The darker side of being a doctor (2017)
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[0] https://www.medicalrepublic.com.au/dark-side-doctoring/1063
The darker side of being a doctor (2017) - https://news.ycombinator.com/item?id=40025261 - April 2024 (500 comments)
* high turnover impacts efficiency.
* Exhausted doctors make mistakes which will lead to malpractice lawsuits
I think incentives are misaligned across the board in the medical industry. This goes for doctors, patients, hospitals, insurance providers, pharmaceutical companies, medical device manufacturers, medical equipment/material supply companies and probably everyone else connected to the industry.
These poor incentives lead to pathologies that drive up costs and result in poor patient outcomes.
Anyone who has encountered a "prior authorization" when trying to get a time sensitive medication filled has experienced this.
Some doctors are opting to "drop out" of the counterproductive insurance game by accepting only cash payments, but that only solves a small part of the problem.
My eye doctor (damn good specialist) told me about how bad private equity folks over the medical industry. He is grateful to his practice has been able to avoid the private equity vacuum cleaner.
You're right that incentives are misaligned. It seems that the choice is either to provide good-quality medical care or feed the ravenous beasts of the finance industry.
I always suggest the "principle of lost packets".
Let things fail early to inform about your limitations. If your internet connection speed is 30Mbps and you send 100Mbps upstream - some packets will be dropped. The earlier packets get dropped - the better for the connection, because feedback will be faster. Ideally at your router.
Practically speaking, for the case in the article: We have 6 doctors working at our hospital. One doctor quits. Look, we're doing ok with 5! Let see, can we do with 4? Sure. Ok, now we're with 3 doctors and things are failing... So, 4 is probably optimal. Well, that 4 doctors working on the edge. Would this doctor "fail the hospital" earlier, - hospital will receive that signal, and doctor's count will be higher.
Few years ago I was promoted to be QA Manager, and learned very quickly, that a lot of people will make sure that I know, that if our QA team will not sign off on that release - we'll lose that deal, or make that client unhappy... At the beginning I tried to accommodate. But that was totally unsustainable. So, I quickly learned to give people realistic expectations: - no, will not complete QA by Friday, tell the client whatever you want, or give me 2 more people (and the only people they can give me were Developers). - no, will not have that release ready by 12th, you should have consulted with me before making promise, not it's on you to figure out, not my headache.
Of course, the real problem is running medicine like a business, but technology can only serve the megamachine...
It's insane that a truck driver _must_ have 8 hours of sleep before work (they should, not arguing against it), but a surgeon can work with a couple of naps for days.
Having been exposed to this only a little, I can imagine what kind of garbage the medical staff has to endure to make their reports and time keeping.
Also, this is one place where AI can potentially provide both a more efficient system and greatly improve job satisfaction for physicians. Automatically generating and updating medical records based off ambient recordings of patient interactions fits right into LLMs wheelhouse.
> Also, this is one place where AI can potentially provide both a more efficient system and greatly improve job satisfaction for physicians. Automatically generating and updating medical records based off ambient recordings of patient interactions fits right into LLMs wheelhouse.
No, LLM's are not reliable enough for that.
If the technology sucks and is in fact a regression, the solution is not to hope yet more half-backed technology will fix the problem. The solution is to dump the technology until someone can actually do it right.
If paper charts are better, go back to paper charts...and maybe hire a digitization/data entry team to realize whatever benefits to electronic records there are.
It requires physicians to read and verify the LLM output before signing it. And not just rubber stamping.
There is a precedent for this with speech recognition, which a lot of doctors use to dictate their documentation. Speech recognition isn't completely reliable either, so the doctor needs to be diligent to review before signing. And not just assume it's all correct.
Then what's the point? That's not going to provide a "more efficient system and greatly improve job satisfaction for physicians."
AI would only improve the situation if it can actually be trusted. You're actually making things far worse if you replace a "production" task with a "continuous monitoring for errors. Humans are terrible at the latter.
> There is a precedent for this with speech recognition, which a lot of doctors use to dictate their documentation. Speech recognition isn't completely reliable either, so the doctor needs to be diligent to review before signing. And not just assume it's all correct.
The one transcript like that I've seen had obvious speech recognition errors, when the notes got to my primary care doctor.
I heard a theory once that there is an artificially high barrier for who can become a doctor, and lowering that barrier by allowing doctors to specialize early on/not spend as much time studying fields they won't work in, we would have a higher supply of medical staff. As a layperson, this makes sense to me, but I also don't know what I don't know.
I have a lot of respect for anyone who works in healthcare.
Expanding residency to cover all qualified MDs would be a great first step.
https://www.nytimes.com/2021/02/19/health/medical-school-res...
- When the goal of medicine is profit instead of helping patients the outcomes will be poor.
- When the goal of education is profit instead of teaching students the outcomes will be poor.
- When the goal of politics is profit instead of collaboration the outcomes will be poor.
- When the goal of business is political, educational or medicinal the outcomes will be poor.
Generic formulation:
Any attempt to apply a metric that works in one context to the entire system will result in poor outcomes.
It is no wonder that people have lost whatever little confidence they had in "the system."
No one will give a damn the next time a crisis rolls around and it will.
"In 1978, a trio of researchers at Northwestern University and the University of Massachusetts attempted to answer this by asking two very disparate groups about the happiness in their lives: recent winners of the Illinois State Lottery — whose prizes ranged from $50,000 to $1 million — and recent victims of catastrophic accidents, who were now paraplegic or quadriplegic. In interviews with the experimenters, the two groups were asked, among other things, to rate the amount of pleasure they got from everyday activities: small but enjoyable things like chatting with a friend, watching TV, eating breakfast, laughing at a joke, or receiving a compliment. When the researchers analyzed their results, they found that the recent accident victims reported gaining more happiness from these everyday pleasures than the lottery winners.
This is how the study is usually written about, in a “gee whiz, ain’t that counterintuitive?” kind of tone. But what’s really striking when you look at the results reported by the researchers is how close their answers actually are: On average, the winners’ ratings of everyday happiness were 3.33 out of 5, and the accident victims’ averaged answers were 3.48. The lottery winners did report more present happiness than the accident victims (an average of 4 out of 5, as compared to the victims’ 2.96), but as the authors note, “the paraplegic rating of present happiness is still above the midpoint of the scale and … the accident victims did not appear nearly as unhappy as might have been expected.”
This is partially because of what’s become known as the hedonic treadmill, or hedonic adaptation, that annoying tendency humans have to get used to the things that once made them happy. I particularly love how the authors of this 1970s paper phrased it:
Eventually, the thrill of winning the lottery will itself wear off. If all things are judged by the extent to which they depart from a baseline of past experience, gradually even the most positive events will cease to have impact as they themselves are absorbed into the new baseline against which further events are judged. Thus, as lottery winners become accustomed to the additional pleasures made possible by their new wealth, these pleasures should be experienced as less intense and should no longer contribute very much to their general level of happiness."
I feel like this happens a lot with creative people as well--an artist can become successful and widely respected, but still become deeply unhappy if their skill or audience declines, regardless of financial success. It is the first thing that comes to my mind when I hear about celebrity suicides--Robin Williams, Naomi Judd, Anthony Bourdain.
If there's no increase in wealth or station, there's no dopamine. And that is depressing.
[1] https://www.washingtonpost.com/technology/2024/06/13/tesla-s...
Just don't fix society, let capitalism sell you solutions to a broken society: it's more profitable... /s
Medical providers care about people, and indeed are responsible for the health of their patients. Some of those patients turn around and bite them. Others die - some die at your hands. Providers, especially doctors, take responsibility for that, emotionally and otherwise.
No person and no system of support can be designed to completely avoid that. There is no religion or personal discipline that will erase the emotional and moral cost of hurting people you're trying to help.
Some say their lost patients help them do better for their present patients. It's a bit like Lincoln saying at Gettysburg that these young boys did not die in vain - while knowing many were avoidable.
Medicine may be a business, and it may even be a calling. But just realize that people doing medicine lose their innocence, in ineffable and unsharable ways, and try to respect that.
Is there really enough supply of new doctors coming in that the hospital can just fire them all and replace them with doctors willing to burn themselves out? -> in part yes there are ( in some fields) but what would happen is that patients would be shifted to other facilities that have staff to see the patients, also when you have 400-500k of school debt its hard to refuse work
Or would it mean the hospital would have no choice but to hire additional doctors so that each one would only have to work a sustainable number of hours? -> this happens as well, they hire locum tenens docs to fill in gaps ( higher short term expense in exchange for not giving staff docs what they need)
Sure, but that isn't the case in this linked article, it seems. Being on call for emergencies, doing elective surgeries, refusing to do that doesn't count as patient abandonment as i understand it. Only when you are actively taking care of someone can you not leave them.
> in part yes there are ( in some fields) but what would happen is that patients would be shifted to other facilities that have staff to see the patients, also when you have 400-500k of school debt its hard to refuse work
Ah, yeah then that's the main problem. There's such an excess of supply that hospitals can afford to treat doctors like crap. Same idea Amazon has about its workers. In that case, hopefully articles like this will make people realize becoming a doctor is a bad choice, and reduce the supply and allow stronger employee bargaining positions.
Of course stronger regulations would always be a better option for this case, but i don't see that happening.
In the end I don't know where the solution lies, sometimes I feel the best solution is to re-design everything from the ground up. Other times I feel like regulation would help, but it would have to come from someone who practices actual medicine, bureaucrat.
The solution to the problem is 15 years before now, not today when there are so many conflicting force out to crush you.
If you try to get out lots of people blame you or sue you.
I got out. Not by being smart or inciteful but by being, as other people called it "lazy".
IT Director of 45 people, high pressure environment, 6 figure salary in 2001, DOT.COM style but not in silicon Valley. I was at my Peter Principle Level of incompetence. This was my 3rd dot.com job running at a frenzied increase in responsibility.
No golden exits. Just layoffs when money ran out.
Luckily it went bankruptcy too. Dot com bust happened. No new Directorship to step into. To get back on the hamster wheel I would have to get an MBA. Other colleagues did. It was not for me. I would have imploded too, if I tried.
Lots of acquaintances wondered why I was so under employed after 20 years of ladder climbing. In absolute $ I am still not back to the number I made back then. Life since then has given me other stresses that would have made today unbearable if I continued.
Everyone who is under those crushing stress today had a set of decision that (their own and other peoples) that corralled them into the situation. After a while there seems no escape.
The people who "tsk tsked" when I left things behind did not consider the consequence of the future.
I am at the end of my career (45 years since first $ in IT). I have "enough money". People are still telling me I should work hard and achieve more. Really want to retire and contribute to society in another way.
If I'm on the table, and something unexpected comes up, how much pressure is the surgeon under to take a short cut to ensure he stays under 14 minutes? Or make a mistake because he's rushing to meet the deadline.
I'm a pretty staunch capitalist, but this further reinforces for me that medicine needs to be completely divorced from the profit motive. Costs should only be considered in order to treat more patients better with the available resources. But never to increase executive pay or shareholders' stock price.
Then to go on sadfishing with this border-line masochism in a blog post...
Being a surgeon doesn't have the same level of demand as a role in family medicine. Both roles provide an income for sustaining oneself, even through student loans. Also, the subject in this article has "been a doctor for 13 years".
why would you blame someone for wanting to have a family? do you hang out with the grinch?
I don't presume anyone can have and do everything. There are constraints on life, and concessions need to be made for certain goals.
Not, I don't want a surgeon pushed past the point of exhaustion and sanity operating on you?
I assume many doctors and hospital administrators, like the overall population, are money or status hungry, and they are willing and able to hurt people to maintain their lifestyles.
There are no regulations enforcing transparent reporting of less than optimal surgical outcomes or what those optimal results are. I would be more worried about that.