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Comment by fleshdaddy | Hacker News Reader

I went down a Reddit rabbit hole, a sub called /r/noctor. Basically people, mostly doctors, complaining about the prevalence of nurse practitioners, PAs practicing independently/outside of their scope, etc. The general consensus I see there is that the only people benefiting from this are private equity firms trying to squeeze more profit since they bill the same based on whether you see a doctor or an NP. This in turn has an affect where it doesn’t make sense financially to go through so much school and take on so much debt.

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The primary utility of most medical professionals is to act as a gatekeeper to distinguish me from a drug-seeker. They are glorified security guards around medication. Fortunately, I always get what I want.

As an internist (not in the US), I would like to put in my two cents to say this is just wrong.

The primary utility of most medical professionals is to diagnose and treat a condition correctly. In the ER and elsewhere, the correct diagnosis is indeed often "drug seeking behaviour". And this is also a major aspect of medicine that many relatively healthy people interface with and remember. They are in pain for whatever reason, they desire to be relieved of said pain, and that desire puts them into contact with the skepticism and hesitancy around opiods that physicians have built up out of unfortunate necessity. It's often a hurtful and protracted experience, and so they remember it and form opinions like yours.

But this area of contact with medicine is a tiny, very visible tip of a much larger iceberg. Your description of "security guard around medication" is not strictly wrong for my field, seeing as internal medicine is largely about administering the right drug at the right time, but the 99% of the drugs we guard are not desirable at all for any drug-seeker. They are potent, full of side effects, are sometimes potentially deadly. But they do work. And you do not see any of this until you get properly sick, which to most people does not happen very often often (at least until they approach 70). And when it does happen, most people tend to focus on the one little side of the ice berg they come into contact with. But it is there, and it is about much more than distinguishing you from a drug seeker.

No professional has ever taken kindly to being told their primary function. The notion of greater grandeur infects everyone from janitor to president. I'm not foolish enough to tell doctors these things. If I did, I doubt I'd get what I want.

There are limits, naturally. I don't really expect to fit the percutaneous pins into my hand myself, even if I had third hand capable of equal dexterity. But if I have to sing a song you can be sure the song is sung. It's no different from selling B2B SaaS. You just need to make the sale.

I'm sure that's at least somewhat correct, but if I'd offer a similar reply, I could say that amateurs rarely takes kindly to being told that they do not understand what they are talking about. Dunning Kruger is endemic, and especially prevalent in populations making reductive comments about a group of professionals they maintain an adverserial relationship with.

My point was not about the emotional experience of being presented with a certain viewpoint of the function of physicians. My point was simply that if you look at the details of what physicians actually do, the stated viewpoint is wrong.

Of course, "primary function" is a somewhat subjective concept that you could define however you'd like, so it is more or less unfalsifiable as a standpoint.

Haha that is just as true. I suppose I should say “the primary function to me of doctors who are not family members is”. They are a vending machine with a code and fortunately I know the code.

Others need to be told to “advocate for themselves”. I simply get what I want and it always works.

What exactly is the problem with giving drugs to someone who might be a drug seeker? Is it worth letting someone sit in pain on the chance you might allow an addict to get high?

Harm reduction by just giving drugs to addicts in an organized fashion is honestly a strategy that might work fine on a societal level, and I'm not against it (although I am unsure about the details of implementations). However when your society does not practice it, and the ER/family med practioner becomes the one point of contact for potentially cheap drugs, you run into some practical problems over time. Essentially you can't have an open "drug seekers in line B" policy due to legal issues, so drug seekers will have to lie about being in pain and figure out a convincing lie.

Let us say they try to simulate an acute ruptured appendicitis. If they do this convincingly, they will get an acute CT with contrast. In my hospital system these machines and interpretation of resulting images is expensive and resource constrained, especially during evening and night time, meaning that the prioritisation of one patient will generally mean that another, let us say a patient in the process of having a very real stroke, might get delayed if traffic is high.

This is beyond the fact that roughly 30-120 minutes of the physicians time in the ER will be wasted in examining the patient, ordering blood work, the imagery, writing notes, and so on, which means that another patients time, who is often literally waiting in line for your time, is being wasted. Furthermore this kind of clientele have an unfortunate tendency to become unpleasant when you tell them that you can't find any reason for their pain or giving opioids, which is an extremely unpleasant and frankly often traumatic experience for green eyed doctors that enlisted in this career with the goal of aiding the sick. You can only get threatened, spat upon or assaulted so many times and maintain your professional enthusiasm. Many quit for this reason. And for the ones that don't, the experience of being forced to take on the role of distinguish between drug seekers and non drug seekers will generally turn you into a more unpleasant human being.

In summary, mostly due to unfortunate societal circumstances, you really, really, really do not want to encourage drug seekers to try their luck. It is an expensive waste of everyone's time, in circumstances where both money and time is tight.

Conversely, you really cannot predict in advance which ones of your opioid-naive patients will become addicts because the opioids that you gave them, which effectively means that you've fucked their life forever. Opioids are really, really dangerous. Sometimes people are obviously in pain and you open the tap quickly. But there's a name for the historical consequence of playing fast and loose with pain relief, it's called the opioid epidemic.

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