asdfj999's comments

At least in the US, in general we talk to the family about code status "Do you want your loved one to receive CPR if their heart stops?". We can make them DNR/DNI. Then next discussion would be hospice. They would have a hospital bed sent to their home, be discharged with a weekly nurse visit and doctor available by phone/text, and get minimal medications focused on minimizing suffering.

If I could change one thing about healthcare, it would be how we handle end of life care. Sadly, hospitals are full of 80-90+ year old people who cannot walk or talk for years, advanced dementia plus many other serious comorbidities, with severe malnutrition and recurrent aspiration pneumonia, with large non-healing sacral ulcers, who shit and piss themselves, and the family continues to insist we "do everything" to help this person. It is by far the most demoralizing part of working in healthcare, in my opinion, and an astronomical amount of expenditure and effort goes into torturing these people - at the direct order of the family - only to prolong suffering a few more months.

Statins are a lot like climate change. Two sides, the establishment versus outsiders, each claiming their side is correct, arguing over mountains of data that you can never personally verify.

However, there is zero financial incentive for a physician to prescribe a statin. They are all generic medications. A month prescription is approximately $10.

We do not yet have final word on this topic, we will have a better understanding as time progresses, but until then I continue to recommend statins to my patients with appropriate risk factors, for the same reasons I find climate change credible. The data showing benefit is not just limited to the United States, it is international, and to essentially falsify something involving millions of individuals and thousands of researchers around the world just isn't feasible.

Both can be true at the same time. Just some rough numbers.

There are approximately 30,000 American medical graduates each year. There are about 40,000 residency spots per incoming class each year. Both of these numbers continue to go up at least several hundred per year, it's just that always residency spots > American graduates. That answers the "not enough graduates" question.

Each year, that 10,000 resident surplus is filled with approximately 4,000 US citizens who went to international schools and 6,000 non-US citizens who went to international schools.

Now for hospitals being saturated with learners. There are at least 162,000 residents and fellows and 60,000 medical students (3rd and 4th year students) in total in the hospitals, not counting students in other disciplines such as nursing, physician assistant, etc. That means there are at least 222,000 residents/fellows/medical students in the hospitals. I am saying that to accommodate 222,000 learners getting enough exposure to all the nuances of medicine is extremely difficult and, as medical schools continue to grow, many schools are finding it hard to place students into environments with adequate opportunities to learn.

I'm a doctor. When I was in medical school, I literally had to call and send applications begging other physicians to take me as a student, otherwise the school threatens to dismiss you for not meeting graduation requirements. Many students don't have that problem, however many do and the number is increasing. It is just very hard to scale massively complex infrastructure while maintaining quality.

ACGME reducing supply hasn't been true for at least 10 years. Medical schools and residency positions are exploding and quality of training is decreasing. Medical schools are now finding it hard just to place their students into adequate clinical rotations because hospitals are saturated with learners. Despite that, we even have to bring in more than 5,000 international physicians every year just to fill the available residency positions because there literally aren't enough American graduates. Meanwhile, reimbursements keep getting cut and physician liability increases.

Another explanation is risk of litigation. Doctors and other health care professionals are so incredibly scared of getting sued - like it is literally something that crosses their mind with every single patient interaction - that if they do not escalate something, in their mind, they are opening themselves and their family up for litigation and financial ruination.

Imagine yourself in their shoes. A patient says "I have chest pain". After you leave the clinic, they have a mountain of documentation they need to complete. How can they justify that you weren't having a heart attack, aortic dissection, etc - it is safer in their mind to just refer to ER. Not saying that is the right thing, it is just the world we live in.