple as throwing more bodies at it.

The number of hospitals and hospitals beds is also controlled by certificates of need.

Certificates of Need were something _hospitals_ themselves lobbied for. It's a case of "this is awesome when it protects me, and an aberration when I'm on the losing end".

Certainly politicians enacted such things, but I'm not losing sleep over the hospitals. Only us mortals, stuck with the cost of the system.

Just an idea (that would never happen)-

Why not make it like Engineering?

You do your 4 year undergrad and at your first job, no one trusts you. Your supervisor/senior engineer checks Everything you do. You are reserved for paperwork and unskilled manual labor which is also checked. After a few years (4) you get some Freedom, but still checked by your seniors. Anything important, even when you are a senior engineer goes through your Managers and directors.

I don't see why this system wouldn't work in medical. We build airbags and bridges. Both safety critical.

I would even say having 1 physician is more dangerous than having a team of Engineers with less Schooling.

The medical system works pretty much like this. After studying medicine you have a long practical education where nobody trusts you.

Yes, but we also have the “fellowship bottleneck” and limited med school seating we use to keep doctor salaries artificially high.

In addition to training new doctors, we should also just loosen restrictions for doctors to enter the US and use their medical expertise.

Doctors wouldn't let either of those things happen because it would lower their salary. The AMA is a powerful lobbying association, no way any law that lowers doctor salary would pass.

Lobbying power can be confronted by other considerable lobbying interests. Large healthcare conglomerates would seem to have considerable interest in reducing labor costs.

A crisis like this would be the perfect opportunity to fix some of these supply side issues. Lobbying is less effective when voters are paying attention and the government is in crisis-response mode.

You don't need full MDs for respiratory therapy, or for many medical treatments. PAs and RNs can do a lot, and it's far easier and less expensive to attain those certifications than full MD.

For sure and we should also expand the jobs that PAs and RNs are allowed to do.

When choosing a primary physician at one of the San Francisco Kaiser Permanente campuses, I noticed that a substantial number of doctors had overseas medical training. Which was fine by me--I'm an enthusiastic Kaiser member and support their cost management strategies--but I found it interesting.

Kaiser also recently opened their own medical school: https://en.wikipedia.org/wiki/Kaiser_Permanente_Bernard_J._T...

So they're now using a mixed strategy of both out-sourcing and in-sourcing medical training to address high costs.

> So they're now using a mixed strategy of both out-sourcing and in-sourcing medical training to address high costs.

Not as much as they could though - there are still federal caps on the number of fellowship seats available as well as pretty strong restrictions for physicians coming from overseas (although if I recall correctly, California has less stringent restrictions than most)

We discuss insurance as a big part of the cost problem, but regulatory capture on the supply end is another huge (and unnecessary) factor.

How do you think medical education works? Because it's basically exactly this.

No. there is an extra 4+ years of classes.

There are two extra years of classes for med students, at which point they begin doing rotations through all the different specialties. During rotations, they are essentially “reserved for paperwork and unskilled labor which is also checked.”

This process continues in intern year and residency, during which time they gradually build competency and trust.

Much of medicine in the US is delivered by nurses, who have a training regime even more similar to what you suggest.

Categorically false for modern medical school. My daughter started rotations almost immediately, alternating with classes every couple of months throughout. She rarely did 'paperwork' (computers), had close patient contact immediately and was doing procedures almost from the start, under close supervision. Her final rotations had her in the operating room, handling her own patients from triage to discharge, doing night shifts etc along with a resident.

Things have changed rapidly in medical education. At least some places.

More medical personel would be great. Another option would be to train contact tracers, much easier to train than medical personel. That is one of the reasons for Singapore's success, I belive. https://www.bbc.com/news/world-asia-51866102

Until we lock down, I suspect that it is far too late to trace contacts. I know of at least 3 different secondhand exposures to Covid, just for me.

Just spitballing here, but to what extent can we streamline or automate COVID-19 treatment for non-comorbid cases?

My feeling is that we should be focusing on training up medical people on a massive scale, as that's something that the USA is notoriously bad at

Or just lock down nationally now, including full lockdown in major cities, and none of this will be necessary. The only reason this is going to get out of control in the US is the lack of testing and the lack of controls being imposed.

By the time they are imposed, it will be too late and more people are going to die because of that.

Nationally lock down now, and once we unlock down the virus will come back from foreign countries and be just as much of an issue.

Slightly more of an issue in fact, because we will have just shot ourselves in the foot in terms of capability to deal with it via manufacturing.

It's a very difficult problem. Here is a paper outlining the cost in lives of your proposal.

https://www.imperial.ac.uk/media/imperial-college/medicine/s...

Exactly. The goal of the lockdowns is to reduce the number of concurrent cases, thereby allowing time for medical infrastructure to scale up.

I wish this was true, but from all appearances the medical infrastructure is not scaling up at a reasonable pace... i.e.

> The Trump administration has not yet formally asked GM to use its network of plants and suppliers to make any medical equipment, the person said. (From the Article)

> Tesla makes cars with sophisticated hvac systems. SpaceX makes spacecraft with life support systems. Ventilators are not difficult, but cannot be produced instantly. Which hospitals have these shortages you speak of right now? (From twitter 9 hours ago https://twitter.com/elonmusk/status/1240492347835604992)

This is a messaging failure.

We cannot just lockdown and “none of this is necessary.” There is no scenario short of locking down for 10 years that would be able to manage with the number of critical beds we actually have. We need to dramatically upscale capacity (which means training new doctors) and quarantine.

It cannot be an either/or.

You're forgetting the development of a vaccine. With enough time (10 years is way more than enough), a vaccine will be developed and deployed, and that capacity won't be needed because far fewer people will contract the disease and develop symptoms requiring hospitalization.

The problem is, developing and testing a vaccine takes some time. How much time do we have before the global economy totally collapses?

> With enough time (10 years is way more than enough), a vaccine will be developed and deployed

Based on what? It’s been more than 10 since SARS and we still don’t have a vaccine. I think you’re making a lot of assumptions about immunization when it is far, far too early to know. Also, the point is that we don’t want to be quarantined for 10 years, we want to build the capacity now.

They probably never developed a SARS vaccine because it didn't turn into a major worldwide pandemic. There's lots of diseases that don't have vaccines mainly because it's seen as not worth the effort or cost. SARS and MERS looked scary at first but never got this big.

As an addition here, look at Ebola. It was perfectly feasible to create a vaccine, but no one bothered as long as it was confined to Africa. As soon as white people in western nations started getting it, then suddenly there was a huge effort to create a vaccine.

I agree with you... last week.

I mean, sure, we should lock down now, but my feeling is that it's mostly too late for the urban areas.

The rural areas might have a chance... they need to lock down hard right now. But... from talking to rural family... I'm not sure that's culturally possible.

Yes you're probably right.

No this isn't true. The competition to get any residency slot is insanely difficult. There are people who graduate from medical school that apply to hundreds of residencies every year and still don't get anything.

There are more residency spots than med school grads. If a grad doesn't match its because they didn't list undesirable programs, not because all the slots filled.

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