It's just a virus, the E.R. told him – days later, he was dead

https://www.nytimes.com/2025/10/05/well/sam-terblanche-virus-death-columbia.html

by wallflower • 10 months ago

247 440 10 months ago

timbritt• 10 months ago

gleenn• 10 months ago

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.

adastra22• 10 months ago

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

jopsen• 10 months ago

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.

actionfromafar• 10 months ago

Yes. Less scrutiny, more insurance middlemen please.

AnthonyMouse2• 10 months ago

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.

AnthonyMouse2• 10 months ago

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.

sr-latch• 10 months ago

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.

hshdhdhehd• 10 months ago

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.

closewith• 10 months ago

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.

esoleyman4• 10 months ago

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.

0xDEAFBEAD3• 10 months ago

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.

CrossVR2• 10 months ago

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.

ludicrousdispla• 10 months ago

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

schnitzelstoat• 10 months ago

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.

aucisson_masque• 10 months ago

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.

throw-qqqqq• 10 months ago

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).

neffy• 10 months ago

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.

red-iron-pine3• 10 months ago

I believe your points, but give me a source.

nradov15• 10 months ago

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.

kakacik• 10 months ago

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).

red-iron-pine3• 10 months ago

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

prerok• 10 months ago

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.

UI_at_80x24• 10 months ago

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.

mouse_• 10 months ago

the problem is greed.

IAmBroom6• 10 months ago

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

lhmiles• 10 months ago

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

leptons• 10 months ago

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.

bell-cot4• 10 months ago

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.)

TrackerFF3• 10 months ago

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.

account422• 10 months ago

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

mnw21cam• 10 months ago

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.

InfiniteLoup• 10 months ago

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..

gtr• 10 months ago

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

globular-toast• 10 months ago

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.

dinobones• 10 months ago

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.

Shank• 10 months ago

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.

InsideOutSanta• 10 months ago

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.

arethuza• 10 months ago

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

magicalhippo• 10 months ago

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.

toomuchtodo• 10 months ago

Well done advocating for her healthcare needs.

0xDEAFBEAD3• 10 months ago

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.)

f1shy3• 10 months ago

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.

rkomorn2• 10 months ago

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.

didntknowyou3• 10 months ago

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.

0xDEAFBEAD3• 10 months ago

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!

ACCount372• 10 months ago

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.

nradov15• 10 months ago

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.

CrossVR2• 10 months ago

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.

quantumwoke3• 10 months ago

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.

cynicalkane• 10 months ago

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.

jll292• 10 months ago

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

draven• 10 months ago

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.

dsego• 10 months ago

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.

potato37328422• 10 months ago

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.

eYrKEC22• 10 months ago

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."

kameit00• 10 months ago

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

bell-cot4• 10 months ago

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.

quantumwoke3• 10 months ago

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...

quantumwoke3• 10 months ago

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.

lotsofpulp• 10 months ago

This is 99.9% of “news”.

wewewedxfgdf• 10 months ago

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.

ThePowerOfFuet• 10 months ago

What could possibly go wrong.

rafaelero• 10 months ago

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.

blargthorwars2• 10 months ago

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

CamperBob2• 10 months ago

What do you think doctors do all day?

OutOfHere• 10 months ago

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.

adzm• 10 months ago

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.

triceratops5• 10 months ago

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

codeulike4• 10 months ago

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.

didntknowyou3• 10 months ago

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.

franktankbank4• 10 months ago

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?

codeulike4• 10 months ago

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... )

jll292• 10 months ago

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)

whereas here, it was the (more rare) zebra, but nobody could take the time to do DD (differential diagnosis, i.e. to tease apart what can and cannot be the case).

notmyjob• 10 months ago

It’s usually something rare, almost by definition.

ryandrake• 10 months ago

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.'"

bcrl4• 10 months ago

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.

GenerWork• 10 months ago

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.

pwg2• 10 months ago

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.

cogman102• 10 months ago

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?

Nifty39293• 10 months ago

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"

devilbunny4• 10 months ago

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.

FireBeyond7• 10 months ago

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".

anon2912• 10 months ago

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

ratelimitsteve• 10 months ago

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?

cm2187• 10 months ago

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

zbyforgotp• 10 months ago

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. “””

codeulike4• 10 months ago

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

cfu283• 10 months ago

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

HelloMcFly2• 10 months ago

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.

epmaybe2• 10 months ago

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!!

FireBeyond7• 10 months ago

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?

n8henrie• 10 months ago

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.

orthozato3• 10 months ago

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...

mscrnt2• 10 months ago

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.

thelastgallon• 10 months ago

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."

IAmBroom6• 10 months ago

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.

gowld3• 10 months ago

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).

Eric_WVGG• 10 months ago

also see the private equity takeover of hospitals

ModernMech• 10 months ago

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

VirusNewbie2• 10 months ago

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?

hn_acc1• 10 months ago

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

chmod775• 10 months ago

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.

sarchertech9• 10 months ago

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.

thegrim33• 10 months ago

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.

dostick• 10 months ago

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

yieldcrv• 10 months ago

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

rediguanayum2• 10 months ago

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.

nick__m• 10 months ago

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

There are also antivirals for Herpes simplex and zoster, HIV, Hepatitis B and C and probably others that i don't know about. It's still a small arsenal but it not limited to Flu and Covid.

shadowpho• 10 months ago

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?

jacobgkau7• 10 months ago

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.)

thephyber• 10 months ago

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.

at-fates-hands• 10 months ago

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.

mindslight3• 10 months ago

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).

TrackerFF3• 10 months ago

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.

kylehotchkiss• 10 months ago

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.

bckr• 10 months ago

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

wagwang• 10 months ago

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

isubkhankulov• 10 months ago

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.

derbOac2• 10 months ago

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.

brandonmenc• 10 months ago

Stop charging $300k for the medical degree.

directevolve• 10 months ago

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.

randycupertino2• 10 months ago

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."

deepsun2• 10 months ago

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.

accurrent2• 10 months ago

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.

newyankee• 10 months ago

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

Ferret7446• 10 months ago

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.

invaliduser• 10 months ago

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.

matheusmoreira4• 10 months ago

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.

hinkley• 10 months ago

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?

khuey• 10 months ago

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".

FireBeyond7• 10 months ago

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.

onlyrealcuzzo• 10 months ago

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.

fn-mote• 10 months ago

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.

derektank3• 10 months ago

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.

MR_Bulldops2• 10 months ago

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.

wnc3141• 10 months ago

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

cladopa• 10 months ago

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.

framerjohn3• 10 months ago

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.

kspacewalk2• 10 months ago

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.

bell-cot4• 10 months ago

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.

Fomite7• 10 months ago

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

downrightmike2• 10 months ago

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.

Whoppertime• 10 months ago

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

hopelite• 10 months ago

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?

scrps• 10 months ago

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.

nradov15• 10 months ago

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/

novok3• 10 months ago

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.

matheusmoreira4• 10 months ago

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.

siva7• 10 months ago

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.

novok3• 10 months ago

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.

darth_avocado• 10 months ago

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.

NoMoreNicksLeft2• 10 months ago

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.

lukan• 10 months ago

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

jacobgkau7• 10 months ago

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.

monero-xmr2• 10 months ago

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

jacobgkau7• 10 months ago

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).

voxl2• 10 months ago

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.

jacobgkau7• 10 months ago

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.

esoleyman4• 10 months ago

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

gnfargbl2• 10 months ago

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.

Fomite7• 10 months ago

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.

mensetmanusman• 10 months ago

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

wayeq• 10 months ago

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

TrackerFF3• 10 months ago

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

esoleyman4• 10 months ago

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.

citizenpaul3• 10 months ago

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.

jimbob45• 10 months ago

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

ineedaj0b• 10 months ago

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

captainkrtek• 10 months ago

“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..

cyberax• 10 months ago

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

citizenpaul3• 10 months ago

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?

tropdrop• 10 months ago

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.

citizenpaul3• 10 months ago

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.

underlipton2• 10 months ago

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.

StarterPro• 10 months ago

Forget PC, its repugnant and incorrect.

You're just spouting dog whistles and fatphobic bullshit.

The system is broken because that's the design.

nialv7• 10 months ago

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.

ChrisMarshallNY• 10 months ago

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.

LeoPanthera• 10 months ago

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.

framerjohn3• 10 months ago

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!

orthozato3• 10 months ago

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'...

Mistletoe• 10 months ago

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.

stuckindoors• 10 months ago

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.

navs• 10 months ago

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.

dcanelhas• 10 months ago

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...

michaelbrooks• 10 months ago

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.

aurizon• 10 months ago

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.

thenerdhead• 10 months ago

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

renewiltord• 10 months ago

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.

nikolay• 10 months ago

This is where AI could make a huge difference!

mannyv• 10 months ago

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.

It's just a virus, the E.R. told him – days later, he was dead

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