The darker side of being a doctor (2017)

https://drericlevi1.substack.com/p/the-darker-side-of-being-a-doctor

by fadali • 2 years ago

47 67 2 years ago

drericlevi1.substack.com

immibis• 2 years ago

Sounds like the hospital is running a successful business, by all relevant metrics of success. They get the most out of their resources. Sometimes the resources wear out, but that's okay because they can get new ones, and they calculate the rate of resources wearing out is acceptable to increase the overall profit extraction from the resources. Anything else would needlessly increase costs.

cratermoon• 2 years ago

That's a very accurate take, as cynical and cold as it is. I'm sure some private equity firm is very happy with the return on investment.

yoyohello13• 2 years ago

This line of thinking makes me lose hope for humanity.

stavros4• 2 years ago

I really hope the GP's comment is sarcasm, an attempt to point out how the capitalist incentives steamroll over real people in the pursuit of profit.

OldGuyInTheClub3• 2 years ago

I think hospitals (or the companies running them) have cynically exploited Covid on top of everything else. Huge sacrifices from everyone to ensure the facilities didn't get overwhelmed but then also NOT doing anything to improve those facilities or the people that work and are treated in them.

It is no wonder that people have lost whatever little confidence they had in "the system."

No one will give a damn the next time a crisis rolls around and it will.

strongpigeon• 2 years ago

Slightly off-topic: I know the Substack says 2024, but I remembered reading this very same post before. Turns out it's from 2017 [0].

[0] https://www.medicalrepublic.com.au/dark-side-doctoring/1063

ctoth• 2 years ago

Thanks! I knew I had read this before but the date was making me question myself.

schu• 2 years ago

Also, two months ago: https://news.ycombinator.com/item?id=40025261

cortesoft• 2 years ago

And the link from that post is now broken... so the author took down the previous time they posted this to their substack, and then reposted it with today's date?

dang• 2 years ago

Thanks! Macroexpanded:

The darker side of being a doctor (2017) - https://news.ycombinator.com/item?id=40025261 - April 2024 (500 comments)

nathan_compton• 2 years ago

I strongly dislike the way people talk about mental health as if it is just a personal problem or a disease when, often, it is a reasonable reaction to the world as it is. When we conceive of it entirely as a disease we fail to focus on making positive social changes which might make everyone's lives better. Somehow it doesn't feel like a coincidence that in capitalism the "individual problem" narrative seems to always be at the forefront.

stavros4• 2 years ago

https://en.m.wikipedia.org/wiki/Shit_life_syndrome

meany• 2 years ago

I think the challenge is that no matter the circumstances our minds are designed to adapt to the situation. This is often called the hedonic adaption. If you live in a modern western country, your life is likely significantly better than the wealthiest and most powerful people from the 14th century. Most likely if you're prone to depression, you will reset to a negative viewpoint even if societal issues are addressed. Below is an excerpt from article discussing research into lottery winners and paraplegics.

"In 1978, a trio of researchers at Northwestern University and the University of Massachusetts attempted to answer this by asking two very disparate groups about the happiness in their lives: recent winners of the Illinois State Lottery — whose prizes ranged from $50,000 to $1 million — and recent victims of catastrophic accidents, who were now paraplegic or quadriplegic. In interviews with the experimenters, the two groups were asked, among other things, to rate the amount of pleasure they got from everyday activities: small but enjoyable things like chatting with a friend, watching TV, eating breakfast, laughing at a joke, or receiving a compliment. When the researchers analyzed their results, they found that the recent accident victims reported gaining more happiness from these everyday pleasures than the lottery winners.

This is how the study is usually written about, in a “gee whiz, ain’t that counterintuitive?” kind of tone. But what’s really striking when you look at the results reported by the researchers is how close their answers actually are: On average, the winners’ ratings of everyday happiness were 3.33 out of 5, and the accident victims’ averaged answers were 3.48. The lottery winners did report more present happiness than the accident victims (an average of 4 out of 5, as compared to the victims’ 2.96), but as the authors note, “the paraplegic rating of present happiness is still above the midpoint of the scale and … the accident victims did not appear nearly as unhappy as might have been expected.”

This is partially because of what’s become known as the hedonic treadmill, or hedonic adaptation, that annoying tendency humans have to get used to the things that once made them happy. I particularly love how the authors of this 1970s paper phrased it:

    Eventually, the thrill of winning the lottery will itself wear off. If all things are judged by the extent to which they depart from a baseline of past experience, gradually even the most positive events will cease to have impact as they themselves are absorbed into the new baseline against which further events are judged. Thus, as lottery winners become accustomed to the additional pleasures made possible by their new wealth, these pleasures should be experienced as less intense and should no longer contribute very much to their general level of happiness."

From the following article: https://www.thecut.com/2016/01/classic-study-on-happiness-an...

DamnInteresting• 2 years ago

The hedonic treadmill also helps to understand why wealthy people--regardless of how they acquired their wealth--seem desperate to increase their fortunes. They have more money than they could ever need, yet they want more. See Elon Musk and the $50 billion pay package.[1]

I feel like this happens a lot with creative people as well--an artist can become successful and widely respected, but still become deeply unhappy if their skill or audience declines, regardless of financial success. It is the first thing that comes to my mind when I hear about celebrity suicides--Robin Williams, Naomi Judd, Anthony Bourdain.

If there's no increase in wealth or station, there's no dopamine. And that is depressing.

[1] https://www.washingtonpost.com/technology/2024/06/13/tesla-s...

giantg2• 2 years ago

I agree that somethings like depression can sometimes be rational responses to the environment the person is in and can't just be medicated away. However, I don't think it's right to ignore the disease aspect, nor to politicize problem.

altruios• 2 years ago

paper straws, conserve your water, wear your mask...

Just don't fix society, let capitalism sell you solutions to a broken society: it's more profitable... /s

newzisforsukas4• 2 years ago

Why do doctors have families on top of a demanding career then complain about it when they are over burdened? They put themselves in that situation. They can also leave that situation whenever they want.

Then to go on sadfishing with this border-line masochism in a blog post...

TheDudeMan• 2 years ago

Kinda what I was thinking -- why not retire or change careers? Being a doctor for many years presumably affords one that option.

exe34• 2 years ago

next month you'll be complaining that there are no doctors in your area willing to see you inside of a month?

bonton89• 2 years ago

I'm not sure they really can leave whenever they want. I think once you're far down the education track you will probably feel like you're trapped into continuing even if you decide you don't want to do it anymore, because the education loans will kill you and you need the big income on the other end to fix this. That probably contributes to the creation of a lot of miserable and crappy doctors.

newzisforsukas4• 2 years ago

because the education loans will kill you and you need the big income on the other end to fix this

Being a surgeon doesn't have the same level of demand as a role in family medicine. Both roles provide an income for sustaining oneself, even through student loans. Also, the subject in this article has "been a doctor for 13 years".

whoomp123423• 2 years ago

you forget that doctors go way into debt for their education and training. so no, they might not be able to leave that situation quite so easily.

why would you blame someone for wanting to have a family? do you hang out with the grinch?

newzisforsukas4• 2 years ago

do you hang out with the grinch?

I don't presume anyone can have and do everything. There are constraints on life, and concessions need to be made for certain goals.

jimbokun4• 2 years ago

THAT is your take away?

Not, I don't want a surgeon pushed past the point of exhaustion and sanity operating on you?

newzisforsukas4• 2 years ago

Not much can be done to change the ethical stance of the hospital or the surgeon that decides to work for them.

I assume many doctors and hospital administrators, like the overall population, are money or status hungry, and they are willing and able to hurt people to maintain their lifestyles.

There are no regulations enforcing transparent reporting of less than optimal surgical outcomes or what those optimal results are. I would be more worried about that.

gnarbarian4• 2 years ago

a couple things to consider:

* high turnover impacts efficiency.

* Exhausted doctors make mistakes which will lead to malpractice lawsuits

I think incentives are misaligned across the board in the medical industry. This goes for doctors, patients, hospitals, insurance providers, pharmaceutical companies, medical device manufacturers, medical equipment/material supply companies and probably everyone else connected to the industry.

These poor incentives lead to pathologies that drive up costs and result in poor patient outcomes.

Anyone who has encountered a "prior authorization" when trying to get a time sensitive medication filled has experienced this.

Some doctors are opting to "drop out" of the counterproductive insurance game by accepting only cash payments, but that only solves a small part of the problem.

rickydroll• 2 years ago

My neurologist has said that she will give you all the information you need to go through the whole preapproval process but she is not going to drive it. I suspect she is doing this because she was not getting paid for the effort and she is tired of fighting insurance companies.

My eye doctor (damn good specialist) told me about how bad private equity folks over the medical industry. He is grateful to his practice has been able to avoid the private equity vacuum cleaner.

You're right that incentives are misaligned. It seems that the choice is either to provide good-quality medical care or feed the ravenous beasts of the finance industry.

hcarvalhoalves2• 2 years ago

This isn’t a mental health issue of an individual. Medicine is severely understaffed and professionals are burned out, worldwide. Doctors should be as common as plumbers given the demand but often, I can’t get an appointment with a doctor within 30 days.

stavros4• 2 years ago

Exactly like plumbers, then?

whoomp123423• 2 years ago

you realize that plumbing is currently one of the highest paid trades because of a shortage?

hcarvalhoalves2• 2 years ago

Yes. I was giving another example of profession that should have plenty of offer since there will always be demand for.

mdaverde• 2 years ago

So much of HN now is medical & healthcare related

luminen• 2 years ago

Heartbreaking pieces like this do make me wonder... what is the better way to approach healthcare? For both doctors and patients, what would need to change? Is it like this everywhere, or does the US have a unique problem?

I heard a theory once that there is an artificially high barrier for who can become a doctor, and lowering that barrier by allowing doctors to specialize early on/not spend as much time studying fields they won't work in, we would have a higher supply of medical staff. As a layperson, this makes sense to me, but I also don't know what I don't know.

I have a lot of respect for anyone who works in healthcare.

saulpw• 2 years ago

A lot of it is the privatization and therefore optimization of healthcare. Why does the hospital only employ one doctor? Yes, maybe they have the headcount and it's an actual shortage of doctors, but I'd guess that the admins have reduced headcount and are trying to be cost-efficient. (This is why nurses are perpetually understaffed; either they're actively trying to keep headcount down, or they're underpaying so the headcount stays open.) Why do they need tonsillectomies to take 14 minutes? Again, trying to "optimize" healthcare.

astura• 2 years ago

There's already around 10,000 medical doctors that don't match with a residency program so they can't practice medicine. These are qualified MDs who graduated from medical school who are ready, willing, and able to work but they are told "no."

Expanding residency to cover all qualified MDs would be a great first step.

https://www.nytimes.com/2021/02/19/health/medical-school-res...

metalcrow4• 2 years ago

It seems to me the only way to fix this problem, aside from some sort of large regulatory changes by the government, is for doctors to start unionizing or striking to force better conditions. What would happen if doctors simply refused to do more then 60 hours a week? Is there really enough supply of new doctors coming in that the hospital can just fire them all and replace them with doctors willing to burn themselves out? Or would it mean the hospital would have no choice but to hire additional doctors so that each one would only have to work a sustainable number of hours?

gnarbarian4• 2 years ago

they can always join or open their own practice.

OldGuyInTheClub3• 2 years ago

The costs to start, staff, and sustain a practice large enough to deal with insurance is prohibitive. A few private practice doctors I know socially are getting out early because they can't deal with the b.s. anymore.

whoomp123423• 2 years ago

there is already a massive medical provider shortage

bena• 2 years ago

In some large part because of the AMA. They routinely advocate for restricting the number of licensed medical doctors.

metalcrow4• 2 years ago

If so, then shouldn't these doctors be able to demand better conditions? Threatening to do less work unless pay is improved or more nurses are hired or some changes to the job are made. That would grind the hospital to a halt.

bshep2• 2 years ago

What would happen if doctors simply refused to do more then 60 hours a week? -> you can get sued for patient abandonment if you refuse to followup on a patient you are responsible for

Is there really enough supply of new doctors coming in that the hospital can just fire them all and replace them with doctors willing to burn themselves out? -> in part yes there are ( in some fields) but what would happen is that patients would be shifted to other facilities that have staff to see the patients, also when you have 400-500k of school debt its hard to refuse work

Or would it mean the hospital would have no choice but to hire additional doctors so that each one would only have to work a sustainable number of hours? -> this happens as well, they hire locum tenens docs to fill in gaps ( higher short term expense in exchange for not giving staff docs what they need)

metalcrow4• 2 years ago

you can get sued for patient abandonment if you refuse to followup on a patient you are responsible for

Sure, but that isn't the case in this linked article, it seems. Being on call for emergencies, doing elective surgeries, refusing to do that doesn't count as patient abandonment as i understand it. Only when you are actively taking care of someone can you not leave them.

in part yes there are ( in some fields) but what would happen is that patients would be shifted to other facilities that have staff to see the patients, also when you have 400-500k of school debt its hard to refuse work

Ah, yeah then that's the main problem. There's such an excess of supply that hospitals can afford to treat doctors like crap. Same idea Amazon has about its workers. In that case, hopefully articles like this will make people realize becoming a doctor is a bad choice, and reduce the supply and allow stronger employee bargaining positions.

Of course stronger regulations would always be a better option for this case, but i don't see that happening.

sandworm101• 2 years ago

They are unionized already. They have independent state licensing boards staffed and operated by other Doctors. These organizations manage the profession and more or less set the standards to which doctors in the state are held.

metalcrow4• 2 years ago

Does the union actually do much for them? I know in a lot of blue collar work unions are actually serious, and can do strikes and stop a business in it's tracks if the workers feel they are being mistreated. Why does that not happen with doctors? I've not heard about it happening, anyway.

EncomLab• 2 years ago

It's an interesting perspective - it would be nice if it was noted that this same article seems to be reprinted regularly without indicating it's a reprint.

w10-1• 2 years ago

I appreciate the candor and the analysis, but I think it's missing the forest for the trees.

Medical providers care about people, and indeed are responsible for the health of their patients. Some of those patients turn around and bite them. Others die - some die at your hands. Providers, especially doctors, take responsibility for that, emotionally and otherwise.

No person and no system of support can be designed to completely avoid that. There is no religion or personal discipline that will erase the emotional and moral cost of hurting people you're trying to help.

Some say their lost patients help them do better for their present patients. It's a bit like Lincoln saying at Gettysburg that these young boys did not die in vain - while knowing many were avoidable.

Medicine may be a business, and it may even be a calling. But just realize that people doing medicine lose their innocence, in ineffable and unsharable ways, and try to respect that.

joe_the_user• 2 years ago

Of course doctors and health care providers face inherent challenges. But that shouldn't distract from the many and now know well pathologies that our current health care system has.

kristjansson• 2 years ago

Sounds like many of the acute problems are microfrustraions created by poor software design and engineering. Slow login/relogin, unrealistic scheduling, illegibility of pre- and post-surgical tasks to the timekeeper, etc. We can't solve the structural problem, but better software could help create more humane working environment under the constraints.

Of course, the real problem is running medicine like a business, but technology can only serve the megamachine...

ghnws• 2 years ago

The article reads like all the little annoyances is what is wrong when the doc is expected to work almost 24/7 for days on end. No amount of software improvement will make any realistic improvements.

It's insane that a truck driver _must_ have 8 hours of sleep before work (they should, not arguing against it), but a surgeon can work with a couple of naps for days.

karmakurtisaani• 2 years ago

I keep asking myself why they hire the worst developers to do time recording software. Ones who can't design an intuitive UI, can't make it help you automate recording, can't make it respond without 1-2 second delay every time.. Of course HR needs us to log in our hours in these systems, and then the managers tell us what hours to put where. It's absurd all the way.

Having been exposed to this only a little, I can imagine what kind of garbage the medical staff has to endure to make their reports and time keeping.

jimbokun4• 2 years ago

There is a strong argument to be made that paper charts were more efficient and provided better quality documentation with better user experience than modern EMR software systems.

Also, this is one place where AI can potentially provide both a more efficient system and greatly improve job satisfaction for physicians. Automatically generating and updating medical records based off ambient recordings of patient interactions fits right into LLMs wheelhouse.

tivert2• 2 years ago

There is a strong argument to be made that paper charts were more efficient and provided better quality documentation with better user experience than modern EMR software systems.
Also, this is one place where AI can potentially provide both a more efficient system and greatly improve job satisfaction for physicians. Automatically generating and updating medical records based off ambient recordings of patient interactions fits right into LLMs wheelhouse.

No, LLM's are not reliable enough for that.

If the technology sucks and is in fact a regression, the solution is not to hope yet more half-backed technology will fix the problem. The solution is to dump the technology until someone can actually do it right.

If paper charts are better, go back to paper charts...and maybe hire a digitization/data entry team to realize whatever benefits to electronic records there are.

SlavikCA• 2 years ago

I saw quite a few of similar situations, when people are doing their best, because they're responsible, and if they will not take care of things - something bad will happen.

I always suggest the "principle of lost packets".

Let things fail early to inform about your limitations. If your internet connection speed is 30Mbps and you send 100Mbps upstream - some packets will be dropped. The earlier packets get dropped - the better for the connection, because feedback will be faster. Ideally at your router.

Practically speaking, for the case in the article: We have 6 doctors working at our hospital. One doctor quits. Look, we're doing ok with 5! Let see, can we do with 4? Sure. Ok, now we're with 3 doctors and things are failing... So, 4 is probably optimal. Well, that 4 doctors working on the edge. Would this doctor "fail the hospital" earlier, - hospital will receive that signal, and doctor's count will be higher.

Few years ago I was promoted to be QA Manager, and learned very quickly, that a lot of people will make sure that I know, that if our QA team will not sign off on that release - we'll lose that deal, or make that client unhappy... At the beginning I tried to accommodate. But that was totally unsustainable. So, I quickly learned to give people realistic expectations: - no, will not complete QA by Friday, tell the client whatever you want, or give me 2 more people (and the only people they can give me were Developers). - no, will not have that release ready by 12th, you should have consulted with me before making promise, not it's on you to figure out, not my headache.

cynicalsecurity• 2 years ago

Why not graduate more doctors?

jimbokun4• 2 years ago

The part about forcing 14 minutes per operation terrifies me.

If I'm on the table, and something unexpected comes up, how much pressure is the surgeon under to take a short cut to ensure he stays under 14 minutes? Or make a mistake because he's rushing to meet the deadline.

I'm a pretty staunch capitalist, but this further reinforces for me that medicine needs to be completely divorced from the profit motive. Costs should only be considered in order to treat more patients better with the available resources. But never to increase executive pay or shareholders' stock price.

orangesite• 2 years ago

Hard to swallow pills:

- When the goal of medicine is profit instead of helping patients the outcomes will be poor.

- When the goal of education is profit instead of teaching students the outcomes will be poor.

- When the goal of politics is profit instead of collaboration the outcomes will be poor.

- When the goal of business is political, educational or medicinal the outcomes will be poor.

Generic formulation:

Any attempt to apply a metric that works in one context to the entire system will result in poor outcomes.

justtinker• 2 years ago

Protestant work ethic Black Swan.

The solution to the problem is 15 years before now, not today when there are so many conflicting force out to crush you.

If you try to get out lots of people blame you or sue you.

I got out. Not by being smart or inciteful but by being, as other people called it "lazy".

IT Director of 45 people, high pressure environment, 6 figure salary in 2001, DOT.COM style but not in silicon Valley. I was at my Peter Principle Level of incompetence. This was my 3rd dot.com job running at a frenzied increase in responsibility.

No golden exits. Just layoffs when money ran out.

Luckily it went bankruptcy too. Dot com bust happened. No new Directorship to step into. To get back on the hamster wheel I would have to get an MBA. Other colleagues did. It was not for me. I would have imploded too, if I tried.

Lots of acquaintances wondered why I was so under employed after 20 years of ladder climbing. In absolute $ I am still not back to the number I made back then. Life since then has given me other stresses that would have made today unbearable if I continued.

Everyone who is under those crushing stress today had a set of decision that (their own and other peoples) that corralled them into the situation. After a while there seems no escape.

The people who "tsk tsked" when I left things behind did not consider the consequence of the future.

I am at the end of my career (45 years since first $ in IT). I have "enough money". People are still telling me I should work hard and achieve more. Really want to retire and contribute to society in another way.

wwweston• 2 years ago

This is the expected outcome of a system that is optimizing for legible costs with little feedback as to the wear on labor and outcomes.

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The darker side of being a doctor (2017)

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