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https://archive.is/MgWJH

Sepsis is hard to spot. Whats interesting about this article is that once you get into the details of whatt happened on the patients second visit, its largely about the hospital information systems and how they got in the way.

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.

> 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.

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.'"

It's even worse, in a way. Mt Sinai uses Epic, as do many (most?) other larger hospitals in the US.

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.

So this story comes down to a gripe about data systens that is as old as these systems themselves: the designers and implementers come up with data models and workflows that feel like they cover every possible case and they deliver a system that is a perfectly rigid implementation of these flows because they seem complete. Inevitably, these systems meet the messy real world and users find themselves unable to do what they need to do for the occasinal really weird case and get hopelessly stuck because they run up against stubborn rule checks.

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".

It’s not even a weird case. I have to specify, but don’t care if it’s back-to-front or front-to-back. Or where the x-ray is taken (yes, doctors have to specify that). That matters to the radiologist reading it (plain x-rays are like a camera obscura, so things close to the emitter cast a larger shadow), but for my purposes, it doesn’t matter because the level of detail I need is not that.

So in your case the SW is a poor fit. That feels underwhelming from a package that is used widely and presumably should have the flexibility to adapt to the requirements of very different customers.

Yes, all major inpatient EHRs do have the flexibility to adapt to those requirements. But that level of customization is itself a huge effort, and many hospitals lack the resources to do it well. The other problem is that hospital administrators and IT staff often give in to internal pressure from clinicians to customize every little thing even when it doesn't actually improve productivity or care quality. Sometimes it's better for humans to adapt to the software rather than vice versa. "Vanilla is the best flavor."

As a clinician, I wholeheartedly agree that adapting myself to the software is usually better than spending tons of money to try to make the software fit me, but at the same time the software really should fit the general norm of practice style.

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 feels underwhelming

That could be the motto of basically every EHR system!

> the designers and implementers come up with data models and workflows that feel like they cover every possible case and they deliver a system that is a perfectly rigid implementation of these flows because they seem complete. Inevitably, these systems meet the messy real world and users find themselves unable to do what they need to do for the occasinal really weird case and get hopelessly stuck because they run up against stubborn rule checks.

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.

Epic has 41% market share for inpatient EHRs so it's in many but not most hospitals.

https://www.definitivehc.com/blog/most-common-inpatient-ehr-...

But that is 41% for a single vendor out of 10. So market leader. And it looks like the data is based on hospital installations but not normalized based on quantity of patient served or patient case complexity.

Edward’s Hospital in Plainfield, Il and Mt Sinai are two different use cases and should not count equally.

That is something to keep an eye on. The system that owns the hospital where 95% of my work happens uses Epic and they subsidize it for hospitals that aren’t formally part of our system but could be a good referral base.

Catholic hospital, so it has its own internal issues, but it’s definitely not PE-controlled.

I think the main problem with pop-ups that makes them a bad place to put important (any?) information is that they interrupt the user's workflow - which is, indeed, kinda the point of the pop-up. But what is a normal human's reaction to this. They are in the middle of trying to do the thing they want to do. To continue with this, they need to get the pop-up out of the way, so they just click the button.

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"

Even claude Code does it.

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.

Oh man! Focus stealing is the worst! Bitwarden used to do this while I was typing my master password, stealing focus in the middle of what I'm typing to ask if I want to interrupt what I'm trying to accomplish to get their next minor upgrade. Which, of course typing my password very quickly I often hit enter at that moment, forcing me down an upgrade path. Beside the point of having my typing part of my password into a context it wasn't meant for. I think they've fixed it though.

Why would you mindlessly type away when you already know ahead of time, that they might be doing something tricky?

because the previous 30 times it didn't do it

Then it clearly it is an issue of overconfidence.

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.

I remember a time when I thought we were past the Windows 98/XP popup malware era. Now every single website and application loves to shove popups in my face whenever I'm trying to accomplish a quick task. I don't think I have ever read anything other than the buttons to figure out which ones not to press.

Engagement metrics will be the death of us.

It occurs to me that maybe user behavior metrics are to blame, because our default response to these stupid intrusions (click any button to make it go away) appears as "engagement" to the devs/markting people: "oh look, people are clicking our popup buttons!" so then they are encouraged to add more of them. "Look how much engagement we're driving!"

The problem is that they actually work. I've been involved in having to implement these nightmares and it turns out that normal people do actually interact with them and it does result in increased revenue.

I am currently waiting for an oven technician to show up to help fix an oven that refuses to operate until I complete a certain cleaning cycle. But the cleaning cycle is blocked on a pop up that cannot be dismissed. I think it’s trying to helpfully give me instructions, but I don’t need the instructions — I already followed them and now it should be the oven’s turn.

2025 is a weird nightmare. Imagine reading your comment in 1990.

Logs, or a message queue, where messages can be filtered / sorted for priority.

> 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!

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".

As a product designer, I can think of 2 reasons why the person that came up with this flow might've made it a popup:

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.

Sepsis is indeed an immediate life threatening condition, and I bet the alert was added as some kind of legal/medical ‘oh shit’ type of condition - without thinking through the consequences from a UX perspective.

What could possibly be a better use case for a progress halting pop up than a potential/likely "immediate life threatening condition"???

The issue is not the UX, it's the provider's arrogance thinking they know better. This thread is literally unbelievable.

Have you been on the other side of this? I get dozens of sepsis alerts a day, usually on the same patient, and the criteria that triggers them is so broad and non specific they are functionally useless. Each alert locks down the entire system ironically preventing you from reviewing what triggered it in the first place. You cannot do anything until it is addressed and you are forced to commit to an action without all the data because of it like administer a medication or order fluids, which may not be appropriate. Lots of things mimic sepsis criteria including but not limited to decompensated cirrhosis, HF, cancers, leukemias. The worst is that they don’t even pop up at the right time, they usually pop up usually way after the sepsis has been treated. In the past year, I’ve only had about a half dozen appropriate sepsis pop ups among the hundreds I’ve received.

Wait what?!

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?

Yes, really. I’ve had to restart my Citrix session to make it go away or dismiss it like the writer did.

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

> It blocks the system with a demanded action

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");})();

UI engineers need to be held legally responsible for false alarms like this.

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?

If your vehicle has a safety defect then you should file a formal complaint with the NHTSA. These things won't get fixed unless customers follow the process.

https://www.nhtsa.gov/report-a-safety-problem#/vehicle

Safety defect: my Tesla has a really distracting giant screen in the drivers field of view. WTF?

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.

Appreciate the added and specific context. I'm not in the medical field but I have worked on EMRs.

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.

Of those half dozen appropriate pop-ups, did they actually change your plan or were you already aware of a sepsis diagnosis?

I think a better question might be ‘was there a sepsis diagnosis?’

We are grading a tool which might not need to be there at all. It shouldn't get points for coming in six hours later saying that the patient being treated for sepsis might have sepsis. See what I'm saying? There's a cost to every flag you wave.

I’m pointing out that it may not have been sepsis at all, so it’s even more ridiculous.

UX is sort of the issue in the sense that people have been trained to ignore pop-ups because they are used for so much irrelevant garbage that it is a "boy who cried wolf" situation. The questions of: "How do you force a computer user to take something seriously?" is fundamentally a UX question.

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.

The issue with popups is that it's all or nothing and you are forced to choose one before you do anything else.

Mandatory "snooze" button for a popup would go a long way.

Also easily accessible history of recently dismissed popups would be great.

If you are actually trying to do something to resolve the situation, why would you want a progress stopping pop-up forcing you out of actually doing the thing you need to do? Especially if it forces you to pick out of two options when the thing you are trying to do is figure out which option is appropriate?

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?

Have you read any of the details? The provider was unable to take appropriate action because the progress halting popup was preventing taking that action.

Of course I did. You're wrong. The provider CHOSE not to take the appropriate action. The appropriate action was ordering the medication because the automated diagnoses was in fact correct.

PS - I would suggest avoiding rhetoric like "did you even read" as per the guidelines. It's just a waste of everyone's time.

Quoting the article:

> 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.

Kind of my thinking here... the fact that popups are abused for BS doesn't mean that they don't serve a purpose and this is one of those times.

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."

> 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.

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.

>implying people read pop-ups instead of just closing them

10000000

Mind boggling

I’m really shocked that nobody stopped and thought “doctors have special training and should be expected to diagnose and treat Sepsis if reminded about the possibility.” I don’t think it was appropriate to block the entire flow, and I’m surprised nobody thought it was possible to want some but not all of the actions for sepsis. If the developers are really making popups that make life or death decisions then maybe EMR customizations should have a tighter safety class.

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.

> that draws product designers to keep reaching for that horrible UX pattern

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.

It's more that modal alerts are easier to reason about. With some other kind of notification you'd need to think about what the user should or should not be able to do until the alert condition is dealt with and what the consequences of dong it without dealing with the alert should be. It's generally easier to make the user deal with the special condition now so that the rest of the code can assume it either doesn't apply or has been dealt with.

I've reached for a pop-up and stopped using them exactly because of the "nobody reads this" problem.

What's the alternative when you have a potentially dangerous action that you need to give the user fair warning about?

You make it possible to undo the action!

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.

This should read "but when there is such a case" and "in which to cancel the email send".

In this specific case it seems a particularly poor implementation of a classic ordered and/or nested Checklist. If the order matters, remind people checking later steps that they missed a previous step. If nesting matters and there's some if->then logic in the checklist based on the answer, add more checklist steps as necessary. If neither the order or the nesting matters, then why is it a modal step?

You could simulate the destructive actions instead of asking beforehand and make user confirm all destructive action before proceeding to actually executing them.

<blink/> tag? (/s)

is it the popup that got someone killed or the fact that they're so pervasive and misused that we're all trained to ignore and dismiss them?

Sometimes I accidentally dismiss a popup and then don't even know what it said. Terrible pattern.

This is why I think that we're getting to the point where software developers need to be trained in ethics and licensed in the same way as professional engineers are around the world. The people building the tools need to be held accountable when design choices kill people.

Most software development is not much like engineering. That's probably the right choice for low-stakes consumer products, but wouldn't be accepted in avionics and shouldn't be accepted in medical software that impacts life safety.

The hospital software that I'm familiar with is absolutely terrible and would never have been accepted in an avionics environment. It is an endless pile of nightmarishly wrong UI/UX choices coupled with opaque documentation and updates that confuse the users. They also make money hand over fist.

Ethics is applicable to many situations outside of life critical systems. Engineers take ethics very seriously because it is important, and I think it is important for software developers as well. The first time I worked closely with a Professional Engineer on a project, it was eye opening as to how the concern of doing things the ethical way shaped the interaction... Everything from identifying potential business conflicts to ensuring data collection for inputs to the design process was done correctly and traceable.

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.

I think including ethics in the curriculum at both the high school and university level is a great idea. I do not think requiring software developers to be licensed is a good idea at all.

Safety-critical software projects should have a licensed engineer in a supervisory role.

Licensing takes many forms. Some are onerous, some are not. Working At Heights training takes 0.5-1 day of training every 3 years where I live, and it's mandated because it saves lives. Yes, it's a form of licensing, but it's an easy box to check because it's accessible.

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.

> 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.

Wait, what happened here? Do you have more details?

I didn’t read the whole thing but the intro seems even handed: https://hendrik-erz.de/post/lying-to-your-research-subjects-...

Name a consumer product that doesn’t impact life safety.

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.

Modern engineering exists because of the people that were maimed or died to give us the knowledge that lets us live the way we do today.

Bureaucracy won't help anything. You can't train people to be more ethical.

Bureaucracy and accountability are two separate concepts.

[dead]

Doesn't the FDA already regulate medical software?

To an extent, but only if the software meets the criteria for being legally classified as a "medical device". And at the lower classification levels the regulations are very light. You don't necessarily have to prove any level of reliability or usability.

https://www.fda.gov/medical-devices/classify-your-medical-de...

Ex employee of the division of imagine devices and software reliability here. I have nothing to add, and I'm not qualified to confirm or deny your comment. Just interesting to see a mention of my past life

But thats part of the problem, as well as part of the solution. The FDA regulations say the software must do this and must do that, and you end up with thousands of pop up alerts. I think the regulations are well meaning but they way they translate into software is not realistic. In the article an FDA-regulated pop-up is part of the story.

There are no FDA regulations that require EHR software to display pop-up alerts for possible sepsis.

It is doctor’s responsibility to know the patient might have such a condition, software system is just for helping

medical opinion is that sepsis was not the cause of death despite the family's insistence.

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.

It may be that the ER's rapid throughput meant they adhere to the heuristic quoted in the article

  "When you hear hoofbeats, think of horses, not zebras."
      -- Anon. (saying in medicine)

This is stated as the likely result in the article, complete with the quote.

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.

This article brought up the sickening memory of taking my frail elderly mom to the er with similarly severe-but-general symptoms.

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.

Hospitals are fundamentally paper pushing bureaucracies that systematically don't give a fuck about patients, and the "case managers" and "social workers" are the worst of the lot. A hospital gave my dad covid in the middle of 2020, then insisted he be discharged still covid positive and unable to stand on his own (the PTs had just let him languish). That was some great public health policy right there. The only consolation was that it was summer so I could keep good airflow through the house. I avoided getting it, as far as I could tell. Found a freelance aide that didn't mind the rona, and we eventually got him back on his feet. And once you see how abjectly horrible this system is, you can't avoid noticing all of those terrible dynamics even in much lower-stakes interactions.

They key element was the introduction of financial decisions into healthcare. This is all in the name of 'efficiency' and never mind the body count. The best thing that can happen to a health care worker is to be subjected to the system themselves.

The health care worker is not the one in charge of these decisions though. I don't consider an executive or administrator a "health care worker" so maybe that is who you mean?

IME, health care workers (doctors and nurses) often defend many of the habits and attitudes encouraged by the system and hated by patients, because the pressure on them has banded them into an "us vs them" or "soldier vs civilian" mentality. Also because the current situation has kicked off a cycle of antagonism between them and patients and especially the people advocating for said patients.

In the 50s and 60s there would be those big hostpitals. But those were downsized in search of allmighty dollar.

Also many families try to push elderly to hospital for few days.

> 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.

I'm sorry for your frightening experience.

Are there no other ER options in your area?

You don't exactly go "ER shopping" with a frail elderly person. Also this was one of the better-regarded hospitals in Manhattan.

You go ER shopping today, before you have an unknown medical emergency sometime in the future.

Closest ER to work, to home, and maybe to any place you spend a decent amount of time at.

The zebra quote is probably paraphrased from Theodore Woodward, who won a NObel prize (though not for that!)

https://en.wikipedia.org/wiki/Theodore_Woodward

Read all the issues with his diagnosis. One way or another the staff wasn't doing what the record says they did. How could you possibly get to the diagnosis if the tests your claim ordered was never done?

I am an inpatient RN. This conversation is interesting for several reasons: laypeople, unless in hospital as a patient frequently, will have no idea how the "systems" in a hospital intertwine and work together - if we're lucky enough to have them do that. (I wish medical professionals had the energy to talk more about the minutiae of their work just so people better understood.) The "systems" I'm talking about are specialties and roles as well as computer this and technology that. Ethics taught to administrators as well as coders would change a LOT about what we are charting - fact is, hospitals are doing more today to cut costs and avoid liability than they are doing to put patients first. This is obvious just by the fact that they keep declaring they are putting patients first. Rule of thumb: the more the thing is advertised, the less likely it is true despite the understanding that THAT thing is extremely important to their target audience. (not to mention outcomes and statistics show who is getting good care and who is not -lots more to do with finances and financial resources than evidence-based practice, seems to me.) To the point of this article: While I'm charting, I get pop-ups CONSTANTLY. Most are from the software company wanting to give me a tour of the programs features while I'm literally just trying to find a note written by physical therapy, or chart vital signs - I would LOVE to have a proficient skill in navigating EPIC but no hospital where i've worked has given me training beyond the first week. No return to chart training after I've worked with their system for a while, later, when I would know what I'm looking to improve. Other pop-ups are for sepsis alerts as this discussion is about, or (for a RN) fall alerts or skin alerts... All the things that are part of my job and training to be regularly assessing. Here is my summary: What I have seen, for docs and especially for RNs is very obviously just micro-managing to insane degrees of interference, when what works to achieve the right process and best outcome is solid training, retraining, accountability by real people and with respect, and excellent leadership. I DID once work at a hospital where they had enough staff to follow up, answering questions staff had (nursing care or software hacks) and -most important- leadership that did not intimidate, and that could and would talk with the staff member not meeting standards, in real time, getting them past whatever hangup or misunderstanding gets in the way of excellent practice. Follow up and follow up again, with the attitude of teaching (versus punitive micro-management by those whose priority is the bottom line) and supporting the staff to do the right and best thing. Pop-ups and multiple clicks to say "ok" and "yes, I really do mean to do this thing" and "for real please confirm!" add too many wasted minutes, interrupting my thought processes every day day when seconds count for someone's life-saving treatment. I don't know if there is any other industry outside of medicine and nursing where the institution itself literally just adds one road block in front of another, keeping us from focusing and doing what our critical thinking and training have taught us to do. ...don't get me started on Moral Distress and Secondary Trauma because of ignorance around letting us care. . .

did you read the article? i have a medical background and his hematology results does not support sepsis. the family pointing blame at the hospital for ignoring the sepsis automated warning is barking up the wrong tree and probably why the hospital ignored them.

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.

I think the real implications are much more chilling. As much as we like to believe otherwise, there is always a chance that a seemingly-healthy college kid will drop dead of something that even the best doctor wouldn't have anticipated.

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.

As a surgeon, one truly humbling fact about humans is we are simultaneously incredibly fragile and impossibly resilient. You will be shocked at what people can survive and what flimsy things kill people

Almost 30 years ago I went to a Penn and Teller magic show. They did their bullet catch (classed up but basically the same trick people have been doing for a century) and other stuff I don't really remember.

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.

Technology can fix plenty. I have narcolepsy and was able to diagnose myself after multiple doctors had failed, and luckily I finally found a specialist in narcolepsy who could actually confirm it. Wouldn't be possible without Google (which any of those docotors could have used but didn't). I would probably still be searching for a doctor to actually do his job. Technology can solve plenty of problems. What we need to do is get the doctors out of the loop.

And for every person who correctly diagnoses themselves despite at odds with what a doctor is telling them, you have 10 people undergoing unnecessary, dangerous treatments because the misdiagnosed themselves.

So you think with just technology, using something like Google or AI, you would be able to correctly self-diagnose with the "doctors out of the loop"?

I was in my case (and I didn't even have AI back then) after multiple doctors failed miserably. Of course I needed to get the actual doctor diagnosis to get insurance to pay for my treatment, but that's bureaucracy, not medical science.

I didn't say that technology won't fix anything, merely that it won't fix everything.

What do you mean? Isn't record-keeping a data-driven practice?

No. I can transcribe every interaction with 100% accuracy, but if those notes aren't used in any way it's not data-driven. This article shows that the notes are inaccurate, suggestions using the notes are routinely ignored, and that doctors and legal review think this process is acceptable. There is no professional or legal liability if the records are wrong. And yet if you talk to a medical professional they'll explain that the records are to establish a legal paper trail if anything goes wrong.

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.

>suggestions using the notes are routinely ignored

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.

The real issue is the administration of the hospital sees every minute the doctors spend taking better records instead of seeing another patient as a loss of ability to bill someone's insurance for that time.

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?

People die of missed sepsis all the time, so if you want to lean on your "medical background" to claim this was not the case, you better elaborate what exactly that background is

OK fair enough, but the detail in the article about the hospital information system and 'Note bloat' are still very interesting to me. I've seen stories like this before - when everything triggers an alert, people start ignoring the alerts. (edit: it was this story: https://medium.com/backchannel/how-technology-led-a-hospital... )

Indeed, it's likely starting to treat for sepsis could very well trigger an antibiotic stewardship alert.

It’s usually something rare, almost by definition.

> The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes.

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.

As someone at an academic institution, this drives me insane. I mean, have some sort of pride in your work. Copy forward but make the necessary changes!!

As someone who’s worked on EHRs, I can tell you that doctors rely on “carry forward” and templated notes and other entry types.

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.

Doctors that I know don't necessarily mind carry forward notes if it is in a standard template, and it's been reviewed for accuracy. The doctors I know rightly hate when trainees (or occasionally but rarely other attendings) do either of these:

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.

Just to be precise. The sepsis alarm was not blocking x-ray or antibiotics but rather suggesting them.

“”” 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. “””

Most sepsis alert implementations ironically do block review of the data to see if the sepsis is real, what triggered the alert, and what treatments are appropriate. Part of the sepsis recommendations always proposed by the EMR is to give lots and lots of IV fluids, even if the patient is in decompensated heart failure which would make it worse

but then "He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders."

The question should be why was he trying to disregard the orders that were part of the standard protocol for a possible sepsis situation - just accept them all as intended.

The system was poorly designed; as pointed out elsewhere: ordering antibiotics before lab results come back is a bad practice. However, the particular sepsis popup required antibiotics to be ordered, and lab results hadn't come back yet, but another procedure (x-ray) needed to be ordered immediately.

People dramatically underestimate how much sepsis protocols and antibiotic stewardship are in tension.

Hard disagree. The information system and its popup was vital information that the attending failed to act on. This anecdote serves as an example of user error and incompetence. And I’m a huge hater of popups.

> Sepsis is hard to spot.

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?

My most recent septic patient had literally zero SIRS criteria, and I strongly did not suspect a bacterial source of infection. Isolated hypotension, nothing else. Said she felt great and asked to go home To date she's grown out GPCs on 8/10 blood cultures. Sepsis actually is hard. Also, it sounds like a bacterial source was not suspected in this case (and was validated by the cultures being negative and the autopsy), so AFAICT this was not sepsis.

> Also, it sounds like a bacterial source was not suspected in this case (and was validated by the cultures being negative and the autopsy), so AFAICT this was not sepsis.

Am confused by this. Sepsis can be a response to bacterial, viral, or fungal infection, no?

It's not that obvious...

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...

You're right, and I should be more specific - what I referred to was things like SIRS, SOFA, and qSOFA (which was being introduced at the BLS level around here in 2022) for "suspicion scores".

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?

I 100% get where you are coming from; however, in the ER setting, multiple non life threatening conditions could cause these symptoms (I assume paramedics don't get as much experience in in-hospital settings, please correct me if I am wrong as I am not from the US!)

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.

You're absolutely fine! Definitely a lot other things can also have those influences on temperature, HR. Our EMS system started teaching SIRS (and then qSOFA) to EMS providers to have them tell the charge nurse that the patient "meets Sepsis criteria", because this was being missed in triage and septic patients were spending hours on hours waiting for care.

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 you make the system idiot proof, they will just build better idiots...

We all want to uphold a system that limits medical school seats and won't create reliable immigration pathways for doctors to arrive here with just so doctors can maintain a specific salary. Then we'll go blame PE and consolidation and insurance or whatever.

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.

Not "we all want", but especially doctors themselves want less competition (even when they say they are overworked).

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.

Doctors and medical professionals are somehow immune from allegations of gatekeeping when in fact that is what they do all the time under the guise of different noble reasons

Happened in France too. It was put in place in the late 70s, and ended in 2020. Called the «numerus clausus» (closed number, in latin) and it restricted the number of medicine students allowed in the country every year.

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.

Not sure if it is valid for France. But there is paid healthcare system in Germany. No wait time and newest treatment methods are used if you bring your own cash. Same doctor has appointment next day if you tell that you‘re paying by yourself. If you come as normally public insured patient… well… come in a month or better in a year please.

> doctors themselves want less competition

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.

There are countries where university education is free and there are exactly the same problems.

Doesn't really matter. Doctors spend a huge amount of time in education. There's a massive opportunity cost, and they want to be paid.

"If I'm going to study into my 30s I want a huge bag."

Understandable, though not necessarily defensible.

So it doesn't really matter because other occupations also have the same opportunity cost and want to be paid and are not getting top of the field salaries straight out of university but have to take shitty internships and maybe get decent pay past 30yo.

If people in those fields could use laws to limit competition, they would do so as well.

> The most interesting part of that is that population typically sides with the doctors, not the government, for some reason.

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.

My understanding is that in many countries the biggest blocker to increasing number of doctors is the fact that there aren't enough doctors to teach. Unlike CS where we can simply increase the number of seats in. A course with medical school there are real bottlenecks on things like cadavers and mentors.

There aren't enough spots in medical schools. I was a 4.1/4.3 GPA in Canada and I didn't get in med school. My sister got in with a 4.24/4.3 GPA (one single A, all A+).

Doctors in control regularly shut down any attempts at increasing this limit.

While true, it's also true that scaling medical school is not like a CS situation. My school quadrupled the number of CS seats to meet demands over 4 years. I can't see this happening with medical schools. My brother who is currently in a medical school regularly says how hard it is for the faculty to find teachers simply because there aren't enough. To add to it there are bottlenecks like not having enough cadavers.

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.

And intelligence combined with ability to deal with people and enough grit, memory and sleep deprivation resistance to pass medical school.

Maybe medical school itself needs to change to make the role easier and split the functions into easier ones that more people can do.

Yes!

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.

Right. Medical school in other countries is certainly not a walk in the park. But nor is it the hellacious endeavor it can be in the US, especially then as an early resident.

But reducing the number of admissions is not going to fix it, it will only exacerbate it.

If we increase number of admissions, then long-term doctors should become less overworked. That's a path to fix it.

There is no limit on the number of medical school seats. The primary bottleneck for producing new practicing physicians is actually the number of residency program slots. Every year, some students graduate from medical school but are unable to practice medicine because they don't get matched. (Some of them do get matched the following year.)

https://savegme.org/

And who exactly, historically lobbied for that low limit to limit doctor supply? Why the AMA and other similar organizations!

And these kinds of issues seem more global than not.

True, but the AMA reversed its position some years ago and has been lobbying Congress for increased Medicare residency program funding. However, Congress hasn't acted due to budget concerns.

The last time the AMA lobbied for capping residency slots was almost 30 years ago. The vast majority of doctors practicing today weren’t even in the field back then.

That may be true, but insurers continue to lobby for capping, and in the US most large employers are "insurers" in the sense that although they might outsource the administration of the health plans of their employees, they basically pay the entire cost of the care.

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.

Stop lying. No major commercial insurer is currently lobbying Congress for limiting the number of physicians. In fact, some insurers have even voluntarily donated to support residency programs (although the amounts are small relative to Medicare funding).

OK, I now tend to believe that when the ACA capped the profit margins of insurers, their previous incentive to reduce cost of care (so they could keep the savings as profit) ended, so they stopped lobbying for restrictions on the supply of doctors. Unless I see evidence to the contrary, I will continue to tend to believe that large employers (not subject to any cap on their own profit margins) continue to lobby for restrictions.

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.

How would restrictions on the supply of doctors help insurance companies reduce cost of 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 a doctor for the doctor to realize that the good or service is necessary (then prescribe or order it) the insurer does not need to pay for the good or service.

Limiting the supply of doctors will increase costs in the long run because it reduces access to preventive care. Residency caps disproportionately impact PCPs.

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.

You don't have to convince me that limiting the supply of doctors is not in the interests of anyone of median income or lower. I am aware.

Your proposed incentive for insurance companies to want to restrict the supply of doctors (prior to the ACA) doesn’t make sense, and that’s what I’m trying to convince you of.

Ah, I see now. Sorry for not getting it right away.

Nope, there are no major self-funded employers lobbying for physician caps either. But hey, don't let facts get in the way of your ridiculous, uninformed beliefs.

I’ve never heard of insurers lobbying for capping residency slots. Do you have any sources?

Regardless I was responding to the claim about doctors lobbying for caps.

This assumes that having more doctors will fix the problems and I can tell you it won’t. I’ve unfortunately had to experience what’s described in the article multiple times in recent years, with the only silver lining that I’m not dead yet.

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.

There was a shift in attitude to where physicians are managing livestock instead of caring for people. It's not great when some of the livestock die, but that's what livestock does... oh well. The psychology of that shift is complicated, multiple factors that are difficult to tease out. But the bad news is that the shift is likely irreversible, it's lasted long enough that the current doctors teach it to the new incoming residents.

The problem at the root is the financialization of everything.

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.

>Public hospitals are one thing, there incentive structures revolve around saving money - yeeting patients out of the door f

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.

Similar experiences, (though not as bad). I still assume more doctors means they can give more attention and actually listen to the patients.

Other industries benefit as well from the lack of credientialing pathway for foreign MDs, because they end up taking under market salary roles in things like pharmacovigilance, sales, clindev, med affairs and other roles in biotech and pharma. I have a Bulgarian MD doing a vendor manager role for central lab and he is criminally underpaid for how overqualified he is. One time at a client dinner I asked him if he misses using his MD and he was like, "It's better than nothing and doing this contract PM role is still 10x more than I would be making being an actual doctor in Bulgaria."

There are nurses that can write prescriptions now. That seems to be how we are addressing the issue.

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 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.

The path (at least in the US, YMMV elsewhere) is "go to medical school".

I hope not. As with everything, YMMV. As an experienced paramedic, I have not any issue with experienced nurses going the route of NP.

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.

It's really tiring how the medical profession can't do what engineering does with jr engineers and pay them a living wage as they gain experience and still do economically valuable work.

What do you think voters should do? How do we increase the number of doctors?

In my opinion, we need to increase the number of admitted MDs and the number of residency spots. But more importantly, we need to also stop thinking of MDs as being necessary for a procedure or set of procedures, and focus instead on actual skill and experience for the procedure or service, and how one might get there.

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.

To prove your point, I believe the last time I went to an ENT to get my nose cauterized for bloody noses cost my insurance around $500 or so. That's for a 5 minute "procedure" I could easily do at home with the right equipment.

Yeah one of the benefits of the NHS, even with its problems, is that you can just roll up to a doctor/dentist whatever and if its something simple that requires slight medical intervention, or a cheap prescription for instance, there's no drama around insurance billing or bureaucracy. Now, on the other hand, you need to go to the ER, you need actual surgery?

A good analogy might be dentists - are there other spices of the medical profession that could be turned into more focused specialties with less total schooling?

I'm most familiar with pharmacy and psychology as examples, although I think there are probably many other fields as well, maybe diagnostic radiology for example. I'm also aware of research on surgical specialists in areas of the world where physicians are scarce, focused on relatively minor surgeries, showing that these procedures can be done with the same outcomes if the providers have the right training.

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.

Ophthalmology? Maybe dermatology. Or at least you could lose part of the training for them. Probably need still a few specialized people with full schooling. But could lot be done there with less?

The current doctor workforce is limited by a congressional cap on Medicare-funded educational slots. Apparently it was established in 1997 to prevent a surplus.

Of course, the opposite happened because of demographics and increased lifespans.

> Apparently it was established in 1997 to prevent a surplus.

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).

There already are 6 yr programs. A school in Ohio has a 6 yr program where you graduate with a BS and MD.

You're missing the point. Anyone already can open a medical school if they meet standards. In fact, several new medical schools have opened in recent years. But that doesn't do anything to address the primary bottleneck, which is lack of residency slots. If you graduate from medical school with an MD you still can't practice medicine until you complete a residency program.

Some schools do have accelerated combined BS/MD programs which can cut 1-2 years off the required total education.

I'm aware and I thought it was implied in my comment that Medicare funding shouldn't be a limiting factor on residency slots, when I said "Every other profession manages to train new members without Congress". I guess that wasn't clear enough. I'd go so far as to pull all Medicare funding for residencies. Let each program figure it out themselves.

Accelerated programs aren't the norm. They should be.

If we pull Medicare funding for residency programs then the system will collapse. Most teaching hospitals are run by local governments or non-profit foundations. They simply don't have the resources to subsidize graduate medical education. The money has to come from somewhere.

(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.)

If Medicare funding disappeared tomorrow the healthcare industry would figure out how to fund residents. The alternative is no new doctors. Nobody wants that.

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.

Nonsense. No other major participants in the healthcare system have the financial incentives or resources to subsidize residencies on the scale needed. Hospital cost accounting is somewhat fuzzy but overall graduate medical education is a money loser. Hospitals have very limited ability to bill for procedures performed by residents: they generally have to be directly supervised by an attending physician, which is expensive. And reimbursement rates are largely fixed by Medicare: hospitals can't just raise prices to make up the difference.

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.

> [you] are essentially making a hand-waving argument

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.

And as for what should voters do: they should choose people that are the most likely to improve the state of government.

We should factor medical tasks into a larger number of specialized roles akin to phlebotomists and dental techs.

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.

Stop charging $300k for the medical degree.

Our society will continue to feel the civilizational tax of not having enough kids unless AI doctor becomes a thing.

So, do your part. Make babies! It's fun and rewarding.

Well, in the US doctors are rich. Something completely different to most of the rest of the world.

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 best doctors in the US are more often than not also the best in the world. The US disproportionately attracts from abroad and produces domestically the MDs that are at the forefront of medicine.

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.

Some US doctors are rich. With a strong bias toward certain medical specialties, where you can bill X thousand dollars for a "procedure". And do a lot of those procedures every week.

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.

> US doctors are not that good compared with a German or French doctor

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.

Just anecdotal, but I visited Shanghai this summer and toured a top clinic - from my perspective, their standard of care is on par with, if not better, than many large (and quite good) groups like Sutter Health or Straub. The doctors there were educated in the U.S. and Germany (Massachusetts and Munich if memory serves).

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.

Chinese public hospitals, at least ten years ago, didn’t provide nursing assistant care, so families would be responsible for cleaning and feeding someone in the hospital. Private hospitals are another matter, and when I lived in Beijing, I would go private even for ER services. And the private hospitals were pretty affordable, most of the doctors were foreign or foreign trained, most Chinese med students go to the public hospitals for residencies and after they graduate (my wife has a cousin in Shanghai finishing up her Med degree now). The program is different, it’s a 5 year degree plus residency, though you can go for a masters or PhD also (many doctors do), I think the American system of medical school is the odd one out.

Private health insurance had a cap (~$100k/year) for some reason. I thought that was risky.

If anyone has a friend or family member in the hospital, the best thing you can do is spend a few hours with them every day until they get out, or arange a schedule with other friends and family members.

Patients need advocates (and someone to help them from getting lonely, which also helps their recovery).

Ya, but bedpan duty is something else.

https://www.commonwealthfund.org/publications/fund-reports/2...

Not all doctors are - infectious diseases, for example, is fairly poorly compensated. As is pediatrics.

Voters voted to close rural hospitals, which Ironically means they get no healthcare themselves and cities will have more doctors. Stupid is as stupid does.

And voters 4 years ago voted for an open border which filled emergency rooms and denied American Citizens from recieving treatment in American Hospitals. The emergency room wait times have been dropping since January of this year

See how those numbers go when premiums spike due to expiring ACA funding & Medicaid cuts.

> emergency room wait times have been dropping since January of this year

Source?

Troll

You're absolutely right. However that salary is 1) not adjusting with inflation and 2) I'd argue is required to offset medical school debts and deferred employment

> If doctors don't have enough time, then there aren't enough doctors.

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.

It's no longer a guaranteed path to being rich, for the record. Since the 1990s, the average income of physicians has grown at less than the rate of inflation (Median physician compensation was ~$140k in 2000 and is ~$240k today). It's gone from being maybe a top 2% income to being a top 10% income.

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.

Name another "standard" profession that makes a median of 240k per year.

Airline pilots make about $230K

240k as an individual is a lot higher than top 10% of American incomes.

Inflation has jacked up salaries and rates. There’s a big disparity now depending on whether salaries have been adjusted.

It's around the 5th percentile but obviously half of physicians make less than that

Doctors, especially young doctors, are not the wildly greedy people you paint them to be. There are dozens of easier paths to riches these days than medicine and we all know it. My medical school is "cheap" and tuition + cost of living is ~$90k/year. Then, we have 3-7 years of residency before we start making the real money which is less than any generation of doctors in 100 years. I could become a senior software engineer at a Fortune 50 company in less time than it takes to graduate medical school and be better off financially than most doctors. Ask me how I know.

"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.

Private Equity is probably responsible for a lot of the ills that are harming society in general, it goes way past their involvement in healthcare imo

I disagree with most of the argument in the parent

> 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 are amplifiers that increase the suck. One is physician ownership of diagnostic clinic(s). A strong tendency to order tests can be remarkably enriching, way more than a paltry $500K.

Isn't that a Stark law violation?

It's complicated. Physicians can own imaging equipment, for example, but they can't require you to use it for the radiology tests that they order. There are weird carve-outs for in-office ancillary services (e.g. you're an orthopedic surgeon who uses x-rays in your office, which is common and arguably necessary).

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.

Can you provide any proof of this?

> there aren't enough doctors

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.

Not to dismiss your claims but the profession is tightly regulated in every developed country in the world. So even if there was an oversupply of doctors in your country, the high bar to getting licensed ( med school and afterwards specialist training) is still the same for everyone.

> the high bar to getting licensed ( med school and afterwards specialist training) is still the same for everyone

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.

Then what you have is a large group of unemployed indebted people. Are we sure that there are even enough competent people that we trust to do medicine in the first place? Maybe the reality is such that we simply don't have that many potential and qualified people in the first place.

The standards to become a medical doctor in the 70s-90s compared to the 2000s and the 2010s are vast. There is a lot of extra bullshit now required to become a doctor like volunteering in africa and a person with A average GPA failing to get in, while if they were in the 80s, did not require to do that. Start with getting rid of the absolutely stupid barriers.

> volunteering in africa

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.

It's not required - you just need to be a promising and interesting student. Most of the students I send to medical school get there by doing undergraduate research.

[dead]

That is a backwards and likely self-serving perspective. You want to not only deprive foreign countries and populations of their doctors so that they can come serve American interests from having mismanaged the supply and the demand for doctors, all while having imported around 60 million foreign nationals in the last 25 years alone, which has only contributed to extra pressures and taxation of the medical field and has contributed to driving up costs for medical services in America.

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?

Or alternatively foreign countries don't value their doctors enough for them to stick around and so they don't... Are you saying someone is suggesting forcing them to come to the west or should people not be allowed to move where they want and can contribute? The US needs more doctors and if there are foreign trained qualified doctors they should be able to practice, healthcare is a free market system or so I am told, labor goes where it gets paid.

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.

The ED is specifically attuned to these presentations but the sepsis alerts and algorithms in place are horrendous and will fire off even for this with viral illnesses and syndromes.

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

> 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.

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.

Perhaps, but it should be noted that sepsis detection is one of the places where ML has been applied for a very long time. A lot of these popups are built off those models.

Huh. So much for optimism: https://news.umich.edu/widely-used-ai-tool-for-early-sepsis-...

I have been in the informatics space for some time and none of these ML generated sepsis alerts are helpful in the ED.

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.

Beyond the case itself, I'd hazard a sad guess that the only reason this made news is because the victim's father was a lawyer who wasn't forced to simply take the hospital president's platitude at face value (and who had the time, money, and energy to put his normal career on pause and enroll in a master's program just to investigate the issue). If that were my family, it would be "that's terrible" but no actual action, because my parents wouldn't be able to do anything about it, nor would I if something like this ever happened to my own future kids.

What action would you like? In this case everyone says it was likely a rare disease and not sepsis. Like, I'm sorry that this is and will be the reality of healthcare for the rest of our lives, if you have a rare thing pop up that can kill you in a matter of days you're going to need an absurd amount of luck for a doctor to notice.

> What action would you like? In this case everyone says it was likely a rare disease and not sepsis.

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.

A doctor is not legally required to follow the checklist.

What I meant by "legally required prompt" was that others in the thread have tried to explain the "poor UX of the pop-up" by saying that it's probably required to display for legal reasons (whether directly, or to avoid liability). Regardless of that, checking an item off that you didn't perform is still logically incorrect whether it's illegal or not.

There are legions of medical malpractice lawyers who would hear out your case. Personal injury attorneys advertise every place possible and they will gladly refer you to the correct place. You wouldn’t get a NYT writeup but a settlement? Litigation is as American as apple pie

I was thinking similar-- a generic law firm could probably get a small payout, but wouldn't necessarily uncover as many details about the situation since they're not personally involved (and, as you said, would probably have less publicity as well).

I think your worries are misplaced. This is bread and butter for lawyers. The problem with this case is it’s very fuzzy. We are seeing one side of the story as a lawsuit is certainly coming. Doctors are human and deal with high stress, life or death situations. They have medical malpractice insurance exactly for this. Even if you have a 99.9% perfect doctor, they will see many thousands of patients over their career, and that still means 1/1000 will die. People play the lottery on far worse odds.

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

> 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.

Its probably not PC but I think a huge part of this is the burnout associated with being forced to treat the same junkies day in and out. At some point you brain shuts off to possible alternatives and you just see everything as a "next, next,next"

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 same experience happened to me, but it was even better – I was told I had a "little paronychia" and lanced without anesthetic. Her scalpel rubbing against two nerves in the nailbed of my thumb, the ER doctor lanced and scraped without so much as lidocaine (or even tylenol!)

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.

Sorry that happened to you. I personally will probably never go to an ER willingly ever again. If you land in an ER without someone that cares about you as an advocate to look over you....IDK I wouldn't want to be in that position.

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.

most people don't really go to the ER willingly really. In situations where there is an emergency i'm unsure what the alternative is.

I disagree. I think current medical technology and knowledge is just not equipped to handle a fast progressing, hard to diagnose case like this. Differential diagnosis usually takes a long time even when done by the best medical teams outside ER.

On the other hand, American health insurance is arguably the most aggressive in the world at punishing overweight individuals and smokers through penalty fees.

That's incorrect. The US health insurance CAN NOT use anything but the current smoker status for pricing decisions.

That's why obesity was added as a medical condition a few years ago. Did anyone think it was added to help people rather than ring up extra bills?

the fees are bought upon by the partakers of food and cigarettes.

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

Obese individuals & smokers actually cost the system less money overall vs slim & healthy people because they die so much earlier - think of the 30+ years of savings!

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...

My mom used to be an MRI nurse.

Patients that were so large would have to be denied and referred to the local zoo.

I wish I was kidding.

“Punishing overweight individuals and smokers”, I’m sorry, while I wish America’s healthcare system was better in terms of cost, some things are choices/habits that have consequences in terms of health and subsequently the care required to treat..

Be the change you wish to see in the world: donate your "skinny person" poop to a needy fecal transplant recipient.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10381135/

Forget PC, its repugnant and incorrect.

You're just spouting dog whistles and fatphobic bullshit.

The system is broken because that's the design.

This sounds like a great way to decimate outcomes for marginalized people. Some significant portion of those perceived as "not wanting to help themselves" are going to just be "people who doctors don't give the benefit of the doubt and consistently second guess or underserve." Which is, statistically, women, minorities, and physical outliers (including obese and disabled folk). People already die because they're not believed, or important signs are missed, but I suppose making that incidence even more likely by giving every personally judgmental doctor the license to let their bias bleed into their professional conduct with impunity is just in line with the zeitgeist.

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.

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Similar thing happened to me, back in '96, but my wife saved my life, by forcing my primary care doctor to refer a neurologist.

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.

If you visit the emergency department of a lot of British hospitals, there will be large posters reminding the doctors "Could it be sepsis?" because of similar instances that occurred over here.

> there will be large posters reminding the doctors "Could it be sepsis?"

I'm not sure how effective this is. Information presented this way quickly fades into background noise..

The patients can also see the posters, and it won't be background noise for them, so they can think of asking about it.

Oh. There is nothing more contra productive than asking an experienced physician “could this not be X”. They will typically go in “if you think google knows better, ask it and fuck off”. Ask me how I know. I think that attitude even has a name (BTW, I’m guilty! If I say “there is a dangling pointer” and the guy starts with another theory, I will dismiss him quickly)

My experience is completely the opposite. It often annoys them, but they are forced to address my question, and that's my goal.

Arguing with a doctor can lead to accusations of "drug-seeking behavior" (which can cause treatments to be refused, and there is some legal pressure behidn this) or "mental illness" (which can cause involuntary psychiatric hold, effectively kidnapping).

https://slatestarcodex.com/2019/09/16/against-against-pseudo...

--- (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.”

------

A good way to ward off the possibility of being accused of drug seeking behavior is to maintain your own stash of drugs. It always helps to have a good BATNA.

They especially love "According to ChatGPT..." these days. Make sure not to even make it a question

Meanwhile they feed criteria directly into their own LLM for diagnosis

See theirs is an expert system.

I'm not a doctor, but I am an engineer --- so I am _SUPER_ used to being wrong -- my systems don't spontaneously heal themselves.

Dammit, Jim, I'm a bricklayer, not a doctor!

I usually preface such suggestions with "according to my google medical degree..." which seems to take the heat off.

If in the UK, you better have some tact, otherwise it'll go down like a lead balloon !

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..."

They even have this on the side of ambulances in parts of the UK. Makes me think it's more for public awareness than for doctors.

>In his effort to understand hospital safety and risk, he learned these oft-cited projections: 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, Terblanche calculated.

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.)

If you read the complete article it specifically mentions that Sam's condition did trigger some checklists, but those checklists were willfully ignored in favor of expediency.

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.

I think it's more like Sam's condition did not clearly fit into a checklistable entity. Our heart rate and temperature go up when we have the flu, but we don't all go in to hospital for antibiotics or die at home. Probably they should have done more work-up the second time he came in but as the article points out that could also have been negative. He was probably just too young for checklists built for older people to pick up on his condition.

Also sounds like he was left alone which does not help either. I had similar to Sam, in early sepsis but none of markers were there until I went delirious. Wife picked up on it right away and that time, ER picked up on it.

I can't remember where I read or saw this, but it struck me as the obvious key difference: In aviation, procedures and practices are developed in concert with experts in aviation maintenance, aviation engineering, various parts of system design, and the people who fly the darn planes. In medicine, the lobbyists, politicians, and software companies have political and economic incentives and communication structures quite divorced from the practiced expertise of actual end users, not to mention the people being treated. So you have all these 'best practices' being imposed that have little to do with the sorts of best practices health practitioners would do or want to do or what patients need.

Being a pilot I can attest how important checklists are, and I do advocate for using them in medicine (have practicing relatives, and I have them tired with that).

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.

The long shifts are the most baffling thing to me. AFAIK they're also common in law enforcement.

"Hey these people make life or death decisions. You know what's going to help? Fatigue."

From the outside, it just seems insane.

Today’s doctor shortage can be traced directly to government policy in the early 80s that lasted for 25 years. They assumed we’d have too many doctors and pressured medical schools to reduce enrollment.

The lobbying by the AMA may go back to the 80s, but the 1997 "Balanced Budget Act" set the limit on residency slots.

Nice background: https://www.washingtonexaminer.com/opinion/1692395/thanks-to...

No, the “limit” is the expectation of free reimbusement by the hospitals. This is lobbying for them to get more socialized gov handouts.

how much more are you willing to pay? more law enforcement = more taxes

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.

> more shifts for docs = more $$ paying for more medical staff.

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?

Two people take twice the vacation of one person, have twice the healthcare costs, etc. It is almost always cheaper to have 1 person work 16 hours than it is to have 2 people work 8 hours.

Not if you count the cost of errors.

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.

Personally, I haven’t had a US born doctor in ages. In most areas it’s typically Chinese, Indian, or Vietnamese. Nurses it’s almost as common too.

Doctors aren't paid by the hour.

One doctor is one salary and one package of benefits. Two doctors is 2x that.

> Doctors aren't paid by the hour.

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.

If the supply of doctors wasn’t artificially suppressed as mentioned by comments above, it’s likely that wages would go down. Whether that would make things overall more or less costly isn’t easy to answer.

Doctors are paid in loads of different ways including profit sharing, RVU-based models, and hourly.

The docs dont get paid per hour, they are salaried, so 2 docs is double the cost of 1 doc.

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.

Perhaps if we didn't expect superhuman schedules from doctors, doctors wouldn't command as much of a cost as they do now.

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.

Do doctors do extra hours per week? I thought they work less days but do this crazy long shifts

sometimes, but extra hours dont get paid extra, so very little incentive to do so. there are many different models for compensation but you can think of it as a 'fixed salary with optional bonuses'.

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.

Yes I don’t get the comments about salary vs hs. You need the same amount of people. The question is if you have 3 people doing 24hs shifts or 3 people doing 3 8hs shift a day… has nothing to do with more people/salary/money is just organization of work.

> handoffs between shifts at hospitals is where things go bad.

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 doctor is going to have to go home some time - some patients are going to have care needs that get handed off regardless. If they are going home after 8 hours instead of 24 hours, maybe they'll be better at remembering to hand off everything properly to the next person.

I personally have no issues paying more taxes for better staffing.

Unfortunately, healthcare is cursed.

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.

It looks that way in hospitals but the demand is not infinite. The problem typically is that primary healthcare is unaffordable and or unavailable because they are fully booked and everyone ends up at the ER.

> 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.

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 pharmacies issue is a constant problem: patient lives out of town so prescription is sent to his home pharmacy at his request, on the day of discharge he realized his pharmacy is closed and wants them sent to a local pharmacy, of course this always happens at 5pm when you are driving in traffic, the patient is angry because they want to leave but there is not much you can do. This happens very frequently, doesnt matter if you ask ahead of time for the patient to confirm the pharmacy, something inevitably happens.

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.

For your first example, wouldn't the friction be reduced just by telling patients the business hours of the pharmacies nearby? I hate how this question is always posed, as if I'm supposed to come up with a name and address out of a hat. If it's the middle of the night or Christmas Eve and I'm trying to get medicine for the baby, the provider probably has a better intuition than myself as to which pharmacy will actually serve me. If I ask explicitly, the provider is usually happy to suggest some options. Even a simple web interface listing hours of operation would be better than the current method, where the patient is expected to pick a pharmacy from memory before they even know what medicine they need or how long it will be before they are discharged.

This setup is crazy, as someone from another country.

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.

We used to! Doctor would write prescription on a pad, and you could take the script to any pharmacy.

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.

In the United States, the government deliberately creates a shortage of medical residencies through a longstanding cap on federal funding for graduate medical education, primarily administered via Medicare. Residencies represent the essential postgraduate training phase that new medical school graduates must complete to become licensed physicians, yet the vast majority of these positions are financed by Medicare payments to teaching hospitals. This funding mechanism traces back to the Balanced Budget Act of 1997, which Congress passed amid concerns over a perceived surplus of physicians at the time. The act froze the number of Medicare-supported residency slots at their 1996 levels, effectively limiting hospitals to reimbursements for a fixed quota of resident positions without adjustments for population growth or expanded medical school enrollment. As a result, while the number of U.S. medical school graduates has surged by over 30% since the late 1990s to meet rising healthcare demands, the pool of federally funded residency spots has remained largely stagnant, creating a persistent bottleneck that prevents thousands of qualified applicants from advancing into practice each year.

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.

Nothing is stopping the market from paying for this themselves. They’re just cheap.

The market has to get money to pay more. Health insurance is already expensive - raising it to ultimately hire more care givers doesn’t work for most people - do you have the most expensive insurance option or the cheapest?

The market has plenty of money to pay as it is, the highest of any first world country in fact . They just divert it to shareholders / admin instead of patient care.

I'm perfectly willing to believe that US has many, many issues that compound the curse - with some low hanging fruits among them.

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".

There has been some improvement in terms of long hospital shifts, but there is value in maintaining continuity of care. Research has shown that preventable medical errors are correlated with the the frequency of handover. Proper documentation in the patient chart can help to an extent but there's tacit knowledge that comes from directly observing a live patient which can't be documented in any codified way. So a balance has to be struck in terms of errors due to fatigue versus errors due to care discontinuities.

I've been in the hospital more than once for a week at a time. At no point did I ever see the same doctor more than once in a 24 hour period - from that perspective, it seems irrelevant to continuity of care how long their shift was.

14 handovers is a lot less than 21 when it comes to opportunity for error.

>But maybe you oversimplified the book? (Or the book oversimplified how safety was achieved?)

Quite possibly!

>There is a whole list of things that can be transferred from aviation to medicine.

Please recommend more books!

this is vastly complex than aviation. it is like 10 pilots and co-pilots trying to fly 100 planes and simultaneously switching between them. and with everyone overworked due to no mandated breaks.

no amount of checklist would prevent mistakes. we need legislation to limit medical workload, which is unlikely due to the shortages.

> no amount of checklist would prevent mistakes.

So, don't even try?

Why not both?

Autopilot makes such a scenario safe.

The Checklist Manifesto: How to Get Things Right by Atul Gawande https://www.amazon.com/-/en/Checklist-Manifesto-How-Things-R...

Three major problems to note in the story:

- 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 don't quite understand your third problem. I also don't think the shortage of ER nurses necessarily contributed, as clearly the doctors and the friend thought he was well enough to go home. Definitely agree with the first problem though. We put our kids through a lot of risk by sending them to interstate college...

My wife (then girlfriend) and I were at a concert. She went to the bathroom to pee. She came back crying.

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.

> 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.

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.

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Hamish MacInnes, the Scottish climber, was sectioned in a psychiatric hospital because of confusion and delirium caused by an undiagnosed UTI. It took 5 years for the infection to be diagnosed and treated.

https://en.wikipedia.org/wiki/Hamish_MacInnes

I recall with my grandmother it was almost 1:1. If she started sounding just slightly confused or slightly more forgetful than normal, my mom got her tested for UTI. And sure enough, in just about all the cases she had it.

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.

Yes, this is so scary! I know I'm just hopping in here with anecdotes but this happened to my friend's mother as well. She was seemingly getting dementia, her health got really bad, she was tired all the time, couldn't figure out what it was for a while. Eventually they figured out UTI, treated it, and all the mental stuff went away as well.

UTI almost always causes delirium in the elderly. Those with dementia go completely off the rails. When my grandma had UTI she was basically in a parallel dimension talking to her deceased parents and that kind of thing.

A common practice at my grandma's care home was if the women's personalities changed suddenly, get them on cranberry juice in case it was a UTI.

> Had the person who evaluated my girlfriend not evaluated seriously or just sent her off that could’ve been her

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.

Well done advocating for her healthcare needs.

There’s a thread about how emergency physicians are paid. It varies from group to group:

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.

From the info laid out in the article, it seems that unfortunately Sam was the Zebra, this time.

The autopsy found pulmonary hemorrhage, enlarged heart, enlarged liver, damaged kidney.

Heartbreaking story. They talk a lot about the possibility of bacterial infection but it was not consistent with the blood tests. It seems he just got unlucky (although should have had a Chest X-Ray).

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.

This is 99.9% of “news”.

The problem isn’t adequate number of doctors….it too many trainees.

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.

what we’re seeing now is that the immune system can go into overdrive, where certain immune cells trigger sepsis-like illness, sometimes in milder or chronic ways. long covid and related conditions seem like part of that same spectrum of immune dysfunction.

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

In my opinion, this is one of the more overlooked side effects of the covid pandemic: stretching resources in hospitals leads to lower quality care for everyone.

I don't think it was overlooked at all. This was the original justification for "flattening the curve".

> Sam’s girlfriend, theorized that in the hospital Sam didn’t want to be a bother and didn’t advocate for himself

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.

If there is anything I've learned in my country (with national health care) where it's common for doctors to ignore you and say it's nothing, is to be overly pushy and even rude. It could be nothing, but a lot of time instincts are correct, and it's a mild embarrassment if you are making a fuss over nothing, but could be a life or death situation. And you could argue that everyone behaving like this is making it worse, and that might be right. But I remember multiple national headlines in recent years where little kids died of pneumonia after being sent home because they ruled out infection, sometimes even after parents already brought the kid back for the second or third time to the hospital after their condition wasn't improving. I know I'm not making chances even if it means getting a second opinion or driving to a different town to a different hospital, sometimes it's better to take things into your own hands than be complacent and rely solely on the medical system doing the right thing.

The "there's someone here who'll still be alive to be deposed and/or testify if we fuck up" factor really gets them to be serious.

Especially if the second person peppers their speech with correctly used medical terms.

My son almost died in the first 24 hours of life. I said, "There's something wrong. There's something wrong." multiple times and the nurses finally told me, "YOU NEED TO CHILL OUT." I did chill out....

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."

Recently I got really, really sick. I was running a fever and bedridden for nearly a month straight. It got so bad one day that I ended up in two urgent cares and then they sent me onwards to the ER.

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.

Not a doctor but I know some- Viruses are notoriously hard to diagnose because they don't culture. Some big academic hospitals do have a virus panel where they use brute force PCR assay akin to many Covid-19 tests targeting different virus but they are very expensive hence not broadly available. Community hospitals will have the same diagnostic experience you have. At most they might be able to test for Flu or Covid but that's about it. Another reason is that even if you test positive, there is very little the hospital can do. For the most part, just tell the patient to rest and take Tylenol/Ibuprofen. The anti-virals are just limited to Flu and Covid.

  The anti-virals are just limited to Flu and Covid.

Good to know. I'm repeating what an EM doc told me available in her community hospital i.e. they only have Tamiflu and Paxlovid, which is why even if she did have access to Viral panels, they couldn't do anything more to treat those other viral infections.

I'd be astonished if they didn't have acyclovir. More cheekily, all HIV medications are antivirals.

What I suspect you were being told is "For a respiratory illness presenting like this, we only have tamiflu and paxlovid."

This. There are a lot of antivirals out there.

I started dating a woman once and she was a widow. I was kind of shocked a woman in her 20's was already a widow and she finally got around to telling me what happened. Very similar. Keep in mind this was some 15 years before COVID.

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.

Consider their situation:

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.

>They were constantly taking my blood, constantly running tests

>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?

> 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.)

Did you ask ChatGPT or something? It usually knows more. And what they were taking tests for.

although this is the new "WebMD" self diagnosis, and the AI will agree with you and make some things up in subtle ways, this is still a great way to steer licensed professionals and cut through their own double speak - since licensed professionals are also making things up in subtle ways, not give you enough information about their findings or medication, and overlook many things

I usually override non-specialists with ChatGPT plus my access to physicians in other countries (Canada, UK, India). Even specialists I always double-check with other countries' specialists I know.

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.

> 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.

This is the crux of the whole article. People who make software please take note the importance of what you do.

FTA: "As hard as the job is, diagnostic accuracy in the E.R. is high overall. But a recent systematic review of published research estimated that 5.7 percent of E.R. patients will have at least one diagnostic error and 2 percent have a setback as a result."

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.

2-3% error is too high, this is something we _should_ be scrutinizing, and healthcare _should_ be more expensive if the reason it's expensive is that we're pouring more resources into it to get diminishing returns on reducing mistakes.

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.

It feels high to me because most ER cases should be obvious i.e. heart attacks, car accidents and strokes etc. So if say 10% of cases are non standard then 2% overall is 20% off that.

Not only is the case mix much broader than you imagine but even the three things you listed all have plenty of nuance at the individual case level.

We don't have an anti-heart attack pill. Medicine hasn't developed the post-car-accident protocol. Strokes vary so much in type that they can go unrecognized by competent doctors for years.

The ER functions as primary care for a large percentage of the population. They see far far more than the kinds of thing a rational person with health insurance thinks of when they think about medical problems they’d go to the ER for.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10121120/

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.

> 2-3% error is too high, this is something we _should_ be scrutinizing, and healthcare _should_ be more expensive if the reason it's expensive is that we're pouring more resources into it to get diminishing returns on reducing mistakes

There will be rapid diminishing returns. It may cost 5x to get to 1-2%. Maybe 10x.

Part of the reason is - people are not machines, its extremely hard to diagnose quite a few situations since every body is a bit unique. Add tons of medications and issues every older person has, within their own unique bodies. Add symptoms like chest or abdominal or head pain which can mean hundreds of conditions, some benign some deadly. Add time pressure to diagnose quickly since that's how medical systems are set up. Wife is a doctor so I can see the perspective from the other side too.

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).

I am happy you were able to solve it. One of my friends had exactly this problem, but he just died the next day :(

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 this be part of it. each aircraft is designed to be effectively identical.

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

An alternative way to throw money at the problem: Instead of trying to further improve accuracy, build out space for more ER beds, and implement continuous monitoring of marginal patients.

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.

This is mentioned in the article, the fundamental problem is a capacity problem. If patients could be moved out of the ER department to hospital wards then there would be a greater ability for the ER department to monitor patients.

This is because beds are artificially expensive because hospitals deploy maximum-feature bed equipment and services, to avoid malpractice claims, and to increase billing.

There is a (somewhat artificial) middle ground in US hospitals where patients can be admitted for observation but still be considered outpatient.

https://doi.org/10.1001/amajethics.2023.901

> 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

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).

That is a factor but a relatively small one. Several US states have instituted limits on medical malpractice liability and that has had only a small impact on total healthcare system costs. It's often the patients themselves (or family members) who insist on trying every possible diagnostic test, and even with the growth of evidence-based medicine we still don't have clear clinical practice guidelines covering many of those situations.

It´s not just the legal system. A lot of US Doctors are typically paid on a piece rate basis, and the medical records systems are extremely fragmented, so there is an incentive to order repeat tests (as you get passed around from specialist to specialist), and no incentive to put the systems in to make that unnecessary.

I believe your points, but give me a source.

> 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.

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.

When the consequences are lethal for that 2-3%, that scrutiny is needed.

A set back is not necessarily lethal.

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.

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Ok Goodhart!

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.

I thought so but reading the whole article, it seems like there has actually been mistakes. Several.

Someone who goes to the hospital 3 times and still die because of an untreated disease is not just bad luck.

That 5.7% number must be wrong. Ask anybody with a chronic medical condition.

I've had uncountable number of doctor's visits including ER for 37 years before a proper diagnosis was made.

We pay too much in the US because of the self-imposed medical labor shortage and that results in mistakes by over-worked staff.

Yeah, it always seems crazy to me that in a country that is often so economically liberal and free market, medicine is still run like a medieval guild.

So, your premise is that the US is unique in its lack of checklists in the ER?

Yes. Less scrutiny, more insurance middlemen please.

It's not quite that one either. The big problem is that most people get health insurance through their employer, and then it's the employer choosing it rather than the insured. Otherwise people would choose different insurance and in particular insurance with lower premiums but higher deductibles, and then use the money they saved on premiums to pay out of pocket for things that cost less than the deductible. And then actually insist on getting a real quote and having the ability to compare prices for non-emergency medicine.

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.

>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?

Yes, tons. You choose to focus on the government-aided ones.

the problem is greed.

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We think that we live in a time of medical miracles, and we do, but people are also still dying very quickly from things like pneumonia, and getting strokes from viruses. Any of us could die or be disabled at any moment. Be thankful if you have your health. You can blame docs, and sure it can be that, but this is not like having a good computer technician- life is full of risks!

Ugh. This article hit me especially hard. I'm a medical student in my final year in a country where the last two years of our education consist of handling ER consultations for cases with a 'non-immediate risk of death'...

It's an interesting read. I guess the difference between this situation and the ideal case is that he would have been admitted for observation as a precaution in a world where there was plenty of room and staff to take care of even the less obvious emergency cases.

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...

Look at the USA age at death charts. The USA is around the same level as Cuba. Dissecting coverage/death, we find a huge bulge of high death rates in the poor which encompasses black/hispanic and others who have zero or minimal health care. To those in this group every interaction with health care costs $$, with cash copays needed. Pharmacare is the same, $$ plus copay. Thus they are driven towards zero/minimal health care = die young and unmedicated. Even an ambulance call can be well over $1000. To be sure, once you have medicaid/care after 65 or if you have a good health plan, your age at death is in the top 10 in the global tier. Once in the system there is a blizzard of administrative fees/codes - all of which require intense administrative time/costs to collect fees. This happens with all levels, doctors/pharmacists/drivers/nurses - all of which have their unions whose sole task is maximal revenue. I feel this is a broken system that protects itself to maximise revenue. At the bottom, generic worm medication that has a cost of well under $2 for a full course ends up at $1000+ for medication plus doctor's fees. Same with insulin, life needed medication and also generic. https://www.visualcapitalist.com/cost-of-insulin-by-country/

There is a corrupt political scheme operating in the USA 350 million people losing 6+ average years of life = that is the cost.

My brother was told his heart was healthy after having serious chest pains. The next day, he passed away from a heart attack due to heart disease. This was four years ago, when they were busy dealing with covid patients and in the UK.

Viral infection + quick death = hantavirus.

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.

Non paywalled version: https://archive.is/tJePt

I lost my dad the same way in Fiji. At the time I chalked it up to it being Fiji, long considered a third world country. I guess it could have happened anywhere.

We need better tests for this. Globally one person dies every 3 seconds from sepsis.

From the article, the autopsy findings didn't support sepsis as cause of death.

that's rough, I'd hate to be that person

Would have lived if he had a roommate. Do universities do single dorms now

The article states that he self-isolated in order to avoid infecting anyone else. A roommate probably wouldn't have changed anything there.

Doubt it. A roommate has a life outside of that room, they aren't likely to be there, or know what to do. There's no certainty that a roommate would have been the factor that saved his life.

I'd characterize it as "another saving throw". The roommate might be absent, or preoccupied with his own life, or "staying away from the virus", or too self-doubting to do anything in time.

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.)

From the story it sounds like the parents were notified by the university one day after he'd last been in touch, so someone (be it a roommate or dorm staff) was checking in at least daily.

The story specifically says Sam's friend Charlie contacted campus security after Sam stopped responding to Charlie and Kayla (Sam's girlfriend). Campus security wouldn't have known to check in within a day if Sam's friends weren't on top of keeping in touch with him. (Put another way, I certainly would've rotted longer than that if this had happened to me in college-- lucked into having my own dorm room & had acquaintances but not any friends who would've gone out of their way like that.)

Sadly, that "checking" was exchanging occasional txt messages with student friends.

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.

Could have died in his sleep. When I did my military service, we had a guy that passed away in his sleep (during night) due to pulmonary embolism. Shared barrack room with 5 other.

This is where AI could make a huge difference!

I really hate that this style of clickbait headline is infecting HN. I know the rules say we can't change the headlines but I wish there was an exception for clickbait.

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Always get a second opinion from ChatGPT, a third from Claude and a fourth from Gemini.

It is astounding how much more you can learn about your diagnosis from an LLM.

I have found it very useful to discuss possible diagnoses and diagnostic steps with the LLM before going to the ER. Once there, I told them what my expectations were along with the rationale for it. They agreed with 80% of it.

Ultimately the ER was of no use in treatment, but the preparation did help rule out a serious diagnosis.

What could possibly go wrong.

Things are already going severely wrong in 1% of the cases. At this point not getting a second opinion from an LLM is irresponsible, imo.

This is precisely the thing that LLMs are great for: spicy auto-complete.

What do you think doctors do all day?

I feel like the urge to fight, sue, and demand answers is the direct result of the constructive maliciousness of the medical environment, as orchestrated by the beancounters and provider/insurance bureaucracy. Let's say doctors had the bandwidth to not cut patient discussions short, not expect patients to need an adversarial "advocate", take the time to entertain unlikely hypotheses, monitor/admit for good faith investigative reasons rather than purely on liability rubric [0], etc. Then, when the doctors failed, you would feel that the failing was of a human group that earnestly did everything they could have. But the way the medical system has been whittled down into some bare bones bureaucratic assembly line, it makes it feel like every such failure is a willful and deliberate goal of the system. Why is the medical industry primarily focused on cost optimization through tightening the screws when they aren't even able to get the right answers?

[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).

Everything is optimized for corporations to make more money, to avoid liability and maximize the billable dollars. Doctors want to move meat as quick as possible, most consultations are a couple of minutes! Every doctor has to be part of this rat race because of how the system is designed!

"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."

> Doctors want to move meat as quick as possible,

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.

A doctor (who is is a licensed professional, not unskilled labor) could accept lower pay for less work (fewer patients seen), instead high pay for less work (false-treating patients).

Doctors can't build bigger ERs or hospitals, you need physical infrastructure to give patients extra time.

This is laughably out of touch with the actual limits of care. It’s nursing staff and the shortage is a willingness to pay the costs of staffing.

A doctor running their own private practice could do that. Most doctors don’t operate this way. Their boss isn’t going to let them take up additional resources (rooms, nursing staff etc…) so that they can spend 30 minutes with each patient instead of 15 even if they are willing to take less money.

It might be better put that doctors are incentivized to do this, and they are willingly doing things they're incentivized to do.

also see the private equity takeover of hospitals

The hospitals in my area are non profit, my insurance company is non profit, I mean, where is the money hungry corporation in this story?

>I mean, where is the money hungry corporation in this story?

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.

There are almost certainly physicians groups operating out of that hospital that are for-profit and likely owned by PE. A large part of your bill is going to come from them.

Non-profit doesn't mean the board/CEO/etc aren't getting paid HUGE salaries..

But that's not really a 'corporation's fault', right?

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?