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Comment by hoosier2gator | Hacker News Reader

As a physician who does care, I found it interesting that he chose to include doctors in this tirade but then patted himself on the back for squashing bugs quickly and feeling badly about having written buggy code. I know that there are outliers, but in meeting and working with literally hundreds of other physicians at this point in my career, I can count on one hand the doctors who truly do not care. And boy do we feel bad when we make a mistake.

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A lot of physicians have terrible bedside manner and that is going to be one of the biggest criteria a non-physician is going to use to judge how much they care.

And I don't think that's unreasonable, either. It's necessary for a physician to communicate effectively with their patient. Trust is a requirement to work effectively together. If you can't establish that, then you've failed. Encounters with doctors shouldn't feel adversarial.

in situations like that, i like to think about Berkson's paradox [0].

In the overall population, bedside manner and medical aptitude are likely uncorrelated. But the individuals that fall into the quadrant of bad bedside manner AND low medical aptitude will be filtered out of the profession. That means that in the remaining population, you have an externally-induced negative correlation between bedside manner and medical aptitude.

So if you find a doctor with bad bedside manner, they're likely to have better medical aptitude otherwise they would've been filtered out.

[0] https://en.wikipedia.org/wiki/Berkson%27s_paradox

There are plenty of professions where it makes sense someone unpleasant still has a job because they're actually hyper competent (like software development) but why would physicians be filtered out of the profession for poor bedside manner? In what part of the world is there a surplus of supply of doctors that would allow for that?

I think you missed a bit of nuance. Psychologically, people are more likely to pursue a malpractice case against an incompetent physician who has poor bedside manner rather than an incompetent physician who has excellent bedside manner. So that specific quadrant would be penalized the most.

or doctors with bad bedside manner could move into non-patient-facing roles like research or pathology

TIL that there's a name for it. I always just sort of intuited this phenomenon.

"In the overall population, bedside manner and medical aptitude are likely uncorrelated."

I'd [citation needed] on that, depending on the condition.

In that for some conditions, successful diagnosis and treatment across a wide range of the population (not just the most educated, articulate, mentally with-it and compliant quartile) is going to depend on being able to get qualitative information from the patient, and interpret that correctly.

Equally though the medical profession has enough specialisation in terms of role to be able to put the right personality types in the right jobs.

citation: i made it up based on my intuition because this is a thought experiment to illustrate a paradox.

also "bedside manner" is not just about conveying information. that would be a big part of successful treatment.

if you ask people about bedside manner is all going to be about personality and emotional sensitivity (where they gruff? did they make you feel bad? etc). somebody can be amazing at conveying accurate information but come across as a complete asshole, and those are the 'bad bedside manner' docs.

I think this application of Berkson's paradox is misleading. A physician can be expected to have a high medical aptitude because of training, not filtering. Medical degrees are not withheld from people with low medical aptitude and given to people with high medical aptitude, people are trained then filtered.

> So if you find a doctor with bad bedside manner, they're likely to have better medical aptitude otherwise they would've been filtered out.

I propose the opposite, a doctor with bad bedside manner likely has lower medical aptitude. I believe there is training for doctors to improve their bedside manner. Then "trainability" may be a latent factor which correlates the quality of a doctor's bedside manner and medical aptitude.

The entire article is a form of engagement bait. It’s a pile of stereotypes with storytelling. Paul Graham does the same thing. Arguing about which stereotype is true or false… you’re just playing into it.

And in particular engagement bait, when you're blogging or writing, requires you to not be circumspect but rather be polarized and absolute in what you say.

My mother is a nurse practitioner who works in an acute care clinic, and I can say that she feels horrible when she makes a mistake, learns that one of her patients’ conditions has worsened and they’ve been hospitalized, or — worst of all — when they die, even if it was expected.

My personal experience with multiple doctors, some in primary care and others in hospitals, is that they often don't care and just want to get you out of the door.

Bring up some symptoms not immediately easily attributed to something? Sorry, those are "nonspecific symptoms" and they can't help you. Maybe see a specialist, maybe not. Figure it out.

Obviously this isn't all of them, but it is definitely a decent chunk.

Regardless of facts about how much doctors actually care, he still perceives the world as one where almost nobody does. I'm glad he expressed himself as such because I feel the same way sometime, even though I know that most people try to fill their role in society well. It's like a special kind of loneliness that grows quick. I like how he describes the development of this loneliness. Once he put on its glasses, he thinks carelessness is everywhere, even in doctors who do care, so he develops existential hopelessness of some sort.

Loneliness is a really good way to describe it. I definitely have had similar experiences to the author. It can make you feel really pessimistic and like a freak outcast for actually caring. It makes me feel arrogant or overly confident too.

I think ironically it does show that the author thinks highly of people and their potential. A truly bitter person would have long stopped expecting anything of anyone, which I think is very unhealthy. You expect people to care but only about things that harm you.

I'm guessing there's more people out there who feel this way, and likewise I'm glad the author shared this experience even if it's not the healthiest mindset to always be in.

Let me ask you a question. What's the longest time you've spent on a single patient over the last month? What do you think that number is like for your fellow physicians?

Of course this will massively depend on your specific workplace, the ratio of doctors to patients in your vicinity, and so on. But I've seen plenty of doctors for who that statistic can't be higher than 10 minutes.

I'll freely admit I'm biased. I have a medical issue that despite visiting a good number of different doctors, none have properly diagnosed. This is despite the symptoms being visible, audible and showing up on certain scans (inflammation), so it can't be disregarded as "it's in your head". Some have made an attempt, and after that failed quickly did the equivalent of throwing their hands up and saying "I don't know", providing no further path.

This is a statement of privilege: find a doctor who cares and stick with them.

I'm T1 diabetic, and it took me a long time to find an endo and a PCP that care. I have long since moved away from their offices, but I still make the drive because they are worth it.

My tip on finding good providers is basically to get lucky and find a good one. Then you should ask who they recommend. They know who the bad ones are.

It’s a statement of privilege to believe (and say) that there are hundreds of good doctors per handful of bad ones? It sounds to me like a statement of fact. And that you dispute the fact. What does privilege have to do with it?

Doctors are at the very top of my list of people who don’t care. Not necessarily that they got into the field not wanting to care, but that in practice they quickly get to the point of caring largely about getting through their day — maybe a few select patients stir them out of their bizarrely intense waking slumber where they go from patient to patient and immediately prescribe nearly the first thing that comes to mind for nearly the first diagnosis that comes to mind. Given the volumes of patients they are expected to churn through though it’s not surprising that they become desensitized and divorced from the ramifications of shoddy work with minimal research — for many (especially nonspecialists) it’s effectively impossible to do thoughtful work for every patient. I think overwork desensitizes many/most and few actually have the time or energy to do more research or think deeply about an individual patient, but ultimately decisions which consume minimal resources from them drastically affect the lives of patients.

Healthcare professionals know this to be true. This is why when their own loved ones are the patients they have such a strong tendency to become very actively involved —- it’s not necessarily that the person attending to their loved one is incompetent, but chances are that their loved ones will similarly be just another face that occupies another physician’s mind for a few minutes.

Artificially high barriers of entry in the field may lead to massive compensations but also to a huge ratio of patients to physicians — this takes a toll.

It's not just the ratio. In many medical roles, engaging your full humanity with every patient would destroy you psychologically, even at a much lower number of patients.

"Follow the process, follow the training" is how medics, emergency responders and the armed forces are able to stay in the job more than a few years without burning out completely.

(It's also, as psychological defensive mechanisms go, somewhat fairer than those used in the past. Ask a retired medic in their 80s or 90s if you know any.)

My primary care physician will only do video meetings or wait 6 months for in-person appointment. He does not care.

Why don't you change ?

Is it not allowed ?

Is that a rebuttal to the idea that the doctor doesn't care?

Why would you think it's a rebuttal?

Six months' wait to see your GP for an in-person visit is a worryingly long wait. If I heard someone say that they were required to wait that long for in-person doctor's visits, I'd wonder why they were still seeing that doctor and ask them polite questions to try to figure it out.

That's the case where I live, there's only a few surgeries I'm allowed to register at and they all have this problem. I think there is some manipulation of statistics the surgeries do to prevent more being created, and to hide the difficulty in getting an appointment. For example rather than having 6 month waiting list, they don't make appointments more than a few weeks in advance, so you just can't get an appointment and it looks like nobody waits more than a few weeks. I think while surgeries are allowed to do this we'll never understand the real capacity.

When you say "surgeries", are you using what I understand to be the UK word for the US phrase "doctor's offices"?

Yes

Cool. Thanks for clarifying.

Man, it should NOT be permitted to play with the "waiting list" stats in the way you describe. I wish you had someone who gave a fuck about (and could do something about) the problem to report it to... that's just bullshit.

> Six months' wait to see your GP for an in-person visit is a worryingly long wait.

I always find it cute to see what Americans consider a long wait for any medical service.

For myself in Canada the very minimum time to see a GP is a month and a half and that's a best case scenario. Get a different GP? Impossible.

No. I was curious as to why they are stuck like that and what country and system they were in.

They might be living in the UK where most of the population has no private healthcare insurance and the nationalized GPs are frequently all overloaded like that.

Yep. That's what I was curious about.

You think PCPs get to decide what their schedule looks like? Or do you think they have a specific patient load they are expected to meet, which dictates how many in-person vs remote slots they have in each day?

Even people posting comments don't care.

Yes. They just choose to fill it way passed capacity because they want more money and don't want to accept the money they will end up getting for doing a proper non-rushed job.

That's why they have 15min slots and rush you out the door if you look like you'll be taking too much of their time. Maybe blame the insurance for dictating they must charge per-session instead of per-hour, sure, but the doctors at the end of the day prioritize their own salary over patients well being. Not to the extent that one can say they are negligent or do a bad job, but they ride that line between in order to optimize their earnings without getting into (too much) trouble.

Presumably, if the GP comment hasn't switched yet, then there's a bit of a shortage of options. So it's entirely possible that there's a shortage of doctors in general in the area, and a doctor that does care about serving patients in that circumstance will find themselves in exactly the same pattern of behaviour, because there's more need from patients than they can satisfy, so they try to help the most people they can even if that means each person gets less help.

More egregously in that regard, in the UK it's common for doctors to part work for the NHS and part work privately. Anything on the NHS is massively underresourced and so long waiting times for short, overworked appointments are common, but you can get an appointment much faster and with better attention from the same doctor if you pay. But then even these private services are starting to have too much demand, because the problem is more structural as the population grows and ages, while investment in the education and training, not to mention reasons to stay in the country afterwards, has stagnated.

His care does not scale and he has to ration his care between existing patients. For him to give you more care, it will likely come at the expense of someone else's care.

This situation has occurred because somewhere and somewhen else, a chain of other people have not cared and allowed primary care resources to get to this state.

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