KLG, who as you may recall is a professor of medicine, sent this note from a long-standing colleague:
From my postdoctoral mentor, who was the first woman to get tenure in a Hopkins Basic Science Department:
There is some rather sad news from Hopkins. The Department of Biological Chemistry will be shut down on June 30th, as part of a consolidation (basic science extinction) plan. All the faculty (even emeriti) who have to have an appointment in the department were reassigned to other departments. I am now in Cell Biology. Biophysics in the medical school was merged with Biophysics at Homewood (main undergraduate campus). Physiology and Pharmacology were combined. I’m not sure whether the faculty kept their lab space in the department or whether that has been “rearranged.” Past graduates of Biological Chemistry should still list the Department of Biological Chemistry as their affiliation. I know, it’s the pits.
The Department of Biological Chemistry in the Johns Hopkins University School of Medicine was established as the Department of Physiological Chemistry in 1908. We had our 100th anniversary in 2008 with an international 3-day event. And when I say “we” I mean it. This is not a trivial thing. It will have repercussions the bean counters and other cowards will never feel. Just another brick falling out of the wall.
IM Doc’s reply put this development in the context of the ongoing devolution in medical education:
They have finally joined the crowd. This has been going on for the past 5 years at both of my alma mater. The anatomy and biochemistry dept were closed in med school in 2022 – and both closed at residency program or at least severely curtailed in 2023. Medicine is basically dead. The kids will never learn how to take care of patients.
https://www.nejm.org/doi/full/10.1056/NEJMp2414384
This is from this week NEJM. It describes what you mentioned. It seems to me this whole movement to minimize basic education started about 15 years ago – where else but Harvard Medical School.
No longer we’re students doing gross anatomy, biochem, pathophys etc.
Rather, they did rotations where all the various components of an organ system were done at once. So the courses suddenly became known as THE HEART, THE LUNGS, etc. The anatomy, phys, Pharma, etc for each organ system were all done at once during these rotations.
Very stupid idea. It is very difficult to discuss universal things like chemo and inflammation among many others in this type of system. I mark the decline in curiosity, knowledge base, etc to the past 10-15 years when this became widespread and whole departments were canned or subsumed.
With this, the EMR, and UpToDate, a kid in medical school could not even have a chance to be what clinicians of yesteryear were. And we can all tell. I have conversations with them every day. The knowledge base is profoundly limited. The foundation is cluelessness. We old guys just sit in the lounge every day and shake our heads.
I hate to be this negative, but it is indeed really that bad. The NEJM and others have realized the impending disaster largely caused by shit like this they have been pushing. Their screaming about it now is hilarious and tragic but far too late. The die has been cast.
US-based readers take warning.
I am lucky enough that the US doctors I still see when I visit are over 40 but not over 60, and in independent practices. That means they are old-school well-trained and probably have at least 5 and maybe 20 years more of professional life (they have also set up their practices so as to reduce interaction with insurers, so they are less likely to retire early due torture by corporate or insurance bureaucrats).
I infer very few Americans are in that boat. And in addition to lower medical competence among recent MD is the problem of nearly all doctors being in some sort of corporatized medical practice, and those are increasingly shoving diagnostics on to wildly low-skill nurse practitioners. This ought to be a crime. Why it isn’t is beyond me.
We do not give medical or financial advice, Nevertheless, I strong suggest, if you have the energy to travel, to start exploring medical tourism options. There are many procedures for which the cash pay price overseas plus travel is cheaper than a US copay. This is also true for extensive dentistry. And you don’t have the risk of surprise charges, which are stressful even when you prevail in beating them back. Better to have pre-identfified some alternatives in case you have an urgent but not emergency need for intervention, than necessarily go the inertial route of US care.
My inner Cynic has been warning me for a long time that The Jackpot is not just a fictional plot device. I have been “reading between the lines” that one of the major ‘drivers’ of world overpopulation has been the emergence of efficient public health programs. The basic tool of achieving that outcome has been a large and well trained medical cohort. Playing Devil’s Advocate, one can argue that the best way to “rebalance” the world’s population would be to stop and then reverse the advances in public health world wide. To achieve that, one would simply degrade the public health apparat.
Equally cynical observers can comment that my scenario is well-nigh unto “clinical” paranoia. My counter argument will be that old chestnut: “Ideation ceases to be paranoia when one realizes that “they” really are out to kill you.” Whether this outcome is the result of greed, stupidity, systemic evil, or Social Darwinism run amuck, the end result is the same; World population is going to drop. Reading as far back as the Club of Rome papers on population (1972), such has been the ‘optimal’ outcome all along.
See: https://en.wikipedia.org/wiki/The_Limits_to_Growth
I would love to be proven wrong, but a lifetime of observing the American Empire from the inside has hardened my “intellectual” arteries.
Stay safe, wherever you are.
I have a question in regard to the counter-notion of “advanced” countries fully on board with messaging about increasing family “values”, and the push to increase birth rates among , pardon the term, “privileged white” portions of the population. Could it be that the powers that be wish to decrease the birth rate among the poor while increasing it among the (ahem) blessed? This would answer the closure of hospitals in rural, depressed areas. If so, not paranoia at all.
Global populations do need to decline. If the “white” nations think they can “engineer” declines in non-white populations while at the same time increasing the populations of white persons they are delusional. Poor medical care will not result in huge die offs of homo sapien. Nature is remarkably resilient. Babies will continue to be born, regardless of what the eugenicists have in mind. If all of the earth systems begin collapsing the color of one’s skin won’t make a whole lot of difference. At that point we are all in the same sinking boat.
The Jackpot scenario, akin to William Gibsons’ Universe?
You wish. That ultimately leads to some very advanced, sophisticated, mind blowing technologies. The trajectory presented to us, for our Jackpot seems to lead to Idiocracy (see the visit to the hospital scene):
https://www.youtube.com/watch?v=hcYbYhjdUb4
I’m sorry, but not surprised, to read of this. I have no direct evidence (my clinically trained friends all being aged 50+ like me) but have suspicions that this change in teaching methods has been creeping into UK medical training too. I think of it as having the square cake no longer being cut “vertically” with each strip being anatomy, biochem, etc, but “horizontally” with strips being the organs (as you point out).
The reason I suspect this has been going on in UK is the increasingly prevalent lack of ability among younger clinicians to think holistically and utilise out-of-the-box thinking. Their whole stock of knowledge is a bunch of “siloes” and this has been very much demonstrated when it came to COVID diagnoses. Only the senior partner at my General Practice “joined the dots” sufficiently with me to get me into the Long COVID service. As I noted in last few days, my opthalmologist (who I’ve known since teenage years) also knew all about COVID and its multi-organ modus operandi.
Sadly I don’t see any solutions to this as a patient, other than to shop around for clinicians who are in the age range you mention, and in UK, find out things like “if a practice’s Nurse Practitioner and their Practice Pharmacist have good records in terms of joining the dots between any multi-factorial issues you might have”. Which in many parts of UK is easier to do than the average US resident who, as you say, may have to look abroad to do this. It’s a sad state of affairs but thanks for the details in the post.
I think the rot started long ago. In 2009 I had a long conversation with an Indian student who was studying to be a pediatrician at Harvard. It was an unforgettable conversation. About room mates studying finance who were on psycho pills since their early teens but destined to become “masters of the Universe” in Wall Street. And most memorably that statistics were showing that kids were starting to walk later and later in the US and that it was concerning pediatricians all over the country. So I said surely Harvard was raising the alarm. No, he replies. They just hiked the average and then told pediatricians that all was ok. I was profoundly shocked. As an aside I might mention that Harvard had been an eye opener for this Indian who back in his homeland had idolized the US. Only the money is better he had summed it up.
Ultimately, medical school itself will be abolished in the U.S. because it will be considered too costly for universities and students. Indian and Chinese medical licenses will be valid in all U.S. states. Patients who don’t trust immigrant doctors will have the option of seeing an AI doctor.
I am sorry to advise you that you are behind the state of play.
I have many Chinese colleagues and friends. None of them would consider for five seconds going back to China for health care. Contrast that with colleagues and friends who hail from Taiwan. Many return to Taiwan for health care. China should be embarrassed at the state of their health care system. As should the United States.
We are now living through problems that in large part were borne of decisions in the 1980s.
In my medical school in the mid to late 1980s, the word came forth from the AAMC and other large governing agencies and bodies that the USA was making way too many doctors. A large part of the calculus at the time was the notion that we had just lived through the Baby Boom generation going through medical school, there were way too many of them, so when Gen X got to be the age to start medical school, the number of slots needed to be drastically cut – the Baby Boom generation of students had caused there to be a huge glut.
Apparently, in no one’s calculus at the time was a very simple fact. There was a huge surge of Baby Boomer docs – but more importantly – there was a huge surge of Baby Boomers period. And no one thought about the fact that the Baby Boomer generational surge was going to hit right about 2020 – and all of the Baby Boom docs would be retiring and it would be up to GEN x and younger to take care of them. It is among the most imbecile decisions ever made, but that is hard to judge, these agencies seem to always make the most imbecile of choices on pretty much everything.
So the year ahead of me was 180 students – my year was about 110 and it went down to about 90. There seems to be no realization that docs cannot just be beamed in from outer space – it actually takes 15 years or so to make them.
Now, add on all the disasters that have befallen medicine in the past 10 years. The absolute disaster of Obamacare and the great harm it is doing to patients/families everywhere, the pre-auth debacle, the lingering effects on the soul from the opioid crisis and COVID, the MBAization of medicine, the handover of the hospitals and care to non-accountable corporations, making doctors type their notes all day, the EMR, the ludicrous reimbursement rules, the onslaught of PA/NP, among many others – and it is now normal for the Gen X doctors to be retiring en masse at age 55. Further exacerbating the doctor shortage. In primary care, the concierge model, where the wealthy among us get Cadillac service for a fee every year has caused panels for internists to dwindle from 1800 to about 200-300. The other 1500 people, well, good luck.
There was a huge push about 10-15 years ago in the maw of the tsunami to make it much easier for foreign docs to come in. Two problems – they are truly foreign. They are not 2nd or 3rd generation immigrant family children who have become Americanized. Your average Pakistani or Filipino really has no concept of American culture, especially rural culture where they largely found themselves. This made it very difficult for many of them to get a patient panel and made it difficult for them to practice. Large numbers left or never launched. Here is the thing – I myself would never dream of moving to Armenia and opening up a medical practice. I have no idea of their culture, how they handle sickness, how they handle death. I would be a worthless cog. How our medical leaders ever thought this was a good idea is beyond me. Also, many of these people came here and realized the Catch-22, paperwork, overhead, administrative disaster that was American medicine and fled for that reason. So, this is an idea that has really failed.
So, Plan B has been now to extend full practice privileges to nurse practitioners and PAs. This has been a disaster in its own way for other reasons that I have discussed many times in the past. Not the least of which it has clearly demoralized a large chunk of the MD young people – who see NPs doing their job with 1/10 of the training time and tuition money and wondering “What the hell?”
So, the moral and physical burnout continues for those of us left. I do my job because I feel an obligation to my patients of years. I am from a generation in medicine that was taught that my convenience and my life are low priorities. It truly was a profession back then. No one signed up for it without knowing the extreme sacrifice in life that was to be made. Nowadays, the young ones want the big checks, but they also want personal time, no stress, and no long nights. Furthermore, recent reports are telling us that about half the graduates are looking for jobs with absolutely zero patient care. You heard that right. Also, their training as alluded above, was also made very easy. They become used to it. They become used to letting computers and algorithms think for them. There is no thinking outside the box. These issues are painfully obvious when you see how they care for their patients.
I have no answers. I work harder now than I ever had. I am drowning in paperwork every day. My goal every day is not to kill anyone. I take great satisfaction in the countless relationships I have with my patients. But this is no longer the same as it once was. It is unsustainable. There are optimistic moments – like yesterday – when RFK announced that the pre-auth regime was on the chopping block. The government leaders know the brick wall we are heading for. Rapid action is needed – and maybe just maybe someone is getting the message.
Time was when American medical care was used as a soft power. That you had the wealthy and the elites of the world flying into America to receive the best surgeries and treatments on offer. It brought a lot of good will and gratitude. Going forward? It may be used as a threat to captured terrorists. I can see it now-
‘Tell us what we want to know or we’ll fly you into the US for incarceration in an American hospital. One full of Harvard-trained doctors!’
‘You monsters!’
The only way that I can understand this is if there is the idea that doctors will be able to rely on an AI to fill in all the gaps on their knowledge because they never learned the basics. Yeah I know that this is a stupid, unworkable idea but the only alternative will be to suggest that doctors will just have to learn on the job – but who will in any case rely on an AI on their mobile to bail them out. And I can see that in action now as a surgeon prepares to crack open a patient-
Surgeon: ‘Hey, MediAI. How many chambers does a human heart have?’
MediAI: ‘The human heart has five chambers. There are two upper chambers called the right atrium and left atrium, two lower chambers called the right ventricle and left ventricle, and one at the bottom called the lower vestibule.’
American “soft power”? With elites from the world coming for treatment to main centers in the US?
I think that is worthless compared with what Cubans have done, and their armies of doctors roaming the por countries of the world. Which the US SANCTIONED!
I feel like vomiting.
So long ago for me now as a semi-retired Internist. But in Med School 1972-6, I was an Independent Study student. And one of my main study methods was exactly as described by IM Doc, by reading Monographs. Of course that was not all I did with studying back then, but I did test well as compared to my colleagues.
Not just doctors, Janet was a 45 year RN who was on track to keep going after retirement age ’cause that’s what she do. Forced out when Medicaid required vaxxination for its providers.
She’d been around long enough to see things, and see them repeated. There were always older nurses who outworked the younger, providing veteran guidance and role modelling. Things like, take care of your patient first.
That ethos had been eroding with the number of Bachelor level nursing degrees, which Janet tracked as desk jockeys looking at monitors, beeping alarms be dam’d. ‘As of 2022, 71.7% of the RN workforce earned a baccalaureate or higher degree as their highest level of nursing education.’ ‘…nearly 28% of employers require new hires to have a bachelor’s degree while 72% strongly prefer baccalaureate-prepared nurses.’
So the erosion is top-down. Less ability to see the person in front of them. And the only person we know going into nursing has a good heart but severe social anxiety. The kids are not alright.
Some of what is described is not new. I am a pathologist and was a junior faculty member of a medical school in the 70s. The school ended its pathology course and incorporated pathology into system blocs like cardiovascular, nephrology and so on. The result was that students did not learn fundamentals such as inflammation, neoplasia and mediating processes of disease like thrombosis and inflammation and correlation of gross and microscopic anatomy with physiology and disease. The school was forced to reintroduce a basic pathology course for the basics that were obscured in the system blocs.
Historically the autopsy by correlating the pathology with the clinic shaped medicine. For many reasons the autopsy has declined. Even residents in pathology have difficulty in doing them to yield useful information. My 70s department chairman instituted a summer program for a few second-year medical students. As part of their experience, they participated in autopsies with the traditional focus of correlating the pathologic and clinical features and reading about what they found. They learned a method of thinking and approaching issues and how to put it all together. Average students became top students and secured prestigious residencies.
Each generation likes to fault the ones that follow. My complaint teaching today’s medical graduates is that too many lack curiosity. Tell me what I need to know to perform the task and do not bother me by expecting me to try and understand the underlying basics.
>>>> This is also true for extensive dentistry.
My aunt went to Korea (of all places) for implants because the total cost including travel was less than the US cost.
the charming irony is that most non-US doctors don’t realize the gold mine that they are sitting on. (that’ll change when the business trades sniff of the tend—and Costco starts pitching medical tourism in its monthly magazine) Standard catch-22 for medical tourism applies (IMO), the really good places don’t need to advertise; Be wary of any hard sell. depending on your health situation, you may really want travel health (evacuation) insurance. but it is a potential win-win for everyone involved.
if possible, try to find someone who is familiar or a native speaker of the country you’re interested in
I’ve found that it’s easier, emotionally if not always physically, just not to seek medical care. Many doctors with whom I’ve had to interact were distant and arrogant, despite not seeming to have the grasp the nurses who provided most of the care did. When it becomes undeniably necessary to see the white coats, the trick is to have extremely low expectations.
I was on Medicaid for years, and now am in the goldilocks zone, meaning that I can’t afford insurance in the marketplace, but make too much for Medicaid, so the problem appeared to have solved itself for me. Then I was hit by a car, fracturing my hip, which has deteriorated and needs to be replaced. Anyone want to sponsor a trip to Cuba?
Going into debt for something which doesn’t work, and which you didn’t need, and which the seller knows little about is profoundly American. This is a predictable outcome of treating both education and health as commodities.
Hmm!
cubamedicaltourism.org/orthopedic-program/
@ The Rev Kev wrote: “MediAI: ‘The human heart has five chambers. There are two upper chambers called the right atrium and left atrium, two lower chambers called the right ventricle and left ventricle, and one at the bottom called the lower vestibule.’”
My experience with AI would then be to say, “There is something illogical in what you just wrote. Please analyse with that presumption and resubmit your answer.”
It will then politely tell me that I am correct, and tell me why I was right and come up with the correct answer. …or at least closer to correct. At some point I have to become expert enough to know where to look for refined errors. But, of course, years of using Google and Wikipedia have trained me to do that.
What KLG and IM-Doc and others describe is dispiriting, but after reading the article I am still befuddled: why exactly were the curriculums in the medical schools reorganized in the way described above? What is the logic behind the merger of those various departments?
There must be public technical reasons justifying those moves, and then there must be hidden, not publicly admissible grounds that really explain why those directions have been taken.
death by 100 cuts: money, intra-institutional power, administrators who have to justify their position by “pushing new thing”, and I’m not going to touch certain political correctness aspects with a 100-meter pole
Vao, let us count a few of the ways:
NB, I am not a clinician but I’ve worked in medical schools since 1995, initially with graduate students and the past 17 years with mostly medical students. Medical school is stressful for the student (and faculty members who see beyond the students to their future patients). But stress is a big no-no. I actually heard the term “participation points” (everyone gets a trophy) in a meeting recently. But I also heard from a clinical faculty member last week that what our students do not understand is the work day ends when the final patient leaves, and not before. He has been practicing Family Medicine for more than 30 years.
Now, it is true that in my past more than a few old timers embodied “curmudgeon” with a vengeance, but they also taught us how to think and gave no quarter for sloppiness. Today? No one acts the complete asshole and gets away with it, which is an improvement. However, making a student, intern, or resident feel “uncomfortable” is the cardinal sin (yes, I am a sinner). I could go on, but you get the idea. The older generation’s complaints about the young goes back to Socrates at least. But there has been a qualitative change, that was lately exacerbated by the pandemic.
Regarding abolishing and consolidating academic departments, the precipitating event undoubtedly has been the outright attack on basic science by the current administration (and yes, I know some scientists are willing to take advantage of the circumstances, but the solution is not to destroy what has been built over the past 80 years and allowed the US to become the world’s leader in science across the board). But contingency plans were probably in place, ready to be implemented under any convenient pretext.
The problem with this is that the biomedical sciences and medicine are a congeries of disciplines. They cannot be studied, learned, advanced, and applied in isolation and they cannot be dispensed with, either, in some half-baked notion of “holism.” Biomedical science and medicine are much greater than the sum of their parts, but without a thorough understanding of the parts…Here is my favorite quote, from Sir William Osler (oh-slur), 1849-1919, who is responsible for modernizing medical education, at Johns Hopkins:
“You cannot become a competent surgeon with out a full knowledge of human anatomy and physiology, and the physician without physiology and biochemistry flounders along in aimless fashion, never able to gain any accurate conception of disease (or health), practicing a sort of popgun pharmacy, hitting the malady and again the patient…usually not knowing which…To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”
Now? Those books mentioned by Osler have been replaced by digital flash cards and videos that “make the study of medicine a breeze” according to one vendor of such magic fairy dust. Breeze. That is the word used. More like a cyclone, as it should be.
Take biochemistry, for example. For more than 30 years at Johns Hopkins this was taught to first-year medical students by a brilliant biochemist, a long time member of the National Academy of Sciences. He would arrive at 5:00 am to prepare the chalk boards (in layers that moved up and down, in various vibrant colors) to cover the major topics of the day. I attended some of these and sat in the back row of the auditorium. One time around carbohydrate metabolism with him and even the most obtuse student understood the underlying derangement of signaling and metabolism that causes diabetes. This foundation was then used to dig deeper in small tutorial groups and in the clinic. Now, something called “active learning” is all the rage. I’ll start listening to those people when they can explain to me the meaning of “inactive learning.”
Without the foundation, the edifice settles, tilts, and eventually falls apart.
The problems started when the early education had to become fun!
I never thought studying to be easy nor fun. My grade 12 biology manual was all covered by bite marks, because it was frustrating. I needed to know that book almost by rote, word for word if I were to pass the admission exam in University. I wish I kept that book.
I don’t mean though that studying shouldn’t be engaging…
I think the Eureka moments are orgasms for the brain.
“Regarding abolishing and consolidating academic departments, the precipitating event undoubtedly has been the outright attack on basic science by the current administration ” I take issue with this statement. If you noticed the rest of the commentators have said it has been going on for years since 1980’s that is good 45 Years ago. Guess who was the President those years? What did that president give US. Do you recall Mike Mullican? Greed is good was the Mantra and has been glorified by the press/clergy etc by buying out corporations and chopping them into pieces (Remember Parts are worth more than Whole). When you have bunch of intellectuals who have no sense of patriotism nor social responsibility what do you expect the students to do? Thanks
This is purely a guess based on my interactions with increasingly MBA taught university administrators during my time in medicine adjacent academia. These people didn’t understand the necessity of looking at an entire endocrine system (or whatever other system a proper doctor could name). Plus when you DO structure departments like that, in the modern world it increasingly highlights the interconnectedness of things, causing hassle to them.
So, in their simplistic minds, why not just separate by organ: all the heart stuff together. Makes sense right? The unspoken bonus is that “difficult patients” like anyone with (say) Lupus or Long COVID is less likely to be a financial burden on state systems like Medicare/Medicaid – ” go die”.
Totally clinically stupid but it’s how certain people silo stuff. And I’m guessing based on the first decade of the millennium which encompassed my first post-doc position when the UK MRC never knew what to do with this bunch of heterogeneous “health service researchers”. So they simply shut us down in 2009 and I moved down under. The reasons (stated and/or real) for this sort of thing that you rightly question will be best answered by KLG or IM Doc.
Years ago I read that in Asian countries, i.e. Hong Kong, medical insurance was done based on organs and family history of disease… I am not well travelled at all and I could be called a hermit now, and I have not verified that information; other people have a different approach to things – not saying better.
From what I gather from reading this and listening to my younger brother who is a 35 year old young doctor, the corporatized medical establishment just want automatons for doctoring. He complains all the time that it’s impossible to stray from guidelines without a mountain of supporting evidence even if there is reason to believe a new approach being tried elsewhere appears to be successful – it’s a no go until someone funds a massive double-blind trial – even when the risks of a negative outcome of trying are even basically zero.
From my own personal experience, this isn’t the first or only educational program that’s been stripped of important program structures in the name of supporting some elite ideolog/ideology. When I did my undergraduate work in Economics in the early 1990’s I was required to take 2 semesters of business school level Accounting. Even back then lots of colleges and university economics programs were dumbing down the accounting requirements, but I was lucky that I was at a state school that had still been sheltered from outside forces to change that. But sadly, even my undergraduate alma mater has finally changed its requirements so that only one very basic (non-business school) accounting course is required. This serves the neoliberal, Micro-foundations and Chicago School ideologs; but it makes for a very dumb economics grad. The world already had too many economists that didn’t understand the difference between stocks and flows or money and banking… now they just come off the assembly line with zero chance of knowing any better.
Last month I had a minor health emergency necessitating an overnight ER stay at a prestigious teaching hospital in a major city.
I hadn’t been to that that hospital’s ER since the 1990s, but I remember being treated by actual physicians (i.e., medical school grads). That wasn’t the case last month, though, as I spoke only to physicians’ assistants and various types of nurse practioners. Those clinicians relayed my statements to the physician, who responded by telling the PA’s and NP’s what to tell me.
The whole situation seemed almost like a telephone/Chinese whispers game. Big difference compared to my 1990’s experience in that exact same ER, and not in a good way.
I can relate to that. April 2023 my right arm was savaged by feral cat. Ended up in ED. Given oral antibiotics (twas a Friday) and told to come back if the extensive blood seepage into muscles/bruising expanded. It did. So Monday was back in ED. Admitted for 24 hour IV antibiotics (to prevent sepsis).
Never saw the consultant who was in charge. HOWEVER, I do owe him a debt of gratitude since he was absolutely certain I had no bleeding disorder/clotting issue etc (which all the juniors were convinced of, making tedious jokes about what kind of cat attacked me, a tiger….yeah yeah yeah). He KNEW the problem was the VEINS, not the blood. Ultimately he was outvoted 2-1 to discharge me after 24 hours – I wanted out because hospitals are plague pits and a senior nurse (practitioner) was on the ball and arranged the “face off between the 3 consultants to decide if I could be “released”).
Ironically I think the orthopaedic trauma consultant was right all along and they’re only now looking at veins as part of Long COVID, given how many ruptures I have had (along with sister and Dad). But I was only ever seen by the monkeys, not the organ grinder.
“But I was only ever seen by the monkeys, not the organ grinder.”
Kudos for a “Goon Show” level pun!
“Dr. Seegoon will see you now.”
I am a dinosaur. Before I retired I touched my patients, talked with them, not to them. I could predict many of the confirming, not diagnosing, studies I ordered. I ordered less. The techs appreciated my non-shotgun orders,. They preferentially performed my requests, often asking how I knew the results before they were done. I examine my patients I would explain. I called it eight ball corner pocket! I cleared necks before the X-ray machine arrived. I stood and walked accident patients when they were safe to do so. In Alaska a senator was in an airplane accident. I had him walking around before his private doctor arrived, who immediately put him back on the gurney, applied a neck brace and irradiated his body, finding nothing.
I learned to reduce shoulder dislocations from local Esquimos who treat this not so uncommon event on ice flows. Relatively painless and easy to do without meds.
I’ve corrected pulmonary diagnosis in deteriorating ICU patients by listening to the lungs, not the past history. Applauded by the nurses it angered the primary.
A chest pain patient was turned over to me at ER shift change. “I’ve done all the tests, just check them will you?” I was asked. When I took the history of the chest pain the patient told me his kid kicked a socker ball and it hit him “right here.”
Where did the art go? It’s all science now.
This post combined with one of today’s links — Groves of Academe: “Republican plans to cap student borrowing could shatter an everyday profession”, together make a searing indictment of medicine in the u.s.
The supply of medical doctors has been deliberately constrained to create shortages. As the costs for med-school have risen the quality of medical education has degraded. This post makes clear the new physicians that made it through the multiple gauntlets of washout to enter medicine start their careers heavily indebted and subject to working as medi-serfs to private equity and corporate, subjugation and constraint by finance. I am not sure what role the AMA has played in the degradation and subjugation of medicine. [I am inclined to think that the AMA has willingly sold out the medical profession.]
Patients face uncontrolled increases in the costs in money and in time for obtaining medical care. The quality of care plummets at a rate matching the cost ascent. As state medical boards raise fees the doctors see more and more of the increases absorbed into profits to feed finance. Nurse practitioners could take up some of the slack for general practice physicians but their education and skills are as limited as their autonomy. All is destroyed by the ever escalating quest for profits to feed the gaping maw of private equity and corporate hunger.
Something must be done soon … but all I can see on the horizon is the continuing destruction and collapse of medicine in america.
What I’m seeing here in northern New Hampshire is the best practitioners being forcibly retired because they won’t play ball with the corporate management. What this suggests to me is that medical care is becoming simply a billable business where the actual quality of care no longer matters, therefore the competence of practice no longer matters. The outcome is not health; the outcome is corporate profit. Doctors are merely labor.
This is essentially the situation we see at Boeing, particularly in South Carolina, where they have a workforce that does not know much about building airplanes, and therefore doesn’t refuse to comply with stupid management decisions.
Thanks very much for this post.
Comments referring to a marked decline beginning 10-15 years ago in the quality of med school graduates’ knowledge and curiosity made me wonder about the following.
On the theory that grade school education primes students to learn and think and not just ‘repeat’, or should do, what changed in US grade school and high school education in the last 20+ years.?
The No Child Left Behind Act was passed by Congress in 2002. It was supposed to improve education by focusing on improving students’ scores on standardized tests. In practice this became known as Teaching to the Test. https://en.wikipedia.org/wiki/Teaching_to_the_test Recesses were cancelled in favor of rote memorization drills and other absurdities.
This had such a bad effect on students’ education and mental health particularly in the grade school aged students, ( there’s a reason everyone needed a participation trophy), that the Act was stripped of all national importance in 2015, basically all but repealed.
I bring up this background in US public education from 2003-2015 as a possible factor in med school students seeming very different from previous classes for the past 10-15 years. The young men and women entering med school 10 years ago would have spent their entire k-12 education in the Teach to the Test mania.
This doesn’t discount various business factors, finances, and possible corruption. It’s another possible factor in the mix, imo.
I’m a recent medical school graduate and soon-to-be IM Doc, as well as formerly an engineer. What I’ve observed is that curiosity, motivation, creativity are not things that are inherent to any particular training program, but that they much more depend on the makeup of the individual.
In engineering, it is somewhat clear to me the distinction between these two groups of people – one might, say, go on to work in a factory doing perhaps not entirely rote, but not significantly rigorous or creatively demanding work; the other might go on to work in a startup developing new technology, or into academia to explore new realms of engineering science, the various criticisms made here and elsewhere about the nature of modern academia aside.
In medicine, this is not so clear – most who graduate from medical school will go on to practice as physicians. A couple things stand out – first, qualifying to be considered for medical school admission selects for a specific type of person, one who can succeed on standardized tests (of information retrieval) such as the MCAT and undergraduate exams, which are often used as time-saving devices to sort students by this dimension of academic achievement. Beyond that, admission to medical school depends on having done some sort of extracurricular activity and being able to convince interviewers that you are not a psychopath. Whether or not curricular design is good or bad seems to me to be much further downstream than this fundamental issue of what we now look for in a medical school candidate.
Another confounding factor may be that in a time where living standards are declining for those of lower incomes, securing a high paying career feels much more of a necessity, and that people are driven towards medicine more for this reason than for “the love of the game.” If people more driven by the security of money could be assured of a dignified life doing something they might like more, would they still choose such a demanding course of study and career?
«standardized tests … which are often used as time-saving devices to sort students by this dimension of academic achievement», a problem I trace back to Darwinism.
As a conscientious objector to the Vietnam War, I performed my alternate service teaching English in a disadvantaged junior high school in Somerville, Mass. I achieved fifteen minutes of fame by bringing disgruntled parents and teachers into a meeting with Bill Saltonstall, who was then chairing a Governor’s commission on educational quality. In the end, I was fired (for teaching poetry to ninth-graders using Simon and Garfunkel songs), but so was the principal and (nearly) the entire School Board. My students had been sentenced to “death at an early age” by standardized tests they took at the age of 12, “as a time-saving device to sort students”.
Bill Saltonstall was not the hero of this story; there have only been losers. Saltonstall apparently served out his years as a Trustee of the Educational Testing Service (at the time the premier US standardized testing service).
Lately I have been reading opinion pieces in which nihilism is pointed at as being a main source of today’s problems; of course nihilism is an end point of other factors. And from nihilism as a modus vivendi comes only destruction. Hopefully not via nuclear weapons, because that is fouling our own bed…
The recent scenes from Paris of the famous Festival de Musique are harrowing.
The average physician knows about 20-30% of what they need to know to be effective at their job. Maybe 50% if they are a sub-specialist. At least AI may eventually provide broader diagnoses (which will still be ignored by the physicians not familiar with them).
On a broader scale, having maximization of “profits” be the highest value for a culture will inevitably lead to disaster. As is already obvious by the corporatization & enshittification of everything. As well as the alienation & despair of such a large portion of people.
Thanks for this article. Reading about the diminishment of the American medical system on NC over the past few months, especially LLM/AI related issues, has been saddening.
I can confirm that, at least as of 2015, Peru is a good place for dental-tourism. A friend found a dentist with great English, top end gear, professionalism, and everything went great. And the procedure cost way less than in the US
Health care in the US is so expensive that it threatens national solvency. Rather can completely upend the system (which is, practically speaking, impossible) in order to reign in costs and provide better health care and outcomes the powers that be have determined that the best course of action that is the quickest to implement is staffing reductions and staffing downgrades. So we see fewer physicians and more nurse practitioners, fewer RNs and more nursing assistants, and of course lower levels of care as in fewer treatment options, more watching and waiting, as well as rationing. Are there better solutions to spiraling costs?