hundreddaysoff

I think the theory is like this:

1. new 30% tax

2. people stop buying so many goods due to (1)

3. due to lack of demand, our shipping industry seizes up and goods stop flowing, at least till (1) goes away

My main source for that theory is https://medium.com/@ryan79z28/im-a-twenty-year-truck-driver-...

There is no shortage of practitioners, ie ~medical middle managers such as myself and other MDs/DOs/NPs/PAs, willing to work in the ER.

(In the narrative of one faction, the suits have in fact created a surplus of us, including docs, that will only get bigger in the next 5 years, possibly hitting n=10,000+ surplus ER docs by 2030. If that happens, a major reason for that in this narrative would be that the suits have directly funded more Emergency Medicine residency slots opening in that time than there are interested American medical students applying to the specialty.)

There is no shortage of bureaucrats willing to shuffle paper and create more work for themselves in the name of Quality or whatever. See this doc's blog for a relatively balanced take on this growth, but I do think there is truth to his first graphic: https://investingdoc.com/the-growth-of-administrators-in-hea...

In my understanding, there is a critical shortage of RNs willing to provide the actual hands-on patient care, for pay that will still turn a profit for the hospital.

This includes skilled ER triage nurses.

But the other side of the coin from labor shortage in this problem is, again, that hospitals simply are not reimbursed sustainably to serve many ER patients, particularly self-pay patients, in the non-literally-emergent ways that those patients should be served, would like to be served, or deserve to be served medically.

Ie, in my understanding the ER is often a loss-leader for a hospital that serves to get patients into higher-total-reimbursement clinics such as GI, cardiology, and orthopedics.

Again, I'm not trying to argue for any faction here including doctors/midlevels, RNs, hospital admin, or even patients. I'm just trying to describe the system from my view down my periscope over 8+ years of doing this.

I happen to agree with you. I was writing not my opinion, but my experiences with the actual EMTALA law, or more accurately and importantly my healthcare administrators' perception of said law. I cannot change either of these things.

Of course I view you as more than pph. My job would not be very fun if I only viewed you as pph. And another part of keeping my job involves minimizing patients complaining about me to admin, which they would a whole lot more if I only [acted like I] viewed them as pph.

And, in order to allow myself to continue viewing patients who are not you as more than pph as well (and thus keep my job), I also consider a lens of pph. Because if I'm talking to you for an hour about low-carb diets or whatever and you feel like I'm the best doctor in the world, but there are 5 more people in the waiting room in pain that I haven't seen yet because I'm totally focused on you... also not doing my job.

The fact that I use this lens does not limit the services I provide to you or the empathetic positive feelings I share with you as a fellow human. (Or not, if you don't want those feelings. As a certified weirdo, I distrust people who come onto me w/ big outward empathy, personally. But most patients like it in my experience. So I tailor it really depending on who you are.)

Agree that forum is very depressing. Bunch of old ER docs who aren't looking for a way out for whatever reason. Part of the goal of my posts in that thread was to get them to smile a little, but they're too crusty. If I hated my job as much as some of them, I would just quit immediately and go back to programming.

No doubt.

I think that admins' interests not aligning with that of patients/consumers or with those of professionals/practitioners is making millions of people sad in a lot of other fields in addition to medicine.

Ben Hunt has written some great essays about this nebulous concept. His phrases "industrially necessary" and "raccoon" come to mind.

Is there a general solution? Dunno. But I suspect crafting even more regulation would be kinda like trying to make Wikipedia better by firing all the content experts and making all the admin-type people write all the words. It wouldn't result in a very good end product.

I seem do my best work when I am left to my own devices and my contact with admin is minimal.

This has been suggested many, many times in my career. The problem in the US is that such posters would violate[0] a federal law called EMTALA, which prohibits an ER from turning away any patient for any reason until I or another provider has performed a Medical Screening Exam (MSE) to assess for A Real Emergency (TM).

EMTALA and confusion around it is another common reason why patients often stay in the waiting room for many hours when really it would be in their best interest to go home and go to a clinic during the daytime. It is the main reason I try to ~break all the soft rules at night and just go out into the waiting room and MSE anything that moves so I can send it home.

EMTALA was passed in the 1980s under Reagan I believe. Good luck repealing it or revising it to make sense in our current political environment!

[0] Or appear to violate the law in the optics of some administrator, insurer, healthcare bureaucracy maintenance organization visitor, etc. In this way, in large bureaucracies, magical thinking reigns, optics becomes objectivity, and 2 + 2 = 5 .

Yes, I think many things are fun or exciting, often for diverse reasons.

ER is fun because, eg, https://forums.studentdoctor.net/threads/patients-per-hour.1...

I do some radiology in the ER. I do find this fun. The core skill of radiology is to find stuff in pictures and then communicate these findings to others. Just like I did as a scientist, which I also found fun and exciting.

I also find it fun to do research in molecular imaging. I suspect I would further have fun researching AI techniques that may allow us to replace some or all of the human work of radiologists with computers. (I suspect "all" will never happen, for the same legal reasons that I suspect we'll never have real self-driving cars. Humans need, um, human scapegoats.)

However, yes, I also have chronic sciatica, or back pain. It gets worse the longer I sit. I don't like standing still enough to use stand desks and treadmills are distracting. Clearly being a radiologist and sitting in a dark room for hours at a time would not be good for this pain.

This is yet another reason I got out of full-time programming.

Well, here's how an ideal night goes for me.

https://forums.studentdoctor.net/threads/patients-per-hour.1...

(Writing this in the middle of the night from that critical access ER I mention.)

I just don't think there's any other medical specialty that has a job as action-packed and gratifying as my job is for me. Surgery would be gratifying, for sure, but also I hate formal clinic and I have a weak bladder, so no.

Yeah, I guess I see lots of sad things. But (1) often patients are sad about things that could've happened but didn't actually happen, and I can cheer them up just by telling them the truth. (2) Often I can make patients happier if actual sad things happen to them, at least in the moment, and that makes me happy too. And (3) if I got sad every time I saw a sad thing, I'd be too sad to do my job and then I'd get fired. So, like, these things don't really make me sad because I'm here to do my job, not to get big feelings?

Does that make sense, or too facile?

Some hospitals do this and it works OK. But patients often believe that they should go to the ER rather than the urgent care part in this situation "just to make sure" or due to other myths. Also, during the day both our main ER and our urgent care are totally saturated at my hospital system.

"Well then your silly system just needs to build more facilities! It's obvious!!" You say.

One thing people need to realize is that it is not necessarily in hospital admins' best interest for all the ER patients to be seen. If it was, they would spend more money on more efficient triage systems so that we could just rake in the bucks. But, in reality they would often lose money on such a gamble in my understanding, due to how patients of different coding levels are reimbursed by payors (and whether a patient is even likely to have a payor).

Main telemedicine gig right now is diagnosing and managing HIV and other STDs. Patients love it as it's super private, and even testing can be done discreetly at home with a mailed kit.

Currently completing an online fellowship in obesity medicine and plan to start my own online practice or collaborate with midlevels who do so. Will probably get into tele-urgent care as well.

I've learned a little about all aspects of medicine as an ER doc, and it's exciting to apply that knowledge to telemedicine. Telemedicine is the Wild West right now. COVID-19 just opened it up a couple years back. We don't really know how to maximally benefit patients with it, but there are all kinds of new models being tried. When it works, it really works, without all the bloat and entrenched rentiers that can make brick & mortar medicine awful for both doctors and patients.

Reminds me of the state of the Internet around 2000. Wide open.

There's nothing in my post that disagrees with anything that you're written.

Everything you've written is correct. I was not trying to argue anything and I think I hedged my words above quite carefully. I was mainly trying to answer OP's question and in passing explain a few things that make it look to patients like me that the ER is even more messed up than it actually is. (And it is actually pretty messed up!)

I love the people with microtears who can't get into the office. I love reassuring parents that they don't need to spend $10k for their viral toddler to be admitted and get treated with nothing all day and then get discharged, but slowly and passive-aggressively. I love helping people who are in the ER for legitimate reasons. I understand that the medical system is broken and most people who are in the ER should, in a halfway sane system, not be in the ER. I understand that way too many people wait for way too long in the ER and it makes me real sad, because as I've written elsewhere on this thread, I do think there are usually fixes that are possible and even easy, from my POV as both geek and JAFERD.

Telemedicine does offer some solutions to some of these problems, but not all of them by any means.

1. Grow up in the 90s and play too many video games and read the Extropians list too much.

2. Decide I want to be, like, the Hagbard Celine of pharmaceuticals and cure death, or something.

3. Learn programming because I still need a job if I fail at (2) and anyway programming is fun and people are scary.

4. Double major in CS and Bio, do bioinformatics research for minimum wage.

5. Move to Berkeley, learn more programming working at a random startup for minimum wage.

6. Get a job as a bioinformatics programmer at a lab; learn lots more programming and some bench biology and publish papers, under the theory that I need papers and a PhD to start a pharmaceutical company.

7. Look around and decide I don't want to be postdocking in SF for $40k/y when I'm in my 40s and have kid(s).

8. Enter an MD/PhD program (MSTP, ie combined and debt-free degrees) as a lowish-resistance hedge even though I dislike premeds and also the entire bloated medical system.

9. (8 years later) Do residency in Emergency Medicine because it's really fun and all the other specialties bore me. (Except radiology, but that's no fun with chronic sciatica.)

The strategy I possess is to use telemedicine in novel and directed ways when it suits the purpose.

Most telemedicine roles I have interest in start with a very directed patient population and a limited set of interventions. Patients at risk for HIV, obese patients, etc. In this context, these subsets of patients are happy to accept special-purpose telemedicine, in my experience.

I personally would not want to see a primary doctor or surgeon over the Internet, and if I needed follow-up testing in the lab right next door anyway, I would prefer to go in person to both places in one "quick" trip rather than dicking around with the Internet before going out to the lab anyway.

Patients are right to be reluctant. Telemedicine offers a lot of benefits, but it can never be as thorough as time in person with a primary doctor. (But this in-person time is just not possible to get for your average patient in my experience.)

I'm sorry this happened to you. I don't know what happened, but good ER docs and nurses prioritize getting people out before they get people in. (No beds left = no new patients can be seen... not that hard of a concept!)

Sometimes things happen that we can't control, but I sure do get tired of ER docs/PAs/NPs overlooking common sense stuff like this. Especially since most good ER RNs would have bugged your provider multiple times to just get y'all the hell out of there!

What is an alternate solution?

In hundreddaysoff fantasyland, the solution is to fire all the bureaucrats and triage everyone immediately. But, then nursing primaries and secondaries and all the other required paperwork wouldn't get done and CMS would come shut down our hospital.

You're welcome! Basic answer: $250/h + benefits and 4 days/week "off". Plus, working in the ER at night is the most fun job I've ever had or probably ever will have. (Programming is second.)

Despite this, I plan to pivot to my telemedicine business full-time within the next year. I know I am not invincible and the older I get, the more mistakes I am likely to make and the more working nights will become a risk factor for heart disease, diabetes, and the like. Plus, working nights wreaks havoc on the family, but it's the only option to work stable days each week in the ER. (Ie, most ER docs either work all nights or work a random rotating schedule of first, second, and third shifts.)

It's very hard to make money as a small, independent hospital with all the healthcare bureaucracy and other requirements. The only way to turn a profit is to merge with other hospital systems and get bigger.

This trend applies to many industries in the US besides healthcare. Agriculture and education, for example.

All this is not wrong. Also, there's another huge factor: frankly, most ER triage systems are not very efficient and they don't hire enough RNs or other front-line workers.

I refuse to work day ER shifts because along with just a couple motivated RNs, I can often clear all the patients from the waiting room at night that have been there for many hours. Often, we just need a break from new patients and we need to work as a team and just focus on getting one patient out at a time. OTOH, day shifts often make me powerless as a doc just because there are so many other bodies around, each with competing agendas and pressures.

I'm an ER doc. I work 3 nights a week and see probably 5--10 patients a week who have waited over 3 hours.

The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.

We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.

The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.

How about this edit:

Instead, people are given the illusion that they have equal opportunity to incite discussion

Doesn't change OP's point. It's just clearer.

No longer program for a living but even 20 years ago that kind of stuff was 80% of my daily job as a LAMP web programmer. I wrote as little code as possible, and only to glue stuff together. The challenge was to understand the pieces to fit together and even just remember how to access all the accounts required. In that light, I'm not seeing much has changed in the past few decades.

My understanding is that the price of food is not generally included in the most-commonly reported version of the CPI for the past few decades. So you could both be right.

Disingenuous non sequitur?

You're saying self-hosting is easier now than in the past?

I have to ask. /So, You're a Sociopath/ was a game, an educational/instructional program, or both?

That's what I got out of it. Small b blogging is more like the original weird Internet of the 90s. Much better IMO.

How about chicory? It's naturalized to the US. Easy to grow perennial with pretty flowers that would look great in the garden.

ānnus = Spanish eñus = not a word?

Exactly. Most academics really can't win. It's how the system is designed.

This is why I sold out after my MD/PhD and became just a regular physician. Maybe in a few decades I'll have enough in savings to fulfill my dream of becoming a mad scientist...

Agree. What is the point of all these laws on the books if they aren't enforced? That will just encourage people to break them when word gets out.

If the counterargument is that these "crimes" shouldn't actually be crimes, then the solution is to remove the laws, no?

But I suppose that whether removing the laws is feasible is another can of worms.