An automated alert popped up warning that the doctors should consider Sepsis. That alert essentially then blocked progress, and the doctors ended up (essentially) ticking the 'not sepsis' box so that they could get on with their (reasonable) next step which was either ordering an x-ray or starting antibiotics. Then somehow after that, sepsis did not get re-considered.
https://archive.is/tJePt#selection-1465.0-1491.52
It was Banerjee’s task to document Sam’s care, and as he began to do so, a pop-up appeared on his computer screen. Sam’s fever and heart rate had triggered an automated warning for sepsis, a potentially life-threatening condition in which the immune system has a dangerous reaction to an infection. It requires speedy intervention. To help the hospital comply with state-mandated sepsis regulations, the pop-up provides a checklist of tests and orders used to identify and treat sepsis.
Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.
But Banerjee, a novice, got stuck. He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders. “This was my first patient that triggered the sepsis pathway,” he explained, in testimony. So he asked Connor Welsh, a third-year resident, for help.
At 8:50 p.m., Welsh showed Banerjee how. From his own computer, he clicked into a field on Sam’s chart to assert that sepsis was not likely: “Based on my evaluation,” the automated note said, “this patient does not meet clinical criteria for bacterial sepsis.” And then Welsh recorded what Banerjee said Agyare had said earlier: “Likely viral syndrome. Workup pending.” Welsh’s name appears on the note, but in his deposition he said he never interacted with Sam. Senior residents often help junior ones in this way, he said. “I signed this note based on the discussion with the provider, Dr. Banerjee, based on his evaluation and the medical management of Mr. Terblanche,” he testified.
...
Sam’s chart is 51 pages long, a catalog of billing codes and abbreviations, check-boxes and shorthand, updates and addenda. The record of the second visit contains numerous contradictions: Sam’s heart rate was documented at 126, yet Banerjee clicked the box “normal.” In one place it says Sam didn’t have a cough, while in another it says he did. The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes. Vital signs were ordered and not taken, as was an EKG.
Man, I feel like I've been trying in vain to fight pop-ups for my whole software development career. Now we have an example where, at worst a pop-up got someone killed, and at best it was part of the chain of events that got someone killed. I don't know what it is that draws product designers to keep reaching for that horrible UX pattern, but it's got to be stopped. Nobody reads these things so a popup is the worst place to put important information that the user needs to read!
I think a lot of pop-up usage comes from company lawyers trying to cover butts: "Well, regulation says that users need to be informed of XYZ, so just stick a pop-up there. Then we can tell the regulator 'Hey at least we did our part to inform the user.'"
The stops - which in my experience (anesthesiologist, not ER doc, so I don't get sepsis warnings but I do get some of my own) are not popups, per se, but warnings that prevent you from leaving the screen until you have dealt with them. In this case, he could not place an order for at least some of the sepsis bundle of orders without placing all of them or making the sepsis warning go away - permanently. And the inexperienced trainee was told by the experienced supervising physician not to order the antibiotics and x-ray until at least preliminary labs had come back. At least for the antibiotics, this is good stewardship - we don't want to be giving people antibiotics for viral illnesses.
I have fought against incomprehensible ordering systems so much that when I order a chest X-ray (usually to confirm the placement of a large central IV), I have found it best to call the radiology technician and tell them what I want and let them order it under my name, because if I don't, I'll inevitably screw up some minor detail and they will have to re-order it anyway. "Chest x-ray to confirm internal jugular central venous catheter placement" (well, "CXR to check IJ CVC") is what I would have written in a paper chart; now it wants to know vast amounts of detail that I often don't know.
This plays out every time when two workers look at each other and go "How do I enter XYZ without ABC?" - "You can't do this. Here's our workaround".
This is more about unnecessary complexity. Medicine is hierarchical and like any hierarchy those at the top should be giving orders that leave lots of leeway for those who have to make them happen. EHRs often push all that onto the physician who never learned how to do that and really shouldn’t.
It’s like the old story about a green lieutenant in the army. Commander says, Lieutenant Smith, I want a flagpole on our parade ground. The dumb lieutenant tells their sergeant precisely how to do it. The smart lieutenant says, “Sergeant, the commander wants a flagpole right here. Make it happen.”
Whenever a question arises (and it will), the sergeant with a dumb lieutenant has to go back and clear every step. The smart lieutenant’s sergeant doesn’t have to call until they encounter something they don’t know how to do or can’t approve on their own authority.
That could be the motto of basically every EHR system!
No. Those systems have nothing to do with the real world. They are just a project manager's idea about "the real world". Have you used any Microsoft product lately ? Every day it tells you: "Hey , i have a new feature".
Just stop.
https://www.definitivehc.com/blog/most-common-inpatient-ehr-...
Edward’s Hospital in Plainfield, Il and Mt Sinai are two different use cases and should not count equally.
Catholic hospital, so it has its own internal issues, but it’s definitely not PE-controlled.
I run into this ALL THE TIME during the normal course of using software. I am trying to do something, then I get a pop-up about something-or-another that the developer clearly thought was important for me to see, but I click past it so I can get back to what I was doing. A lot of times is these "look at this cool new feature" kind of things - ARGH! And the worst part is, I might actually WANT to come back and learn about the new feature, but often I only get that one chance, and I'm too busy on my important task to focus on it right now.
Actually - a specific example of this just case to mind: I want to take a screenshot with Snagit - so I press PrtSn. But now Snagit pops up and asks me if I want to update. Sure, maybe I do - but not now! Now I just want to take my damn screenshot! So I click 'no.' And then I don't see it again until the next time I want to take a screenshot, and also do not want to be interrupted in my 5sec tasks with a 5min update.
Much better is to provide the information in a conspicuous, hard-to-miss area of the UI, but which DOESN'T block my workflow. Like, literally just put the text right on the form/interface in bold, red font. Like for Snagit - don't make it a popup update notification. Just put a bold/red link on the capture window and editor UI that says "Update"
Be typing a prompt and get 1) Do Action 2) Always Do Action 3) Don't Do Action
But if, like me, one looks at the keyboard while typing, you might not notice and be typing away and it has stolen your focus. Worse it used to default to 1) when you pressed enter and so you might have agreed to anything.
DO NOT STEAL FOCUS.
Since you can’t reliably catch 100% of tricks 100% of the time, continuing to do so is effectively guaranteering yourself to be tripped up in that 1 out of 100 times.
Engagement metrics will be the death of us.
Hi, Product Manager and paramedic here.
The type of popup you are talking about is not what is happening here. It's a modal dialog requiring the provider to answer multiple questions to evaluate their patient (see my other comment in this thread).
And then it will warn you that the patient meets SIRS or sepsis criteria. It's not quite as simple as "regulation says user needs to get warned of blah".
1) That's the default design system pattern for alerts, so whoever was the designer just went with it.
2) There's other alert patterns (alert bar, toast, etc), but sepsis was deemed to be so dangerous to the patient that it deserved to have its own special friction inducing UI element to alert doctors to take action.
>I don't know what it is that draws product designers to keep reaching for that horrible UX pattern
There are legitimate cases for alert modals like this one, but this definitely is an example as to when it shouldn't be used.
The issue is not the UX, it's the provider's arrogance thinking they know better. This thread is literally unbelievable.
It blocks the system with a demanded action, but doesn't even show you what triggered the alert condition? I would completely expect a "List of conditions that suspect sepsis" and get those details up front and center.
I'd be putting in medical records "Due to software popping up an un-dismissable sepsis screen that does not show details, I dismissed it due to needing the data it was flagged on".
Lemee guess? Epic?
You’ll get something like “sepsis criteria triggered by wbc 13, cr 1.5, hr 101, rr 22.” And that’s it - usually in the middle of a night on a new patient I just got a page for. Can’t open documentation to see the patients med history. It’s ridiculous. I’m not using Epic but I am using a major EMR.
To be fair I’ve written almost exactly what you mentioned out of sheer frustration once or twice but it’s not ideal
Yes, in almost every case, the default "popup" GUI library call is also a modal dialog. You cannot access anything else, anywhere else, in the entire program (even if the program had multiple separate windows open). All you can do is read the dialog's text, and hit the "ok" button to dismiss it (or pick from one of a set of "buttons" that are shown on the popup to dismiss it).
The worst ones also do a global grab, with the result that you can't even switch away to another unrelated application on the system without first "interacting" with and dismissing the popup.
To see the version that is built into Javascript in the browser, put the following into the URL field of a new bookmark, and save the new bookmark.
javascript:(function(){alert("hello");})();
My older car regularly hallucinates an incoming frontend collision and takes over the speedometer with a flashing red/black screen.
The new one (Kia) overrides the steering and forces the car to depart the lane (usually over double yellow lines).
If the alert regularly produces false positives then such behavior (and the behaviors of these EMRs) should open the vendor to civil and criminal liability. The courts should just assume the behavior will lead to loss of life, in the same way as discharging a firearm randomly in the city might.
It probably makes sense to have a short grace period to push a patch. Maybe one week after 0.1% of users complain?
Closed: Working as Intended, Elon has us by the balls.
It’s similar to alarm fatigue in the ED. In most, every piece of equipment is alerting on at least one thing at any given moment, if just because the patients pulse-ox sensor is not attached super well.
But they came in because of a diabetic emergency and we’re just waiting to make sure the treatment worked and 99% of the time it does, so no one really cares, but the UX around silencing it isn’t great (and may be a liability if used). Like in this example.
Because maybe this is one of those 1/1000 cases where the insulin didn’t work, and they lost all peripheral circulation and that pulse-ox sensor’s bad reading is warning you that they are about to lose all their fingers.
What, by your estimation, would be the better user experience for alerting the imminently life threatening situation?
It sounds like a signal to noise ratio with false positives, but IMO I'd rather a provider be at least given the time to pause and consider the diagnosis. I'm not sure about the optimal way to do it.
When people encounter a jarring interaction with a computer, most people's default response is to blame the computer for not doing what they expected it to... even when the computer is telling them that they need to do something differently. This makes it very difficult to guide users into changing their behavior. And if the user has experienced this message erroneously in the past, they have been conditioned to presume it is erroneous.
Anyone who has ever worked helpdesk can tell you that people call in with "computer errors" all of the time that are simply messages telling the user to do something... but it doesn't occur to them to actually follow the instructions. This is a fundamental HCI issue that is tough to solve, and usually isn't solved by someone who is just building a form to check off a compliance item.
Mandatory "snooze" button for a popup would go a long way.
Also easily accessible history of recently dismissed popups would be great.
Using EMR systems are nightmares for anyone actually doing things, but great for figuring out what was documented later. The two are rarely related.
If someone is trying to land a plane, would a pop-up about an engine fire that takes over all control input also be a good idea?
PS - I would suggest avoiding rhetoric like "did you even read" as per the guidelines. It's just a waste of everyone's time.
> Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.
> But Banerjee, a novice, got stuck. He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders. “This was my first patient that triggered the sepsis pathway,” he explained, in testimony. So he asked Connor Welsh, a third-year resident, for help.
> At 8:50 p.m., Welsh showed Banerjee how. From his own computer, he clicked into a field on Sam’s chart to assert that sepsis was not likely: “Based on my evaluation,” the automated note said, “this patient does not meet clinical criteria for bacterial sepsis.”
The provider was instructed (possibly wisely) to take some of the automated sepsis actions and to defer others. The computer did not allow this without generating an automated note saying “ this patient does not meet clinical criteria for bacterial sepsis.”
Imagine if your email UI auto-classified one particular email as so high priority that it would allow you to do nothing else, including reading other emails, until you archived the priority email and, to for good measure, would auto-reply “no action needed” when you hit archive. You get a priority email, and you determine that the correct action is to wait up to 20 minutes for another email that you expect and, while waiting 20 minutes, to read other emails from the same sender. But you can’t because your UI won’t allow it. So you archive it, send the “no action needed” reply (which is outrageously inappropriate but you don’t actually have any control here), and hope you remember in 20 minutes while you are horribly overworked.
ISTM the patient’s family should consider suing the software vendor.
The fact that it was confusing and a second Doctor went ahead and bypassed it altogether that hadn't seen the patient is a bit problematic to me.
Beyond this, as much as I empathize with the family here, people still die... I had two similar ER visits in my life and it's only chance I wasn't sent home both times... when I came down with Guilliam-Barre and when I had ketoacidosis. The former, was about to be sent home when one of the residents recognized my symptoms (sudden onset weakness all over). In the latter, urgent care said it was just a cold/virus etc.. but I couldn't even keep water down, after 4 days I couldn't stand up and called for an ambulance I dropped over 50# of weight in under a week. I remember thinking to myself "if I go back to sleep I won't wake up."
Doctors are humans, and humans have cultures. In this culture, it was normal for people to dismiss popups that seemed to be distracting, and one human shared with another human this useful tidbit of information.
People need to get real about who doctors are. They are not super-people.
The system was set up in such a way that the popup became a distraction, and humans naturally want to get rid of distraction.
If it were me, I would have also named the developer or administrator who implemented the popup. It sounds like a key stumbling block in a medical device.
Because in almost every GUI library, they are the default built-in "alert" setup that can be used. Almost any other alert system other than a "popup" has to be coded, and the designers and coders take the easy way out and just use the "built in popup widget" already in the library.
What's the alternative when you have a potentially dangerous action that you need to give the user fair warning about?
In rare cases that's not possible; four that I know of:
- the action is controlling something in the physical world such as a CNC milling machine, or
- the action involves acting on somebody else's computer, for example sending an email, or
- the action involves securely deleting information so that future adversaries who obtain your data storage medium can't recover it, or
- data storage space is so limited that you don't have room to log an undo record.
Obviously none of those were the case here, but when there are, there are well-known techniques for reducing the risk. For example, you can include by default a "cooling off" period to cancel the email send in or restore from nightly backups, or figure out how to do a "dry run" without a cutting tool in the chuck to see if it looks like your CNC program is going to smash the mill.
You can put a molly-guard over inevitably destructive actions; that's why the IBM PC's reset keystroke is a three-key chord, and Emacs asks for you to type "yes" or "no" rather than "y" or "n" in certain cases. (Although in many of Emacs's cases, being able to undo would have been better. Freeing up the memory of a closed buffer with unsaved changes, for example, could almost always wait a few minutes!)
It's also important in such cases for the user to be able to clearly see all the relevant information.
Corporations already push enough random HR requirements on tech employees. I can't see how having a semester or 2 of ethics courses is particularly onerous.
Safety-critical software projects should have a licensed engineer in a supervisory role.
For example: running experiments on humans without their prior consent is considered unethical. However, large tech firms routinely run A / B tests on their users without providing Informed Consent. If software developers were trained like engineers, they would be ethically obligated to obtain Informed Consent prior to engaging in this kind of conduct. More importantly, when software developers realize they were being experimented upon (as happened in the Linux kernel community a while back), they were justifiably outraged.
I know this isn't going to be a popular position to hold here, but there's a lot of harm being done by unethical practices that are currently widespread in big tech. Ephemeral ads that prey on the elderly would be considered Not Good by anyone that has seen a parent fall prey to them, yet there doesn't seem to be any concern whatsoever amongst the industry giants themselves to prevent this practice. So long as an ad brings in money, it's good to run seems to be the bar for advertisers at present, and I don't think that's good for society.
When there are no ethical considerations given to the consequences of an action, unethical outcomes are inevitable. Fixing that starts with learning, which is something every great developer already does.
Wait, what happened here? Do you have more details?
Phone notifications do. Logging out software while someone’s driving does. Every button on your car impacts life safety. Every interlock in your kitchen does.
Remember, each of these things gets rolled out 100M’s of times, so one-in-a-million scenarios kill 100’s of people.
https://www.fda.gov/medical-devices/classify-your-medical-de...
it is likely a rare condition that the doctors missed. this case is sad but being fixated on one diagnosis and building the case around that is just trying to pin blame.
"When you hear hoofbeats, think of horses, not zebras."
-- Anon. (saying in medicine)
The article notes that the ER, at that stage of the visit, is not tasked with a diagnosis but deciding whether to admit to the hospital or discharge.
The complaint is that, sepsis or not, horse or zebra, the symptoms presented were severe enough to warrant further tests (such as a chest x-ray, if for no reason other than to rule something out) as part of a hospital admission. Those tests might also have been inconclusive, and the patient might still have died, but it would have at least reflected the severity of what was presented.
Instead, in a chaos of paperwork and a supervising physician who overruled every warning flag in favor of discharging the patient, the kid got sent back to die alone in his dorm room.
The er was crowded and the hospital was crowded. The er clearly couldn’t treat her beyond basics, she needed to be admitted and monitored. But, as a sympathetic resident told me before mysteriously disappearing “there’s no space upstairs, I’ll try to get your mom in somehow”.
I worked with EHRs at the time and knew how to advocate. They kept trying to discharge my deeply ill mom without explanation and bumping into my objections, I was talking to a different nurse or social worker or resident every 3 hours round the clock. I felt scared to leave even for a short time lest they expel her.
In the end, I needed to go home to sleep and they discharged her at 6am, and when I arrived they had her bundled up and already waiting to be taken home, shivering and ashen. All they told me was that there’s no diagnosis, no reason to admit her and no beds anyway, she just needs to rest and have fluids, try urgent care if needed.
Multiple social workers sympathetically assured me and my mom’s aide that we were good people for being up to taking care of my mom at home, so they could tick a discharge box. We emphatically were not.
In the end, eventually, she was ok. The experience was harrowing. Many people talked to me but no one engaged with us, the interest was clearly in getting my mom out. It felt cruel and uncaring.
I’m surprised the article doesn’t address the “refusal to admit” angle. It used to be that you could admit patients for care and monitoring without a diagnosis, but this simply isn’t a thing anymore. So, deeply ill people who for whatever reason don’t have access to adequate care and monitoring from a caretaker at home are simply surrendered to their fate.
Also many families try to push elderly to hospital for few days.
And rightly so. As people age and their health deteriorates, often a few day's monitoring and nursing care can forestall downward spirals, or catch sudden downturns so family can react appropriately, instead of the usual sudden crises and desperate scrambles. This is nursing, and hospitals used to do it, which I think is what your comment implies. But these days, without the right golden-key "diagnosis", nothing happens, and those diagnoses are certainly deployed "strategically".
There's no other accessible institution that really provides this kind of care, thus dumping responsibility on the beleaguered "community", as the social workers call it. If you happen to have insufficient wealth and willing empowered family to take care of this, I strongly suggest not getting sick. Or old.
Are there no other ER options in your area?
Closest ER to work, to home, and maybe to any place you spend a decent amount of time at.
not saying the hospital is faultless because they clearly failed in this case but as in any courtroom if you charge a criminal with the wrong crime you are bound to lose.
And as much as we would like to believe otherwise, the modern healthcare system is riddled with problems that no technology or checklists will fix. It doesn't take someone's death to verify this- just go read your own charts and discharge papers. Even for something relatively routine there are bound to be inaccuracies. Doctors know this, which is why they spend so much time doing handoffs and interviewing patients.
We pretend that the medical 'record' is infallible, helping to reduce the mental load on doctors while protecting them from liability. But as this case shows, the 'record' is both inaccurate and not useful in showing fault. It's a paper tiger. I'm not saying we should scrap the whole system, but I do think it needs to be examined in a data-driven manner.
The trick I vividly remember was just Penn standing behind a table, putting a piece of green cloth (like a surgical thing) over a water balloon, and then giving a long speech of all the damage that friends of his had survived, as he stabbed the balloon (under the cloth) repeatedly in time with his speech, and talked about the wonder of medical science, and how doctors he knew had saved people from all these horrendous accidents and damaging the balloon in sync with every example.
And then he removed his hands from the table, holding them up to the audience, leaving the balloon still under the surgical barrier, and said "And the other thing that doctors will tell you, if get a couple of beers into them, is that sometimes people just die for no reason at all." And the balloon collapsed right on cue.
I can't seem to find a video of it but I remember it clearly.
Some executive(s) have been told that detailed medical records are the solution to so many problems in modern medicine. But they lack either the guts or the expertise to make sure that these systems are actually accomplishing what they set out to do.
Of course. The records are known to not be 100% accurate. Any conclusion you derive from them will be faulty.
>There is no professional or legal liability if the records are wrong.
Again, of course. In many cases it may not even be possible to show a record is incorrect. For example, if the record doesn't say a test was performed, but the patient insists that it was, is the record wrong, or is the patient mistaken? Or a doctor could incorrectly write down something that only he saw, such as a blood pressure value on a gauge.
I would guess a key obstacle to eliminating all these inaccuracies is that doctors don't see strict record-keeping as actually useful in helping patients. Every minute that they're taking notes of dubious future utility is a minute they could spend seeing a patient.
I'm sure there's many doctors who would like to take better notes if they were allowed the time to do so.
Maybe the case for better records reducing costs to insurance by assisting in prevention / early intervention is a path forward?
I'd bet 10 to 1 this is due to residents or fellows copy-pasting prior notes forward. An extremely common albeit rarely problematic practice that is nevertheless lazy and underpoliced.
They are fixated on fast and smooth workflow, both because they want the computer out of their face, they want software to help them jump through the ever growing number of mandatory hoops, and they are under serious pressure to keep their numbers high.
1. Carry forward non-templated notes that reuses another physician's prose with zero or near-zero updates as it invites mis-interpretation from colleagues.
2. Carry forward templated or non-templated information that clearly hasn't been reviewed, best indicated by signatures/names of physicians that had nothing to do with the note as in this article or dates that are clearly wrong.
And it's doubly-bad when it's non-templated notes with incorrect physician names and/or dates.
“”” Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis. “””
What? It's simple enough that it's taught to EMTs with ~160 hours of education (I'm a paramedic and EMS instructor and evaluator):
Temperature <96.8 or >100.4
Heart rate >90
Respiratory rate >20
WBC count > 12000
Add confirmed or suspected source of infection. Simplified, each additional match increases the suspicion.
The issue, as described later, is not that it's hard to spot, or the SIRS criteria tool didn't flag it, it's that the doctor didn't do their job or document correctly.
"VS were ordered and not taken"? What kind of ER is this?
Am confused by this. Sepsis can be a response to bacterial, viral, or fungal infection, no?
Let's do a chronological analysis of some prior definitions of sepsis.
The first one, from the 1990s, utilized an elevated white blood cell count plus three clinical variables (temperature, heart rate, and respiratory rate). This definition is very broad; statistically speaking, it's very sensitive but has low specificity.
The most recent definition describes sepsis as 'life-threatening organ dysfunction caused by a dysregulated host response to infection.' Septic shock is defined as a subset of sepsis in patients who have a vasopressor requirement and a lactate level greater than 2 mmol/L.
Scores such as NEWS, SOFA, and qSOFA exist, but they primarily assess disease severity and prognosis for patients who are already in a hospital setting.
It is very important to always maintain a high degree of suspicion for sepsis, but it seems to me that few clinicians would have had a strong suspicion of it in this case...
But even then:
> but it seems to me that few clinicians would have had a strong suspicion of it in this case...
Tachycardic, febrile and with a suspected infection?
The issue here seemed to me to be two-fold, misdiagnosis of a viral infection versus bacterial, but in the setting of treating for a bacterial infection to then be consciously overlooking multiple markers for sepsis?
That said, there was a cascade of errors that ultimately led to this very very unfortunate outcome (that maybe could have been prevented, or maybe not)
Had the chest x-ray been ordered perhaps his enlarged heart could have been noticed in due time.
I do not mean to be pretentious in any way. I hope my english does not interfere with this.
Paramedics don't get very much in-hospital time here, other than getting intubation experience in the OR with an anesthesiologist.
I appreciate your input, it does not come across at all pretentious - and as a paramedic, I would never want to "not learn more medicine".
If doctors don't have enough time, then there aren't enough doctors. Our population is aging rapidly and the need is increasing despite population growth metrics. If there are more doctors, they will need to need to spread further into regions where they're in demand.
This is a problem that we as voters should start to act upon.
There were multiple similar stories on that, e.g. "Thousands of doctors in South Korea took to the streets of Seoul on Sunday to protest the government's plans to increase medical school admissions." from 2024. Similar stories from Nepal and Bangladesh.
The most interesting part of that is that population typically sides with the doctors, not the government, for some reason.
The number of students fell by 50% between 1980 and the mid 90s: 8500 new students/year in 1972, 3500 in 1993.
Of course, now the number of doctors in France is far from enough for an aging population, in every specialty and it will take at least a decade to improve. It's not uncommon to have 1-year waitlists for ophthalmology appointments, and several weeks or even months for dermatology.
Which is entirely rational. A medical degree is expensive and doctors want a return on their investment. In that sense, doctors are very similar to real estate investors (and to a certain extent labor unions); they all want a return on investment (don't we all!) at the detriment of society. Because damn, competition kinda sucks compared to coasting along, especially as you get older.
"If I'm going to study into my 30s I want a huge bag."
Understandable, though not necessarily defensible.
I wish.
In my country, the government blames everything on doctors despite displaying truly sovietic levels of corruption and inefficiency. Doctors working for the government in poor areas might not even be provided with a functioning sink to wash their hands with, yet society still expects them to provide the highest standard of care.
Entire media campaigns have been launched against the "mercenary" doctors who put profit over the well being of the poor patients. Now doctors manning ERs routinely suffer physical violence. 15 minute waits are enough to provoke literal vandalism in the ERs. I know of one case where murder charges were pressed against a couple of stable flu patients who after sitting around for less than 15 minutes decided they had waited enough due to the laziness of the doctors, invaded restricted areas of the hospital, vandalized them and disrupted a team managing a myocardial infarction, obviously leading to the patient's death.
Doctors in control regularly shut down any attempts at increasing this limit.
Medical education is very hands on unlike engineering where we just throw people in the deep end at work. This is with good reason.
I'm absolutely for having more doctors and medical school seats but I think it's important to acknowledge that it maynot be as simple as increasing seats. There needs to be more fundamental reforms. That being said yes there are completely pricks of doctors who enter politics.
Maybe medical school itself needs to change to make the role easier and split the functions into easier ones that more people can do.
After I finished grad school (electrophysiology and imaging in large animal models, so seemingly relevant experience), I thought about becoming a clinician. However, I wasn't even eligible to apply to med school because it had been 5 years since I took an introductory biology or physics class (with lab!). It seems I was qualified enough to teach in a medical school but not to be a student.
A faster scientist -> practitioner pathway would be such an obvious win-win: it'd help with the overcrowded academic job market AND relieve clinical shortages, but most of the emphasis seems to be on getting MDs into research instead.
If we increase number of admissions, then long-term doctors should become less overworked. That's a path to fix it.
And these kinds of issues seem more global than not.
Although doctor pay is only a small fraction of the total cost of health care, limiting doctor availability is an effective way to limit total cost because most expensive health care goods and services require a doctor to order or prescribe the good or service. I.e, until the patient gets enough time with the doctor for the doctor to realize that the good or service is necessary, the insurer does not need to pay for the good or service.
I tend to believe this because of how strong the correlation has been in my own "career" as a patient between my ease of access to doctors' time and how much my insurance plan ends up paying for tests and treatments.
It might reduce the costs they pay for preventive care or non-urgent care, but serious issues will progress.
You might not have to pay for metformin to treat diabetes, but you’ll eventually end up paying for a hospital stay and amputation.
Regardless I was responding to the claim about doctors lobbying for caps.
Majority of doctors simply do not go beyond the textbook definition of “standard of care”. You tell them this doesn’t feel like flu? Nope go back with Tylenol and come back if gets worse. Still not getting better 10 days later and you tell them your sinuses are clogged and hurting? Let’s get you Flonase and send you back. Finally you’re half conscious and in the ER almost 3 weeks in? Ohh my bad, should’ve started antibiotics a while ago.
Get transferred to a new urgent care because the one that sent you back with a Tylenol yesterday can’t take you in today because you got worse? Let’s start from scratch and tell you exactly what you heard yesterday and refuse to do more tests.
Most doctors I’ve had to interact with are laughably clueless when it comes to even slightly non standard illnesses. They are highly opinionated and refuse to do things differently. And surprisingly the only good doctors that I’ve encountered are the older ones, sometimes closer to retirement. Maybe something went horribly wrong in the past 50 years but the new ones are terrible. No wonder people lose their lives when they get sent back home with NyQuil and Tylenol.
Public hospitals are one thing, there incentive structures revolve around saving money - yeeting patients out of the door far faster than you'd have don in the past, to a large degree made possible by new operation technologies (minimally invasive surgeries).
But private run hospitals? They see you as a cash cow, extract as much money as possible from you. And yes, often enough that includes outright billing fraud.
That's a popular narrative, but doesn't much explain many of the variations of this phenomena at all. Women have complained forever that doctors don't listen to them when it comes to their treatment... even prior to the "financialization of everything". It is a popular narrative that it's the moneygrubbers or something like that which causes all the problems in healthcare, but it's not a very explanatory narrative, just a popular one.
The internet asserts that there are pathways from NP to MD, but I’m not close enough to the problem to make heads or tails of how realistic the path is. Is it legitimate or a sop?
The path (at least in the US, YMMV elsewhere) is "go to medical school".
But there are also zero-to-hero schools that will take you out of high school and have you as an NP in 5 years, able to prescribe medications (in many states, without any physician supervision).
There's a happy medium. I have the same feeling about zero-to-hero paramedic strip mall schools that will turn you out in under a year and 1,000 hours whereas others will require you to have 2,000+ patient contacts as an EMT before they'll even admit you to a 1,800 hour course.
US doctors are not that good compared with a German or French doctor, they could be as bad as bad doctors in other countries.
The good and the okay doctors, i.e. the vast majority, are also very good. Probably a wash with most large Western nations.
America's actual problem, and failure, is prevention and uniform access to primary care. No surprises here.
Vs. merely billing by the hour - then having to pay your office rent, utilities, medical school loans, nurse's salary, receptionist's wages, etc. etc. out of that. I've read quite a few accounts of that sort of doctor going bankrupt...unless they were being supported by the specialists, to whom they were referring patients who needed procedures or other expensive care.
Any evidence to back this up?
Granted, I’ve had some bad docs in the U.S., but the trick is to get good recommendations from people that work with the better doctors.
Plus, if you can wait, treatment is nearly free, but you can get same day service for many procedures, like overnight ecg, for say $100 -$200.
Private health insurance had a cap (~$100k/year) for some reason. I thought that was risky.
Patients need advocates (and someone to help them from getting lonely, which also helps their recovery).
I guess what I'm suggesting is that the solution is not "increasing the number of doctors" but rather "increasing the number and types of providers". Some of those could be more MDs, but some of them could be other types of providers. We need to create alternate paths to MDs, and also increase the number of degree endpoints that result in similar kinds of independent practice authority within a given medical field. Let other types of providers provide a wider range of services — maybe with increased scrutiny over training pre and post degree, like MDs have.
My guess is there is probably a way to encourage fields to come up with ideas that any given person out there outside the field wouldn't think of.
Of course, the opposite happened because of demographics and increased lifespans.
Perish the thought that we have slightly too many doctors. That can never be allowed!
I can't believe they passed that shit with a straight face.
I'll repeat what I've said before: no other profession in America requires a literal act of Congress to fund the training of new members. What's so special about doctors? Let anyone open a medical school if they meet standards. Give anyone an MD if they pass the exams and do the residencies, like lawyers.
And while they're at it let doctors go to medical school straight out of high school like they do in every other country in the world (other than Canada, I think). You'll give every new doctor an additional 2 years in their career they would've spent in undergrad doing a useless "pre-med" degree (assuming medical school becomes 6 years of study after high school instead of 4 years after an undergrad degree).
Some schools do have accelerated combined BS/MD programs which can cut 1-2 years off the required total education.
Accelerated programs aren't the norm. They should be.
(And let's not have any stupid comments suggesting that residents should pay for it themselves. They're already tapped out in terms of student debt.)
I'm not advocating pulling the plug overnight without planning an alternative. That would guarantee a collapse as you said. But announcing an expiration of the program would heavily incentivize all participants to figure something out.
Residents make like $70k a year plus benefits. I'm sure the hospital bills their work for a lot more than that, even accounting for the time of attending physicians. Right now that profit margin probably subsidizes other loss-making activities in the hospital.
You have no clue what you're talking about here and are essentially making a hand-waving argument without any facts to back it up.
I'm not the only one.
"In Elisabeth Rosenthal’s excellent book, An American Sickness, she notes:
'The median cost to a hospital for each full-time resident in 2013 was $134,803. That includes a salary of between $50,000 and $80,000. Federal support translates into about $100,000 per resident per year. Researchers have calculated that the value of the work each resident performs annually is $232,726. Even without any subsidy, having residents is a better than break-even deal.' "
And
"In the old days, hospitals paid for resident training by building those costs into the bills they sent patients. But in 1965, Congress acknowledged resident medical training as a public good deserving of public investment, and firmly established federal funding for graduate medical education costs with the Medicare Act.
(What’s interesting is that Congress intended for the public funding to be temporary, with language in both the House and Senate reports noting that the funds were intended to last only “until the community undertakes to bear such educational costs in some other way.” Unsurprisingly, once governmental funds became available, hospitals have had little interest in undertaking how to bear these costs any other way.)"
https://thesheriffofsodium.com/2022/02/04/how-much-are-resid...
> they generally have to be directly supervised by an attending physician, which is expensive
The blog post argues that they also free up attending physicians to focus on the highest-compensated doctoring activities.
These roles should perform highly in-demand, relatively straightforward and repetitive tasks that don’t require complex medical decision-making, where training can be efficiently scaled up.
An example that currently doesn’t exist would be a specialist who can prescribe short term courses of drugs like methodone for opioid addiction as a bridge to longer term care by a doctor. This would enable us to have bridges to treatment readily available all over cities whenever an addict walks in ready, perhaps only for that moment in time, to start treatment.
Source?
It's not until around 1950 that medicine becomes a virtually guaranteed path to being in the top 1-2%. It's not until the late 70s that it's viable for anyone almost anyone (people without already wealthy parents). It's not until the late 90s that the average person who cares about nothing but money has figured out that medicine is a virtually guaranteed ticket to being "rich".
I think the problem stems from there being too many people in the profession that care about almost nothing but having a lot of money - which isn't any different from most professions where you can make a ton of money.
I do believe that the vast majority of doctors, especially older ones, AT THE VERY LEAST have decent intentions.
But even a very small percentage of wildly greedy people can damage a system severely.
I'm not sure how you put Pandora back in the box here.
At the end of the day, good doctors are providing a service of almost unlimited value.
Modern medicine is basically a miracle if you're literally about to die.
Not to say it's not still remunerative, or anyone is going to go poor choosing to become a doctor, but there are other paths to a good wage that don't require 8 years of schooling or nearly as much student debt.
"But even a very small percentage of wildly greedy people can damage a system severely."
You are close to placing the blame in the correct place. My emergency department was just bought by a private equity group. There were 28 doctors. Most of whom worked there because they could spend adequate time with patients and work a reasonable schedule. After the PE company bought us, they mandated less of EVERY position from CNA to MD. The MD headcount is now 11, and the 17 physicians who are looking for jobs are having a tough time (relatively) because most other emergency departments in the area are also owned by PE firms who care about money over health outcomes. Those are the greedy people damaging the system you are looking for.
> I think the problem stems from there being too many people in the profession that care about almost nothing
IMO you need to substantiate this claim.
> even a very small percentage of wildly greedy people can damage a system severely
This is medicine you're talking about. If the doctor doesn't have contact with patients, they aren't affecting them. I just cannot follow the claim that a greedy doctor can have an outsized effect. What is the mechanism?
(Half a joke, to make my point:) Greedy doctors aren't like greedy venture capitalists... It seems like they can only suck $500k out of the system every year.
There's also rules regarding things like percentage ownership of physician owned facilities and the percentage of referrals to that equipment that come from the physician owners.
Urine drug screens in an in-office "lab" are another big source of revenue for certain specialties that involve referring patients to your own tests, or doing your own pathology on biopsies as a dermatologist or whatever. My understanding is that most of those things, and many like them, are not Stark law violations.
Be very careful with what you're suggesting and to what degree.
I live in a country that has taken "we need more doctors" to the max and opened hundreds of new medical schools backed by student loans. As a result, the medical profession has become a shadow of its former self. It used to be that only the best students would be selected for medical school. Nowadays any moron can become a doctor.
Pay is nosediving since about 40 thousand new doctors enter the market every year or so. Emergency rooms are supposed to attract the most experienced, most cold blooded doctors in the field. Here they have turned into total shit jobs that only attract the heavily indebted and quite possibly incompetent newly minted doctors.
Do you know how much damage a stupid indebted inexperienced doctor can cause? People are going to fucking die. I'm actually afraid of getting sick.
> If there are more doctors, they will need to need to spread further into regions where they're in demand.
Yeah, that's essentially my country's strategy. Squeeze doctors so much they'll have no choice but to relocate to the literal Amazon jungle in search for jobs.
Would you like to live in the jungle? Raise a family there? I sure as hell wouldn't. There's a reason the doctors are all concentrated in the capital. Same reason why people migrate to the capital. No one actually wants to live in some undeveloped shithole.
"They will need" betrays the fact you think you're qualified to dictate the careers and life paths of an entire category of people. That borders on magical thinking: if you squeeze them, then they'll do what you want the way you want it. No such deal exists. People have any number of options laid out for them. They can just as easily give up on medicine altogether, take their capital and start a business instead. I've actually seen a few do just that. Buy trucks and start a goddamn logistics business because medicine wasn't cutting it anymore.
Oversupplying doctors will lower that bar one way or another. Medical schools are a bottleneck? Race them to the bottom. Fund hundreds of them so that it's always possible for any student to find one that'll accept them. Problem solved. Now the medical licensing process has become the bottleneck. Millions will be spent on lobbying in order to subvert it via whatever means. Once that's done, medical specialization will turn into the bottleneck. Repeat.
No system retains its integrity when you inject billions into it via loans. And that's just financial interests. Factor in the fact reelections of politicians might very well ride on their providence of more doctors to the population. Just look at the post I replied to:
> This is a problem that we as voters should start to act upon.
That's the sort of populism that could very well decide elections. Politicians do not give a shit about anything other than reelection, least of all the quality of the doctors their voters are getting. They will always be able to afford the best care.
Realize that it's against my interests to warn citizens of developed nations about this. If I were a socipathic person, I would be praising their openness since it could facilitate my own immigration into their countries. I genuinely don't want to watch other people suffer the same fate.
What the hell? Volunteer work is a requirement to get into medical school? Yeah, maybe some calibration is warranted.
Just be very careful about it.
So again, where do you want to get these doctors from that are in excess in their own countries, in order to bring them to the USA in order to serve American interests, while harming the communities you want to deprive them of?
Also given the much higher wages in the west, sending a portion to relatives back home often does quite a bit to alleviate suffering and stimulate some economic activity.
On top of all of that the US govt could step in an increase supply of doctors in various ways, the medical industry could stop artificially keeping supply low to drive wages up, the medical industry could totally opt out of a free market model and operate like a public service. I am sure there are plenty of different solutions I am leaving off.
Sepsis alerts are meant to find bacteremia in patients who present with a set of vital signs and laboratory findings indicative of it and even those definitions are not readily agreed upon.
The ED is highly accurate with its diagnosis and treatments despite everything that has been said.
Trying to find a zebra in the hoof beats of horses when the number of patients quickly outstrips your department’s capabilities is a fools errand because if the workup require will overwhelm throughout to the point that the delay in care will put other patients at risk.
There is a fine line between doing enough and doing too much that will grind your department to a halt and then have your waiting room backing up.
Unfortunately for this patient, his occult condition didn’t manifest itself within his two ED visits and we don’t have prognostic capabilities to tell who will and won’t decompensate. We all make value judgements and treat the patients in front of us
This is where that I hope (as a non-physician) that AI, used carefully, should actually be able to help. A well-designed ML system should have a decent chance at distinguishing a zebra from a horse because it has read absolutely everything, has perfect recall of that corpus, and has some ability to contextualize the knowledge it has to the situation at hand. I suspect that a good proportion of ER doctors already have those characteristics, but surely not all of them do, and surely not consistently.
An AI-assisted system will still false-positive, because the computer is still just a tool, tools are never perfect and designers of safety systems tend to err on the side of false positives. However, a thoughtful pop-up that displays when the situation really may warrant it is surely more helpful to a physician that one that cries wolf to you constantly?
My optimism assumes that there's fundamentally enough information available to make the diagnosis, however. If you're actually saying that finding the zebra would require gathering so much more information for each patient that it would lower overall outcomes for all patients, then I guess we're stuck.
We can readily tell who has sepsis when confronted with patient appearance, vital signs, and workup.
The issue is trying to find a signal in all of this data where they have an occult condition that we are not yet observing. These folks get sick real bad and real quick and we often do miss this!
Trying to find that signal with our current medical technology is difficult but there are some immune markers that could potentially alert us. These tests are now coming online and should be prevalent within the next few years. Hopefully, more research will show whether they are helpful or not.
Sometimes, even the best tests or calculators or ML generated alerts do not measure up to physician gestalt.
I'd like them to follow the legally required prompt instructing them to test for/treat as sepsis, rather than ignoring it but falsely asserting they followed it, so they can rule that out instead of guessing about what "likely" happened.
You can hand-wave all you want about how medicine is complicated, but a doctor checking a box for something they didn't do is objectively incorrect in my eyes, regardless of what "might have happened" had they done their job correctly. All of the discussion in this thread blaming the design of the checklist that the doctors didn't follow anyway is insane to me.
I found the article interesting less as a damning of the medical system and more of a spiritual situation. None of us know when a freak random event will end us. It is a sobering reality
Should we say the same about potentially life-threatening defects in our food supply? "Mistakes happen, so it's not about fixing or preventing them, it's about spiritually accepting that you might get a bad can of meat and die." Obviously not.
> that still means 1/1000 will die. People play the lottery on far worse odds.
I don't play the lottery, though. But I can't choose whether or not I might need emergency care one day. So comparing odds to the lottery isn't useful. Make the odds as good as possible.
The answer is unfortunately you cannot treat everyone equal if they don't want to help themselves.
I was at a ER for a bleeding puncture wound and was told to hold a bandage on it and wait while several 500lb people were seen because "they don't feel good". No $hit they weight 500lbs.
Also kids apparently are always first, but I can see why that one is needed. They don't have automy like the other people there that are the source of their own problems.
The next day I almost lost my thumb, because this sadist that enjoyed cutting me open without any painkillers didn't bother to check whether the infection spread to my bone. I was also misdiagnosed by her, and would have lost it had my PC not found a hand surgeon in the nick of time.
Meanwhile, to curtains on either side of me at this hospital were people who were clearly homeless and had come in with some fentanyl withdrawal symptomps, but mostly so that they could sleep on a bed. When my partner tried to intervene and say that he's never seen me in this much pain, the doctor looked at me like I was a junkie, telling me that "it wouldn't hurt if I wasn't acting up."
I understand the "next, next" that happens from burnout, but this was next level sadism. No empathy; she actually seemed to enjoy my pain. No legal action was possible since this was an "emergency room environment" and she was only there "part time."
This was UCSF Saint Francis/ Dignity Health in Nob Hill. Please avoid this hospital if you're in San Francisco.
This thread is filled with terrible people. Self righteous self aggrandizing zero real world experience "Justice warriors" I hope they all need an ER someday to see just how dire it really has become. Maybe that will shove some real world knowledge into their empty heads.
Neither of us is the villain here. The people massively abusing the system are.
I realize my comment is not "nice" but the people on here jumping on villainize my real life experience are terrible people. Both of us were wronged by a system. We did not do the wrong. We just noticed what was a large cause of it because we actually experienced it.
do they realize the strain excess weight carries for organs? would it be cheaper in china or Europe to be that size? No. Logistically, other countries would not have equipment readily available and having your poor lifestyle choices subsidized doesn’t mean the cost isn’t there
Dutch researchers compared three cohorts (healthy-living nonsmokers, smokers, and people with obesity) from age 20 to death. They found annual costs were higher for obesity through midlife, but lifetime spending was highest for healthy-living people, lowest for smokers, and intermediate for people with obesity, due to shorter life expectancy in the latter two groups.
https://journals.plos.org/plosmedicine/article?id=10.1371%2F...
Another study found total lifetime costs were ~14% lower for the obesity cohort and ~26% lower for smokers versus healthy living peers, again because longer life spans among the healthy group accrue more late life costs.
https://www.researchgate.net/publication/5596865_Lifetime_Me...
Patients that were so large would have to be denied and referred to the local zoo.
I wish I was kidding.
You're just spouting dog whistles and fatphobic bullshit.
The system is broken because that's the design.
Per your anecdote: yes, the 500-pound people were likely to be dealing with some unknown ailment. Painful as yours likely was, I'm guessing it was simple to triage and determine that you weren't likely to bleed out imminently? While the people who went ahead of you might have been facing any number of life-threatening situations. You don't know, so you don't get to make that call. Duh.
But if we're going down this path, why not add ER fast passes and "tips" that rearrange care order a la Uber? That seems to be the next logical step.
It was a brain tumor in the cerebellum. Bad place to have problems.
The PC declared it a "virus," despite the fact that I could barely stand, and basically threw me out of his office.
The neurologist took one look at me, from a dozen feet away, and said "Meet me at the emergency room."
The next day, I was getting my noggin cracked open.
I'm not sure how effective this is. Information presented this way quickly fades into background noise..
--- (long extract) ---
This paper lists signs of drug-seeking behavior that doctors should watch out for, like:
– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriate
– Consistently disruptive behaviour when arriving at the clinic
You might notice that all of these are things people might do if they actually need the drug. Consider this classic case study of pseudoaddiction from Weissman & Haddox, summarized by Greene & Chambers:
> The 1989 introduction of pseudoaddiction happened in the form a single case report of a 17-year-old man with acute leukemia, who was hospitalized with pneumonia and chest wall pain. The patient was initially given 5 mg of intravenous morphine every 4 to 6 h on an as-needed dosing schedule but received additional doses and analgesics over time. After a few days, the patient started engaging in behaviors that are frequently associated with opioid addiction, such as requesting medication prior to scheduled dosing, requesting specific opioids, and engaging in pain behaviors (e.g., moaning, crying, grimacing, and complaining about various aches and pains) to elicit drug delivery. The authors argued that this was not idiopathic opioid addiction but pseudoaddiction, which resulted from medical under-treatment [...]
Greene & Chambers present this as some kind of exotic novel hypothesis, but think about this for a second like a normal human being. You have a kid with a very painful form of cancer. His doctor guesses at what the right dose of painkillers should be. After getting this dose of painkillers, the kid continues to “engage in pain behaviors ie moaning, crying, grimacing, and complaining about various aches and pains”, and begs for a higher dose of painkillers.
I maintain that the normal human thought process is “Since this kid is screaming in pain, looks like I guessed wrong about the right amount of painkillers for him, I should give him more.”
The official medical-system approved thought process, which Greene & Chambers are defending in this paper, is “Since he is displaying signs of drug-seeking behavior, he must be an addict trying to con you into giving him his next fix.”
------
Personally I'd make up a lie: "Oh! What a great idea those posters are...I lost my dear brother to sepsis...they told us it's so easy to miss..."
This reminds me of the book The Checklist Manifesto by surgeon Atul Gawande. The book argues that aviation has achieved such a good safety record largely through the use of checklists, and Gawande describes his attempts to apply them to the field of medicine. Recommended. (Edit: I see that checklists are discussed later in the article; I would still recommend the book, as it has thoughts on how checklists can be applied more effectively.)
The problem isn't that there's not enough checklists, the problem is that there's one pilot and he's trying to fly 3 Boeings at the same time from the air traffic control tower.
> These unreliable warnings can lead to “alert fatigue” and, sometimes, a mental habit of discounting them.
This is a problem the airline industry also struggles with and even more checklists is not the answer. A lower workload and better crew resource management is.
But maybe you oversimplified the book? (Or the book oversimplified how safety was achieved?)
There are some other 100s of reasons why aviation is safe. Heck, some of them could also be applied NOW: people must rest! I do NOT want to be treated by a doctor doing an idiotic 24hs shift, which is the norm in every country I know of…
There is a whole list of things that can be transferred from aviation to medicine.
Another point I know of is the “handover” of patients. Just as ATC hands over planes from one controller to another, some procedure should warrant the correct transfer of information between shifts. Oh boy I have hear some funny (and some bot at all funny) stories about it.
"Hey these people make life or death decisions. You know what's going to help? Fatigue."
From the outside, it just seems insane.
Nice background: https://www.washingtonexaminer.com/opinion/1692395/thanks-to...
more shifts for docs = more $$ paying for more medical staff.
I can't speak to the police, but there have been a bunch of studies that showed that handoffs between shifts at hospitals is where things go bad. Someone doesn't document they gave an extra 2 cc of a drug to a patient, and next shift gives them more and causes issues, etc.
Basically longer shifts = more fatigue, and the number of errors caused by fatigue were still lower than hand-off related errors.
I don't follow. It can't be more expensive to pay 2 doctors for 8 hour shifts than 1 doctor for 16 hours; if anything, I'd expect it to be cheaper (no overtime).
> but there have been a bunch of studies that showed that handoffs between shifts at hospitals is where things go bad. Someone doesn't document they gave an extra 2 cc of a drug to a patient, and next shift gives them more and causes issues, etc.
Hence pushing for checklists so that doesn't happen?
Also, just bring in more affordable doctors from overseas. Have them take a test to qualify.
US doctor comp is much higher than any of our peer states due to industry protectionism. Other industries don't put a cap on training and licensing and haven't been so distorted.
One doctor is one salary and one package of benefits. Two doctors is 2x that.
Not explicitly, but do you think the salary wouldn't change in the medium to long term if the hours changed significantly? Of course, in the short term you can burn out your doctors by making them work longer.
This is why they are overworked, why pay 2 docs if 1 can do the work, the burnout of the doc is irrelevant as there are more docs to hire after they burn-out.
From the doctors I know, it seems like most don't get into it for the money, but they put up with it long-term because of the money. If we treated them better and increased supply, they would almost certainly cost less.
EDIT to add:
Most places have a base + bonus structure. You get your base salary, and you see patients, for each patient seen you generate 'RVUs' which is how your group/practice generates income ( by billing insurance companies ). Once you generate enough RVUs to cover your base salary, you start accumulating 'bonus' and that gets paid out down the line using whatever formula your employer uses. There is some variation to this but for the most part groups follow a similar scheme.
EDIT #2: This is US centric, i dont know how other countries do it.
It'd cost more money, but the solution here is overlapping shifts.
The reason shift handoffs go bad is it's usually a singular information dump right as the next round is getting into work mode.
Overlap by an hour, long enough to pair on a round or two, and that information is much more likely to get remembered.
I've been in hospitals a few times for shift changes and there have been a few times I've been the one to inform what the last shift was doing simply because it wasn't communicated.
We do need more shifts and almost as important we need shift overlap.
The demand is just short of infinite, it requires an extremely specialized and highly capable labor force, and it has piss poor labor productivity forever.
Which is why the staff is stretched thin, as a rule and not as an exception.
Not that there's a shortage of other issues that compound that. But even if those issues weren't a thing? The curse is far too strong.
Just because demand (typically) outstrips supply doesn't mean demand is just short of infinite. It just means it's hard to measure the demand. This is just like highway traffic --- you can't know what the demand is when it's all full, you just know there's more demand than capacity/supply.
If you built a crap ton more hospitals, and forced everyone into mandatory service in healthcare for 20 years, I'm sure you'd have more supply than demand. That's a terrible plan, but it would solve the supply problem. You could modulate the mandatory service period to adjust to the needs, and it would still be a terrible plan. :)
Something better would be some steps to address the bottlenecks. How can we attract / train a larger labor force; how can we retain the labor force; how can we increase productivity; something about facilities. Who can make the changes and how can they be incentivized to do it.
I'm outside of healthcare, but here are some armchair ideas. There's a lot of "administrative busy work" that makes everything harder to do; if you ever need to call around to multiple pharmacies to get your meds, there's two problems there: the first problem is that shouldn't need to happen, the second one is that it's amazingly difficult for pharmacies to communicate; it's not uncommon for a physician to order a test and the wrong test is performed, etc ... it's not easy to streamline communications, but it would improve productivity if done correctly. There's also a lot of things that reduce quality of life of healthcare professionals which reduces desire to go into the field and reduces time spent in the field. And of course, there's limitations on the number of residency spots.
The other issue is peer to peers and prior authorizations, these take up a significant amount of time and are essentially ways the insurance companies put barriers to care and reduce their costs.
I think some of your ideas could work but good luck getting anything past the politicians, some of these things would be expensive and others would be unpopular to those that donate to the politicians.
Why don't you have a unified system for the pharmacies and doctors to tap into?
In my country, if I get a prescription it goes into my card. Then any pharmacy can read the card, see what prescriptions are yet not used, and provide the product (which marks the prescription as covered). Recurring products, like allergy medication or chronic illnesses, become automatically available again after a certain time, like a cooldown. You only need doctor intervention during the original diagnosis and prescription, or after rare issues (like needing an extra prescription because you lost the meds).
I'd have thought this system or a very similar one is universal.
Of course, doctor penmanship is terrible, and we're going paperless, so we've got to digitize. And every doctor's office and every pharmacy has their own system, and sometimes they can talk (but I think there's a lot of faxing behind the scenes)
Of course, you can't know what drugs will be covered, so the doctor has to guess, and if they guess wrong, the pharamacist will want to check with the doctor to see if something else is OK to save you money, but nobody can be reached, ever.
This cap not only constrains overall physician supply but exacerbates shortages in critical areas like primary care and rural medicine, as hospitals hesitate to expand programs without guaranteed reimbursement. Recent legislative efforts, such as the bipartisan Resident Physician Shortage Reduction Act, seek to add thousands of new slots over several years, but until such reforms pass, the 1997 policy continues to throttle the pipeline of trained doctors, leaving patients with longer waits and uneven access to care.
But there are numerous countries that aren't US, and don't share US laws.
Do they have medical staff that's not overworked, or a healthcare system that doesn't suffer from a constant labor shortage, long wait times, poor treatment quality, or all of the above?
The root of the issue is deeper than just "US is uniquely dumb".
Quite possibly!
>There is a whole list of things that can be transferred from aviation to medicine.
Please recommend more books!
no amount of checklist would prevent mistakes. we need legislation to limit medical workload, which is unlikely due to the shortages.
- Lack of any low-intensity monitored recovery option. If the kid could just have been sent home to a traditional worrying mother, who'd been told to watch for certain warning signs - then he very likely would have lived.
- Critical shortages of front-line medical staff. (ER nurses especially noted here. But a dishonorable mention to the computer systems that the residents were fighting against.)
- However short our medical system might be on front-line resources to treat patients needing care - once it's lawsuit time, resources seem plentiful.
I told her she might have a UTI. It was not normal for it to hurt that badly to pee. She denied it. I bought her a UTI test, it came out positive. She was shaking. I told her we had to go to the hospital, she thought they were period cramps.
I call a teledoc. They video chat. She explains the pain shes feeling in her lower back means it’s likely a UTI, the infection has likely reached her kidneys, and we should go to the ER immediately.
In the ER we think they’re going to just give her some antibiotics and send her home. Nope. She throws up. Things go bad fast. Her heart rate is 160. She turns a color I’ve never seen a human before.
The next 3 days were so incredibly hard. But I’m so thankful to all the medical workers that were attentive to us.
Thankfully she makes a full recovery. For a week or so she was lethargic/tired but she’s fully healthy now.
A few months before I had read a story about a woman who’s boyfriend had died from a UTI because they went to a gospital, gave him some antibiotics, and he ending up dying at home because the infection was already too progressed to fight off at home.
Had the person who evaluated my girlfriend not evaluated seriously or just sent her off that could’ve been her. I’m so thankful they admitted her and took her care seriously.
It’s scary how quickly a UTI or some other benign infection can become sepsis. Take it seriously.
This might sound strange, but I think you deserve some credit for taking it seriously and being there. It’s a documented issue that women’s problems are frequently written off and downplayed as normal things like period pain.
I’m really truly happy to hear that she made a full recovery as well. It is wonderful to hear that she is okay.
However the first time it did indeed take quite a while before they figured out she had a UTI, and it took a few times before we figured out the pattern.
Everybody did well in that instance, including you. Many people won't advocate for themselves, so having someone around who will do it for them is incredibly important.
Physicians can be salaried and receive benefits from their group or hospital
Physicians can be 100% productivity based meaning that they will only get paid by the amount of patients they treat but they receive no other benefits from the group or hospital
In between these two groups, there is a wide variety of compensation Packages that are complicated to discuss in this comment.
Nonetheless, the overwriting factor for all emergency physicians is that we triage patients, not only after triage, but internally as well, including those patients at reside within the treatment rooms and those outside in the waiting room.
The question is, can we see less patients and spend more time with them and the answer is yes but to the detriment of the entire department and possibly not seeing a patient who is sick and who hasn’t been seen yet. Do you have to be able to tell who you can spend five minutes with and who needs 30 minutes.
Through put his king, but quality is queen, so there’s always a trade-off between seeing patients fast enough and to see enough patients through your shift, but to also how they were with all to determine which patients will require more time and more due diligence.
Every shift is a pull and push between these two dichotomies and it’s never easy and there are multiple decisions that have to be made.
The autopsy found pulmonary hemorrhage, enlarged heart, enlarged liver, damaged kidney.
Trying to reframe it in a coding analogy, there were a few abnormal logs maybe an exception or two but the coder was unable to figure it out and these exceptions happen all the time and so pushed to live anyway. Due to resource allocation issues they were pulled to a different job. Then the site crashed. Just awful.
Trainees training others is what happens at frequently at teaching hospitals. All these folks are too busy. Somethings the third year is inadequately trained to teach a first year - they teach them bad habits. And often academic facilities don’t value good patient care….they value national recognition and publications. It is the folks of the lecture course that get promotions.
This I’m sure happens in all fields…in medicine it leads to deaths.
There was a joke that you never want the visit an hospital in July, as that is when new residents were around. The fact is that there is an ounce of truth to that joke. It sure feels like mortality increases in July.
there’s some great new research out of the university of virginia looking into this https://www.science.org/doi/10.1126/science.adq2509
mis-c and the adult versions are rare but real, and there’s early promise with a treatment called larazotide https://www.science.org/doi/10.1126/scitranslmed.adu4284
the nih recover autopsy studies are also finding viral persistence in multiple organs, with more results coming soon https://recovercovid.org/pathobiology
i work on multiple NIH RECOVER efforts on this topic and post long covid research on x, and honestly the picture is both fascinating and pretty grim https://x.com/atranscendedman
I'm like that and it sucks, I now bring my wife to medical appointments so she can complain for me while I downplay everything.
Next morning the pediatrician did his rounds, checked on my son, and immediately started speaking Latin, to go over our heads while rushing around and getting equipment to clear his lungs of amniotic fluid.
Reminds me of what my first engineering boss told me -- "When the people on the line say there is a problem. There is a problem."
They were constantly taking my blood, constantly running tests, and in the end they basically just shrugged and said it was seemingly some random virus they didn't have a test for, nothing they could do. I heard some doctors talking outside my room about how unusual it was for me to be sick for as long as I had been, and they just seemed to brush it off and one said something like "well he's still fairly young, he'll probably get through it eventually."
They never figured out what it was, never were able to do anything to help me, just kind of shrugged, kept me overnight for more observation and then kicked me out the second the sun came out. My body and mind were absolutely shattered, especially after being woken up every 30min all night long for more blood draws, and I was told I could at least eat breakfast before I left, but they ended up reneging on this and kicking me out before breakfast time.
This was at a major hospital, a well ranked one, in a major city. The experience really opened my eyes.
Husband was pretty healthy. Nothing in his family history. Most of his family had died of natural causes. One day got really sick. Was bedridden for a few days. Fever, body aches, coughing. Third day they go into urgent care. Doctors think its just a bad case of the flu since it was late October. They give him some antiviral stuff and told him to take it easy and let it run its course.
Two days later he got up and said he felt a little better. Spent 45 mins on the treadmill and afterwards said he was feeling great. The next day he got up and was pale AF, and she said when he was talking to her, she could smell the sepsis on his breathe. Called 911 and they took him to the ER. Took an xray and saw the sepsis had spread, and it was terminal. She spent the next 36 hours watching him slowly die.
She said had they done a chest x-ray the first time he came in, they probably could've had a chance to save him. The way health care is now, doctors make you jump through all the hoops before they're willing to order more extensive tests and bloodwork.
Just a sad story all the way around but I'm not surprised by your similar story either.
The anti-virals are just limited to Flu and Covid.
What I suspect you were being told is "For a respiratory illness presenting like this, we only have tamiflu and paxlovid."
Multiply the number of diseases/conditions by the average number of environmental factors multiplied by the number of genetic conditions which change how they present. The cross product is a MASSIVE search space and the ER doctors need to search it about 1-3 hours (on average).
Sometimes patients lie or mischaracterize their symptoms, leading to uncertainty about the data they get.
The emergency room is a triage center. For every bed that is full, there is back pressure into the lobby and out the door. Their job is to create a priority queue (or occasionally to turn into a triage center) based on patient volume keeping the highest average treatment quality possible, not to maximize treatment for any one patient.
Symptoms alone aren’t always determinative. Many flu-like viruses present with almost the exact symptoms, despite being different viruses and having different impact on the body. The ER may discharge you before the labs come back with a positive identification of the exact virus strain, meaning it may be way more dangerous than the seasonal flu, but they play the odds unless you have known comorbidities.
Even if the doctors make a mistake in the ER and discharges you, there’s a decent chance that will live. The body can fight off many diseases by itself (without doctor’s intervention) and if not, there’s a chance you can make it back to the ER for a second attempt. An ER’s job is to keep you alive during your visit to the best of their knowledge, not to see you through the entire course of your disease. As discussed in the article, there are a shortage of hospital beds in other departments, so Ears end up being a poor stopgap for those.
Chronic diseases became more common as doctors and medicine increased our lifetimes. ERs are not the right place to manage chronic diseases, but it’s de facto where the indigent go for their only health care access and where acute issues related to chronic conditions are managed.
People need massively more hospital care during their last year of life and boomers are going through that time of their life. Hospitals are businesses, so they are min-maxing their capital outlays (how many beds they can support) with equipment and staff. If they overspend, they have to charge more than the already outrageous prices they have. If they underspend, some people will get undertreated and hospital staff will get overworked, but that seems to be acceptable to American society, so that’s what we get.
Medical science isn’t perfect. It doesn’t have infinite resources to investigate every possible condition. You couldn’t afford it if they decided to do every diagnostic test possible.
>My body and mind were absolutely shattered, especially after being woken up every 30min all night long for more blood draws,
Would you rather they don’t take your blood and run tests? How do you expect them to do any diagnosis?
>They never figured out what it was, never were able to do anything to help me, just kind of shrugged
What do you expect them to do?
Figure out what was going on, very obviously. Failing that, be open to observing longer instead of kicking him back out when he was still showing obvious symptoms.
His point in talking about being woken up all night was not that he didn't want to be tested, it was why would you even kick someone out onto the street at the crack of dawn who you know hasn't slept all night because you kept waking them up, let alone doing that if they're also sick? (I know the answer, not enough beds, but your "I don't see a problem here" attitude really doesn't contribute to anything.)
There's a wide variation in doctor skill and they don't have interview systems like we do in tech. You need to be ready to override them.
I always wondered why other people talk about "needing to advocate" and so on until I realized I'm just a really pushy patient. "would you mind prescribing this anyway?" And "Could you order an MRI just to confirm anyway?"
They'll do it with some warning that insurance may not cover it and then you can choose to pay or not. And you have to push repeatedly (not forcefully, just repeatedly) to get your imaging and all that.
Except for some paediatric infection for my daughter and the ob/gyn care for my wife, this is mostly for me: I've been in hospitals many time because of trauma (Motorcycle accident, stuff like that) and so long as I'm lucid I assume control.
This is necessary in the US because there's no quarterback for your care here. There are people who do things but an overall CEO of Me does not exist. You have to play that role yourself or find an authority who can.
This is the crux of the whole article. People who make software please take note the importance of what you do.
I feel like scrutinizing the industry for a 2-3% error on an obviously difficult problem is exactly why we pay so much in the United States for health care.
Costly healthcare due to scrutiny is not the problem with healthcare in the US. The problem is drug monopolies, medical (mal)practice without a license by insurance companies, and the lack of taxpayer funded healthcare-as-a-right.
We need to create an environment where someone like Terblanche feels comfortable advocating for himself without feeling like he's being a burden on the ER, and physicians don't feel like they're wasting time by investigating seemingly trivial cases. Such a situation exists because we are not pouring enough money into healthcare in this country.
The study performed by AHRQ used incorrect methodologies and datasets to extrapolate its findings.
The ED is far more accurate with a much lower error rate than the study found.
There will be rapid diminishing returns. It may cost 5x to get to 1-2%. Maybe 10x.
I've had a thrombosis formed in my calf after having a broken leg and using cast. I also caught covid during that time, and from what I've read now I believe it increases temporarily clotting of blood for certain people. When cast was removed, leg was still stiff as wooden plank and ankle didn't bend. I wasn't told to keep the leg higher so I didn't. Some weird mild pain started in the middle of the calf after few days, wife suggested it may be thrombosis rather than stiff muscles or tendons. Went to Switzerland's biggest hospital's ER, got blood tests, they were below limit for thrombosis, so I was just sent home.
Pain didn't go away, luckily my wife considered it suspicious and asked another doctor who is an expert on this to recheck. Voila, thrombosis there.
The cause of miss - ER doctors should have done more than just a blood test (even by their own ER protocols, checked that with wife and her colleagues), echography would have shown blood clot in the veins. If it got dislodged and ended up in lungs, that's a quick death within cca 20 mins, ambulance & CPR usually are not sufficient to keep person alive without major brain damage. Or blood clot goes into brain, cutting off some part of it with similar result. One peer from back home died exactly like that (lung variant, the most deadly one).
Sorry to have the need to have shared this, but at least it's been on my mind every time I hear someone take their cast off and experience something similar.
yeah yeah there may be some gremlins or bugs in the airframe but in theory it should fly and handle just like each other aircraft.
each human may be wildly different
Or, build devices to send home with patients which allow for cheap, continuous self-monitoring. That might be a legitimate application of AI actually, if you could use e.g. phone camera tricks to measure more health parameters. Even if imperfect, it could still pick up a few patients who should not have been sent home.
All research I’ve read on this topic finds that it is the US legal system that causes the crazy prices (incentivizing more testing to cover-your-ass and avoid liability etc.)
Many comparative studies on health care cost and quality use the US military as a proxy, as it is free on the condition that you cannot litigate (very coarsely; it is more nuanced).
The costs for treating US military personel is much closer to other countries (while treatment quality remains equal).
If only. Then the outcomes would be better.
The real reason is that it's ostensibly supposed to be a market but the pricing for everything is completely opaque and shrouded in bureaucracy and corruption.
We expect so much from our health care providers, and we sometimes don't appreciate that they deal with a wide array of patients.
Some will come in with a tiny brushing, asking if they are going to die. Others will walk around with a critical condition for days, saying maybe they were a little sore, but they didn't think it was too bad.
We might need other measures. It might be damn complex. Ideally 100% would die from "malpractice" (or unknown able issues) because people are so healthy and society is so safe there is barely anyone in ER.
Someone who goes to the hospital 3 times and still die because of an untreated disease is not just bad luck.
I've had uncountable number of doctor's visits including ER for 37 years before a proper diagnosis was made.
So the main problem is employer middlemen. Which happens in significant part because of tax incentives for employers to do that which you can't get if you do it yourself.
Is there any problem today that DOESN'T boil down to the government giving preferential treatment to some class or group?
Even in a very well functioning system similar cases might happen eventually, anyway (but at a much lower frequency). ROC plots come to mind.
https://en.wikipedia.org/wiki/Receiver_operating_characteris...
There is a corrupt political scheme operating in the USA 350 million people losing 6+ average years of life = that is the cost.
The article does't provide enough information about what he was doing before the game, unfortunately. But if he was cleaning out a shed or garage then Hanta is in play.
Similar for Sam's girlfriend Kayla. If she'd been assertive and physically present, she might have saved his life.
Similar any close friend of Sam's.
Similar a bottom-tier resident staff member in Sam's dorm, worried about one of his residents and regularly checking.
(Yes, the U's dorm system "could" officially try to keep an eye on sick residents. But with America's legal system, don't expect any sane university official to sign off on doing that.)
Compared to an in-person check, or a video call, or even just a voice call - txt messages convey almost nothing about a person's medical condition.
It is astounding how much more you can learn about your diagnosis from an LLM.
Ultimately the ER was of no use in treatment, but the preparation did help rule out a serious diagnosis.
[0] Like seriously I wish I could have given this kid one of the many weeks of observation that hospitals have given my paid-by-Medicare family members. The beds are available, they're just full of elderly people who had some acute problem but the hospital won't readily discharge them due to chronic medical conditions (plus they're messed up after being starved for a day in the ER).
"More than 200,000 people will die each year from preventable medical errors. He was shocked. Conservatively, these estimates amount to at least one fatal Boeing 747 crash per week."
"Doctors talk about electronic medical records as an unpleasant and frustrating chore. They object to how the charts have evolved to prioritize billing and liability defense over clinical care. And they regard the symphony of well-meaning alerts and pop-ups as a distraction at best."
"The check boxes and templates can aid efficiency, several doctors told me, but they also may distract physicians from the patients right in front of them."
I don't know a single doctor who wants this. Insurance companies want this. Don't blame healthcare workers for the hellish scenarios they are forced to work under.
In the staffing and service provider companies the nonprofit funnels its money into. And let's not even mention the cost of medical devices and medicine.
And your theory is that the reason medical care is so outrageously priced is so the CEO and the board of directors can get exorbitant salaries?