jac241

The disclosure section in the cited research article may indicate a financial interest in the authors being able to say that Prozac is not effective:

“ MAH and JM are co-applicants on the RELEASE and RELEASE + trials in Australia, funded by the Medical Research Future Fund (MRFF) and the National Health and Medical Research Council (NHMRC), evaluating hyperbolic tapering of antidepressants against care as usual. MAH reports being a co-founder of and consultant to Outro Health, a digital clinic which provides support for patients in the US to help stop no longer needed antidepressant treatment using gradual, hyperbolic tapering; and receives royalties for the Maudsley Deprescribing Guidelines. JM receives royalties for books about psychiatric drugs, and was a co-applicant on the REDUCE trial, funded by the National Institute of Health Research, evaluating digital support for patients stopping long-term antidepressant treatment. MP and RL have no conflicts of interest to declare.”

I would caution those in this thread who have never seen or treated patients in any psychiatric clinic or hospital let alone a pediatric one to be careful assuming that they have adequate experience to make sweeping judgements on the utility of antidepressants in children.

If there’s a brain microbiome then why does nothing grow when I send CSF from an EVD?

Maybe, but I think more likely is the time factor for med students. There’s really only time to find the major structures implicated in disease. Surgeons also not likely dissecting around the clitoris much. Wouldn’t want to risk injury obviously.

That is known as the perforator drill bit - https://www.reddit.com/r/toolgifs/comments/z2zikm/cranial_pe...

Used to make burr holes so that the dura can be stripped away from the skull using the Penfield 3 instrument.

Then what's used is what's known as the B1 with footplate to create the bone flap - https://www.researchgate.net/publication/323134344_Exposure_...

Here is an example of the drill system - Midas Rex MR8 - https://www.ebay.com/itm/125960633809

Here's a video of a surgeon performing the pterional craniotomy, probably the most common craniotomy for things like aneurysms, - https://www.neurosurgicalatlas.com/volumes/cranial-approache...

Strong work. Looking forward to / dreading the update with the 2023 and 2024 data that I've been more involved with. RIP to all of the young people in their late teens and 20s who made the mistake of using a road for anything other than driving. RIP to the older folks who got smoked just crossing the street. RIP to everyone else who didn't deserve to go. Hopefully there is traffic calming and reliable, frequent public transit in heaven.

Unfortunately this dataset doesn't include the, probably more frequent, severe TBIs. Surely wouldn't take many patients for the cost of a hemicraniectomy, 2 week neuro-ICU stay, trach/peg, and long term acute care stay to equal the cost of a few measures to slow drivers down. Not to mention lost earning/tax potential. Too bad it's not from the same budget.

Wear your seatbelt and a helmet and hopefully you can avoid the pain of your family having to have a surprise end-of-life discussion with me.

You electrically stimulate around the spot with a probe where you’re planning to resect. If the patient can’t perform whatever task you’re evaluating then you know you can’t resect in that area. Generally looking for a 1cm margin between tissue you’re going to resect and a positive stim site.

Can’t undo brain cuts. CNS neurons don’t repair themselves like peripheral neurons or your skin. Generally not cutting glioma brain tumors out per se more likely to use ultrasonic aspiration to suck the tumor out piecemeal. Depends on the tumor though.

Amen. The American Hospital Association wields way more power now. Mergers between hospital systems have led to the large hospital systems being among the largest employers in many states, which means that senators and representatives are going to listen to what they want. Certainly more than they do to the AMA, which might only represent like 25% of doctors anymore.

Probably many people you know have seen a doctor for depression and gotten better, they’re just not telling that to the guy who says things like you did in your post… Very stupid take here man…

Yeah sterile technique has to be meticulous in shunt cases. There’s evidence that the number of people scrubbed into the case influences the shunt infection rate so students like me occasionally would not be permitted to scrub.

There’s generally no bacteria outside of the food tube though it certainly could happen the way you describe if there happened to be.

They tunnel it in the subq until the abdomen then they make a tiny incision in the peritoneum and depending on the neurosurgeon may have general surgery take a look laparoscopically to make sure there’s CSF flow then use the grasper to try to toss it in the right pericolic gutter over the liver.

The hard part in medicine isn't diagnosis and it's not performing the surgeries, it's disease prevention, it's working with patients to find treatment plans they can tolerate, and it's coordinating all of the moving parts (skilled nursing facilities, pharmacies, inpatient rehab facilities, outpatient rehab facilities, durable medical equipment, home health care, insurance companies) to deliver care that results in a good outcome. Where hospital care falls apart is when labs/tests don't get performed in a timely manner and when protocols/standardized treatments aren't followed. You don't need AI to make that work, you need wider adoption of checklists with workflows that are efficient enough to continue to deliver care to the same amount of people while they're being implemented so that hospitals are willing to adopt them. The diseases that can be effectively caught with screening tests - colon cancer, cervical cancer, breast cancer, lung cancer in high risk patients, abdominal aortic aneurysms, hyperlipidemia, hypertension, depression, etc. - already have screening programs in place.

Every dollar spent coming up with the next automated imaging diagnosis model would be better spent on a model that encourages people to get up and exercise 5x/week, quit smoking (or never start), and get their colonoscopy. Once the patient is presenting to the doctor with heart failure, coronary artery disease, carotid stenosis, COPD, colon cancer, etc. the battle is already lost.

Complain all you want about the healthcare system holding data back. You don't need the healthcare system to make the biggest impact on people's health.

—- I’ll add that your shamanism comment sounds like the typical bs that the 20-something software engineer, who thinks they know everything because they make more than 100k a year and have never had to go to a doctor for anything other than strep throat or generalized anxiety disorder let alone spent anytime in a hospital other than to visit family members, that are everywhere on this site loves to say about physicians or other healthcare workers to shit on them.

Many studies comparing NP and physician outcomes will have the NPs under supervision by physicians, which is ideally how they would be used, but in practice the true supervision level varies widely. I wouldn't see an NP for my care personally, and I doubt there are many physicians who would. The wait time to see primary care physicians is typically less than a week in most places and would be worth it. If you're experiencing something you feel is too serious to wait a week I would visit the ER (and make sure to ask to be seen by the physician also). It's your health. Personally I would only trust mine to the people who are the experts in their subjects, and not those who have less training and can switch between specialties without any additional training.

I don't have anything against NPs when the supervision is close, but more and more doctors are put into positions where they are acting as liability sponges for de-facto independent NPs/PAs.

Here are a few studies - (CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625

Comparing urgent care visits between MD/DOs and Midlevels. Doctors saw more complicated patients, addressed more complaints and deprescribed more. https://link.springer.com/article/10.1007/s11606-021-06669-w

NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/

Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/

Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082

Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullar...

Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696

The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)...

Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/

If someone was making more than twice as much as you, working half as many hours as you, seeing half as many patients as you, and were less qualified for their similar role, you would be upset too.

It's a mischaracterization for PAs because doctors only have ~7.5x minimum more clinical training and not 10x, 15000 clinical hours (for med school + family medicine, the shortest residency program) vs 2000hrs. Ask any radiologist you know what they think about the imaging orders from NPs and PAs and that will give you your answer.

I would guess that most people entering NP programs at this point have less than 3 years of work experience as a nurse, a job where you are not diagnosing, coming up with treatment plans, performing procedures or doing any other physician tasks.

I don't know if 500hrs of shadowing after a 2yr part-time online only program that you don't need any nursing degree or experience to enter would count as highly trained or skilled. Here's a list of direct entry nursing masters programs - https://nursinglicensemap.com/nursing-degrees/masters-in-nur...

Here's Johns Hopkins doctor of nursing practice program's curriculum - https://nursing.jhu.edu/academics/programs/doctoral/msn-dnp/... - where more than half of your classes are not medicine related and which requires an astounding 1000 clinical hours and less than 10 credits a semester before you can call yourself "doctor". Most medical students will have 1000hrs after 3 months in 3rd year, where they will be expected to diagnose and come up with treatment plans vs just shadowing, and they still have 9 more months of 3rd year, 4th year, and a minimum of 3 more years in residency. Doctors will likely end up with a minimum of 15000 hours of training. The difference really is that large, and I feel bad for the patients and for the NPs who have no idea how deficient their education is. PAs have 2000hrs of clinical experience. Here's a chart - https://i.imgur.com/Cj5z4f8.jpg

Please list some of the solutions, because from where I am (actually in a hospital) all I see are people who care about patient outcomes.

I thought we’d have banned software engineer lobbying by now, look how much harm they’re causing - https://www.healthline.com/health-news/social-media-use-incr...

There’s no price segmentation. You pay the same for a visit with a PA or NP as for one with a physician, so why see someone with less than a tenth the experience who may have gone to an online only school with 100% acceptance rate and shadowed for 500hrs of “clinical experience“ right out of nursing school?

Totally side effect free if we ignore the risk of stroke from cardiopulmonary bypass (at least 0.5%), infection of the chest cavity (0.5-3% incidence of mediastinitis after median sternotomy), anesthesia complications, post op pulmonary embolism, pneumonia, UTI, etc.

One of my former coworkers who went to private schools said the same thing. All I could think to myself was that we have the same job and title except my education cost $300k less after going to public school and a public university. If it's a circus I guess I'm just a stupid monkey who didn't get an education dancing my way to becoming a neurosurgeon...

Those greedy doctors trying to protect their livelihoods from a bill that gives insurers an easy path to drive down their reimbursement when an alternate method of doing the same thing (New York's law on surprise billing) exists that does not have that same feature. I for one know that software engineers would certainly support bills that would reduce their pay for the greater good! Physicians are the only group that everyone expects to work for less and less money. It may surprise you, but most software engineers will have an easy time outearning the majority of physicians. It's not the 80s anymore. Doctors aren't super rich. Doctors aren't the ones who made you sick, but they are the ones who trained for 7+ years to take care of the problem. Shame on them for wanting to earn a living.

It's not. Physician reimbursement has been going down year over year since the late 90s. Each unit of physician work (relative value units, RVUs) is worth 50% of what it was in 1998 for Medicare at least, and most insurers peg their reimbursement at a specific multiple of the Medicare rate. Sorry, the insurance companies, PBMs, and hospital administration is to blame for the high cost of care, not the physicians who don't control how much they are reimbursed for each office visit or procedure.

The hospital is reimbursed on a fee for service basis. Most (all?) countries use a fee for service model, but most countries also don't have for-profit payers that are incentivized to drive up the cost of care.

Maybe it doesn't cause permanent psychosis but people do become psychotic due to it and need to spend the night cooling off in the psych ED.

Yes they are indicated for that.

No one is being forced to live in a mental institution because they sent someone texts one time that expressed suicidal ideation... There aren't enough psych beds to take care of the patients with schizophrenia, bipolar disorder, and suicidal intent with a plan to spare any to suicidal ideation patients. The OP spent one night in a psych emergency room, was not forced to take any medication, and was released.

People who are suicidal with a plan are not generally thinking clearly and are happy that they received care once they've been treated. We take people who are acutely intoxicated or unconscious to the hospital all the time and have no qualms about that.

Regarding being "pumped with drugs", I can only speak from experience rotating for 6 weeks at two different psych hospitals, but the only people who I saw forced to take medication were acutely psychotic, manic, or incredibly agitated. The schizophrenics that are picked up and brought to psychiatric hospitals generally are so psychotic that they would not be able to care for themselves - risk of harm to themselves. Same thing with acutely manic bipolar patients.

I don't think torture is a remotely accurate description of psychiatric care. How do you think they treat people with suicidal ideation? Tie them down with chains, stuff a sock in their mouth, beat them with whips, and inject them with deliriants? Seriously dude... You get a room that looks like a normal hospital room. You have the choice to take antidepressants or not. You do group and individual therapy for a couple days. If you're actually being held on a 72 hour hold, your time will be up and you will be free to go. Otherwise you may realize that being in the hospital is beneficial and you choose to stay.

I respond to these comments because I don't want people to hesitate to call for help if someone they know reaches out in need because of what a bunch of software engineers on HN who've never seen the inside of a hospital have to say about psychiatric care.

I think the negative and totally inaccurate depiction of psychiatric care on TV and in movies is why people are surprised that antipsychotics actually really help most people who are prescribed them.

This is literal survivorship bias. I'm sure there are many people who are no longer alive because people did not take their texts seriously. I can easily imagine someone posting something just like this from the other side of the coin.