The BG Health Care Thread: Decreasing the Surplus Population

[Tyche]

You gotta know what to look for when researching a diagnosis/differential. And to do that, you need a knowledge base to pull from. Patients know their symptoms and can easily Google them, but they probably are not getting the right diagnosis.

NPs aren't physicians, they shouldn't pretend to be. They don't have near as much training (600-1000 hrs for an NP/PA vs a residency program that varies in length, but is measured in years, not hours). NPs have about 2/3rds the amount of schooling. The standards for NP/PA school isn't that high, either. It should be higher, but NP schools are money printing machines for universities.

With that said, the lobbying of the AMA and the deficiencies in the medical system are almost entirely their own fault and is what has led to a proliferation of NPs and PAs. The barriers to medical school are artificially higher than they need to be.

[kuronosan]

^

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[Day]

which ones use BMI

[Heavencloud]

The real fuckery began with the whole DNP thing. The training makes no sense and is so variable. PAs have more consistent training. Still no where near the breadth of knowledge gained from med school and residency, but PAs seem to know their role more than your average (D)NP.

[Byrthnoth]

Just so we are clear "they use experience and evidence based medicine" is not using evidence based medicine, whose primary supposition is that average quality of medical care goes up if doctors use consensus treatments instead of their faves. Humans are horrible at developing theories about rare events in complicated systems and many faves end up being problematic. The evidence-based medicine approach is to just bypass all the personal bias problems and tell people to only give consensus treatments.

There is no "evidence and _____" in evidence-based medicine. It is philosophically the absence of an "and."

That said, give me a doctor that genuinely understands human physiology and can explain how the body works any day. All the ones I have met are MD/PhDs unfortunately, which means they typically don't see many patients.

You have no idea how many GI residents can't answer the question "how do humans poop?" with any level of specificity/technical accuracy. Seems kind of critical, but it isn't involved in collecting signs or doing a specific procedure so they don't know.

[Salodin]

What kind of doctor was House? Thats the best kind of doctor and they should all be like that

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[kuronosan]

Just so we are clear "they use experience and evidence based medicine" is not using evidence based medicine, whose primary supposition is that average quality of medical care goes up if doctors use consensus treatments instead of their faves. Humans are horrible at developing theories about rare events in complicated systems and many faves end up being problematic. The evidence-based medicine approach is to just bypass all the personal bias problems and tell people to only give consensus treatments.

There is no "evidence and _____" in evidence-based medicine. It is philosophically the absence of an "and."

That said, give me a doctor that genuinely understands human physiology and can explain how the body works any day. All the ones I have met are MD/PhDs unfortunately, which means they typically don't see many patients.

You have no idea how many GI residents can't answer the question "how do humans poop?" with any level of specificity/technical accuracy. Seems kind of critical, but it isn't involved in collecting signs or doing a specific procedure so they don't know.

I'm sorry dude, but no. No way is there a majority of GI fellows out there who cannot explain how humans poop. That's basic fucking medical school shit there that fellows would be required to explain.

No. Done here.

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[Byrthnoth]

Oh? Why do antidepressants cause constipation?

[Roranora]

if i wake and bake, a second morning poop is imminent

[kuronosan]

Oh? Why do antidepressants cause constipation?

The GI tract has its own nerve plexus and is filled with Serotonin receptors so typical SSRIs USUALLY cause diarrhea because of that.

Some, like tricyclics, have anticholinergic activity that actually slow gut motility and peristalsis and cause constipation.

That doesn't even need to be looked up. It's my job to know that shit so I imagine a GI specialist would know way better than me.



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[archibaldcrane]

What job would that be

[Byrthnoth]

They cannot and your answer was about the best I have ever gotten on a basic "do you know anything about how the gut works" quiz and it didn't propose an actual mechanism for how it might work as much as note that receptors exist for the purported target of these dirty drugs.

"The enteric nervous system has seratonin receptors" to "therefore the shits" is a bit of a jump and not much of a slam dunk considering the same drug causes constipation occasionally too.

Tricyclics slowing gut motility is possible (if you meant contractions) but not imop the likely mechanism because such major contractions (like moving your arms) aren't inhibited by an appropriate dosage of tricyclics. It is likely affecting the muscle tone of the gut and subsequent pressure-based mucus secretion. If you meant "speed at which things move through the gut" by motility, then I concede that things moving slower through the gut is the definition of constipation and you are correct.

GI residents that know me well enough just straight up admit that they have no idea what is going on chemically down there and it doesn't matter because constipation is generally going to be dealt with using stool softeners regardless what caused it.

So what I'm saying is, if they don't know the mechanisms and have one useless level of abstraction worth of knowledge over a ten year old, why not let a PA do the job?

I don't want to give the false impression that there is some perfect theory of how the human body actually works out there that they are ignorant of. Biology is super complicated. However, most don't even try to understand how it works because they don't need to in order to apply evidence based medicine and give stool softeners to constipated people. Medicine's embrace of evidence based medicine was the moment they gave up attempting to understand (unless they are MD/PhDs attempting to be involved in research). Given the lack of understanding, why TF not let PAs do colonoscopies?

Making med students memorize trivia that they won't use is just a way to haze them and forms a barrier to entry. If that is their edge, then fuck it.

[kuronosan]

Well when you draw that comparison then yea why not?

But if doctors are just going about their day talking basic shit and don't focus on the physiologic mechanism then they're shitty doctors.

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[Byrthnoth]

OK, let's go closer to home then.

1) Do antidepressants work?

2) How do antidepressants work?

3) Does the mechanism actually matter for treating depressed people?

4) If the treatment for depression is to give antidepressants to people who report depression and cycle to a different dosage/drug/class if they don't see improvement in a month, what use is the theory?

[Boyiee]

How does tylenol work, what does it do?

[Heavencloud]

there's no such thing as a "gi resident" in the USA. they're fellows, or residents who are rotating on the gi service (who may have no interest in gi)

[Byrthnoth]

Sorry, the terminology escaped me. I dealt with these people during their research rotation when they worked as a postdoc in a lab or did a lit review for a year or so.

GI fellows were way better than the aspiring pain specialists, I will say.

[Tyche]

OK, let's go closer to home then.

1) Do antidepressants work?

2) How do antidepressants work?

3) Does the mechanism actually matter for treating depressed people?

4) If the treatment for depression is to give antidepressants to people who report depression and cycle to a different dosage/drug/class if they don't see improvement in a month, what use is the theory?

This is such a weird line of questioning. It's basic patho and pharmacology. Not even psychopharmacology. Just pharmacology.

[Byrthnoth]

Correct, it is WebMD level Google results.

The answers are:
1) probably, although they are typically only marginally significant when compared with placebo and animal models of depression are generally shitty. The improbability of demonstrating efficacy over an existing drug is the reason that all big pharma companies killed their antidepressant programs in the mid-late 90s. Not because what exists is good, but because the problem is really hard. Now that they have changed R&D business models a few are starting to pop up again.

2) The real answer to this question is that no one knows. There are no genuinely selective antidepressants, and even if there were the mechanism would be unclear. The NIH abandoned mechanism-based basic pharma research funding years ago because a shotgun approach (permute a compound with some efficacy to try and make it more potent or remove side effects) using animal models for rapid testing is just more cost efficient.

3) We don't understand the mechanism and we treat people, so it does not.

4) Not much. You need to learn when to treat and memorize a rubric indicating what should be tried for whom, but it isn't like there are a thousand competing drugs.

My point with that line of questioning is that medical school isn't giving people genuine mechanistic understanding, which makes sense because medicine/pharmacology isn't based around understanding anyway.

Learning where dopaminergic receptors are and what synaptic spillover is might let you feel that you have something, but the science is super shaky and memorizing a different proposed mechanism of action for each different drug doesn't let you choose between them.

TL;Dr: we should train doctors as technicians of the human body, which is arguably closer to PA training than MD training.

[Heavencloud]

My point with that line of questioning is that medical school isn't giving people genuine mechanistic understanding, which makes sense because medicine/pharmacology isn't based around understanding anyway.

Learning where dopaminergic receptors are and what synaptic spillover is might let you feel that you have something, but the science is super shaky and memorizing a different proposed mechanism of action for each different drug doesn't let you choose between them.

TL;Dr: we should train doctors as technicians of the human body, which is arguably closer to PA training than MD training.

you're hilariously wrong for so many reasons. you cherry picked an example - psychiatry and psychiatric medications - which are not well understood. there are examples like this in all parts of medicine (off label use, etc), but psychiatry is notorious for it.

medical school certainly does teach towards synthesizing mechanisms, biochemistry, and pharmacology towards treatment of disease. knowing the science behind the medications is precisely why MD training is absolutely essential in the care of undifferentiated critically ill patients. particularly in the litigious united states, where perfection is expected.

the suggestion of dumbing down physicians to be "technicians of the human body" is appalling. not just because of the intense training, but insane responsibility that comes with the job of taking care of patients. less training and less understanding is beneficial? absolutely wrong.

hopefully many PAs learn the essentials in their short duration of training, or have enough sense to know when they do not know something (really this is what medical school teaches -> do not be overconfident, know when to stop and take a step back).

i particularly like your example of antidepressants because this is such a small portion of medicine, and many MD psychiatrists don't want to deal with non-mental health problems period (not really a problem, everyone gets into their niche)

if you get in to other types of medications, such as antibiotics, sedative medications, paralytics, biochemistry, chemistry and pharmacology become extremely important. could you simply memorize which antibiotic to give for CNS coverage? sure. but is it better to understand why the larger molecules can't pass through the BBB, why x drug will cover y bacteria in a particular case with z comorbidities?

also, even experienced MLPs often fail to recognize truly sick patients. imagine a technician who doesn't know what test to run, or simply doesn't have the equipment (knowledge) to recognize the true pathology and hedges on their own bias. there's tons of lawsuits on this subject. e.g.: https://www.medicalmalpracticelawyer...ear-old-in-er/

the other day i hypothetically worked with an experienced PA who came to me and had me see a pt - he was concerned about the pt but hadn't given antibiotics yet because he didn't have a source yet. i saw the patient and had him give abx right away just based on a 30 second encounter and a physical exam. pt died of septic shock later. the 30mins of delay in abx prob didn't make a difference, but if had been a physician see the patient initially i almost guarantee you treatment would have been started faster. unlucky for this patient. my shop is reducing MLP coverage because physicians are faster w/ each patient and sometimes the "fixing" of what the MLPs did is more work than it is worth. and we only have PAs, i can't even imagine how bad it would be with NPs.