What You Don’t Know

My trip to the DMV was fruitful.  Perhaps I should mingle with people who live outside my head more often.

The most fruitful part of it, arguably, took place while we were standing in line outside. Robert was studying for his MCATS which he takes later this month.  Now, if you’re a creature built like the proverbial brick sh*thouse and about six one, reading about muscle groups in line, the people behind you – a very nice family with a young man probably 18 – are going to ask questions.

Robert told them he hoped to be an MD, and then proceeded to explain the process.  For those who don’t know it: he’s in pre-med.  He’ll have to try for admission to Medschool.  Right now, if you don’t have perfect grades and near-perfect MCATS you might as well not try.  If you have that you should be aware your chances are less than one in ten.

How do they pick once they have all these people with perfect grades?  Well, mostly by people they “like” so a certain amount of political correctness is involved (and hopefully I haven’t shot the boy’s chances, and G-d do I self censor.  You have NO idea.)

Why do they pick, you ask?  If the school record AND test are perfect, why not admit them all?

Because our medical student numbers are capped by Federal decision (I’m putting decision because I don’t know what drives it: law or exec order.)  They were cut in half under Clinton, and then again recently.

THEN, supposing you get into medschool, you have 50% chance of becoming an intern, without which you can’t practice medicine.  You have a medical degree, but you aren’t really an MD.  Not licensed.  This too is centrally planned.

But – the family behind us, who looked fairly smart – said “Why not have ALL the doctors?  Wouldn’t that make their services more abundant and therefore cheaper?”  And we said “you got us.”  We didn’t say “they want to keep the rewards high, so more people will study medicine” which I THINK is the idea, which makes it a bizarre piece of absurd central planning.

And it occurred to me that the point of this was FAR bigger than healthcare.

Look, the problem is that our society is complicated.  REALLY REALLY REALLY complicated.  Which allows pockets of utter irrationality to subsist because only the people suffering through them or under them know how absurd they are.  And they often cna’t speak on pain of not having a job any more.

Take publishing.  How long would it have subsisted had people known that the publishers controlled how many copies a book printed and what the distribution was?  And the distributors then entered these numbers in the system, and after that it ruled the writer’s life?  So that if your editor/publisher slated you for failure no one would even know your book EXISTED, no matter how good?

Well, people in general have great awe for “new york times bestseller” but would they still if they knew 99% of those are determined by the LAYDOWN?  (That is how much money the publisher was willing to spend to print a massive number up front?)  That it had nothing to do with how many books were bought?  That in fact, point of sale data only covers a third of the sales and no one really knows how many books anyone sells?  That being in good with your publisher was the fastest route to bestsellerdom?  That in Great Britain not so long ago they found a “bestseller” had sold exactly two copies, and that our system allows for the same absurdity?  That Terry Pratchett – a mega bestseller in Great Britain (and a real one.  They can’t keep his books on the shelf) was selling low mid list here until he changed – not his writing style, nor his subject but – his publisher and agent?

Most of what drove people to buy what was pushed at them was the assumption that this MUST be the best of the best.  If they’d known how sausage was made, given how bad or at least how bland the sausage had got towards the end (I was reading a book on Romania where before they kicked out their dictator, their sausage was mostly saw dust.  Like that.) and before indie upended things, do you think people would have bought even as many of the books as they did?  I don’t think so.

The same thing as if most people knew of the absurdity that is our doctor training process, and how much of it is dependent on being a good boy and playing along not just with the learning but with the superiors political prejudices and knee jerk reactions they’d go “But that’s ridiculous.  We need doctors capable of independent thought.  Also, wouldn’t have more doctors make it cheaper?”

These absurd practices exist in other places, I’m sure.  Places where I don’t know things as well and can’t speak with as much knowledge.  I CAN tell you that throughout the nineties the response to “IT company is in trouble” was ALWAYS “Fire the entire research and development team.  Hire more managers.”  I still wonder where that piece of nonsense came from.  Maybe a lot of ex-government employees teach MBA courses?

I can also tell you when I came to the US with a newly minted teaching degree from one of the oldest colleges in Europe (not Bob’s school of teaching) I wasn’t ALLOWED to take the teaching certification exam.  No one argued, mind, that my college didn’t have a good enough preparation.  Certainly no one would put it to the test by letting me TAKE the test.  They just didn’t give my college a number so I couldn’t take the computer-scored certification test.  Which meant I foamed at the mouth when someone talked of certification as a guarantee of quality.  Or for that matter when they talked about raising teacher’s salaries to attract professionals from other fields.  What good is THAT if the professional has to be willing to go back to college, just to be ALLOWED to take the test?

Why do all these counterintuitive, not to say daft “processes” continue?  Well, because the people affected CAN’T speak, and no one else knows.  Indie has unmuzzled writers, thank heavens.  Med students?  I don’t know.  Teachers?  I’ve said before, I’ll say again, that’s the next field innovation will hit hard.
Our society is really, really, really complex.  Strangely, this allows pockets of utter irrationality to exist – irrationality that affects both providers and consumers and which in the long run affects society.

What you don’t know CAN kill you – and bore you.  And make you ignorant.

A free society is ALWAYS a function of informed citizens.

Think.  Read.  Inform yourself.  And TALK.  We have the internet.  Use it.  Your first amendment is the best guarantee against needing to use the second.

NOTE: I’m continuing my interrupted timing workshop today at MGC — post will be up in a couple of minutes.

153 responses to “What You Don’t Know

  1. Med students are CAPPED? WHAT? I thought that it was just in the “you have to have perfect scores.” (I was briefly in pre-med, but for pre-veterinary. I still have a “hobby” of medical knowledge/searching…)

    I mean, okay, med school is expensive and doctors “need” to be able to command prices high enough to pay for that, and it’s easier to create artificial scarcity than to smack the universities to charge less, but STILL. WHAT THE I DON’T EVEN!

    No wonder Nurse Practitioners exist, I guess? It’s kind of an end-run around the whole artificial scarcity of doctors thing?

    • They’re capped. I know the student last year whom my son thought was the best candidate — brilliant, perfect grades, has STARTED A MEDICAL TRANSCRIPTION BUSINESS WHICH HE RUNS ON THE SIDE WHILE IN SCHOOL, volunteers an unreal amount, still has best grades, and manages all this while being a type one diabetic — didn’t get in. Which has poor Robert terrified. And the reason I said that “it’s an insane piece of central planning” is that part of the intention of health care “reform” is to cap DOCTORS’ earnings at about the level of teachers. Which won’t allow them to pay back those loans EVER.
      Think about that loop a second. People need to inform themselves. Seriously.
      Look, even if every potential doctor got in, we wouldn’t have an excess. It just means it would get cheaper. Which would attract fewer people. It would self-correct. But no…

      • AGUAGFRAGFFBRBBBRLGAAHHHHHHHHHHH!

      • You can’t have that kind of choice in medicine! Why, the next thing you know, people won’t have a governmental stamp of approval, and then how will we know who’s the best? You can’t let people take their money elsewhere and have market forces decide because anarchy will ensue!

        Next you’ll be telling me that Kelo v. New London was wrong. Sheesh…

      • The Daughter, who has had forensic pathology as her goal in life since she was twelve, in one of her more growly moments suggested that what is being proposed is simply a form of enslavement or an open ended indentured servitude. The government has been talking about an exchange for their student loans where future doctors agree to assignment to positions where the government deems, while setting their compensations. She envisioned that it would be the company store all over again…however much you worked you always end up behind. She was wondering where she could seek sanctuary…

  2. Amen Sister Sarah and Sister Beth!!!

  3. Well I’m of two minds on this. When I went to college many years ago, I started as an engineering student. I switched to a different major sophomore year because of the number of classes graded on a curve where a majority of the class would fail – the program was designed to weed out, eventually, 90% of the engineering majors, and it succeeded at that. And while there is some degree of protecting the salaries and such of the people currently in the profession, there was something else. Bad engineers kill people. The same thing would go for med school. So I really don’t mind that those professions be so difficult to get into.

    However, teachers, lawyers? Personally I don’t think either should require a degree – just pass the certification exams and you’re done. A bad lawyer just won’t be able to keep working outside of government.

    • yes, but no. These classes ARE like the ones you went through. Robert was one of two people out of HUNDREDS that had an A in ochem which IS designed to weed out people. Almost every one of their classes are like that. BUT then they weed out from perfect. This is not for safety, Skip, sorry. It’s for power and picking “the right sort of people.”

    • There’s a difference between making the requirements difficult so that only the best move on, and capping the numbers eligible from those who DO make the grade.

    • K. P. Caudell

      REALLY??!!!!! So just let ANY sort of person can teach kids just so long as they passed a standardized certification exam? REALLY? So any child abuser that can pass a certification exam can get access to a child? WOW!

      Or how about the current excessive proliferation of ambulance chaser commercials that are a glut in just about any media outlet today? Wouldn’t these get even more numerous under more lax requirements?

      Personally, I’d rather have someone who majored in say education mathematics teach me our my kids math or the same for English, Science… whatever. Or, heaven forbid, need a real lawyer because someone has hired an ambulance chaser because they were successful in pulling off a “swoop and dive” maneuver on my wife or kid.

      • For the love of BOB — of course they check backgrounds. BUT having gone to an “approved school” doesn’t guarantee they AREN’T abusers. Abuse is rampant in our public school system, ANYWAY. As for people taught in EDUCATION MATHEMATICS… You’re dreaming. They’re taught in education and the school assigns them whatever. “So long as you know how to teach.” I could tell you stories. EVERYONE HERE COULD.

        • I agree with Sarah whole-heartedly. At least someone with a mathematics degree (and not a major in education) would actually know the subject matter. I used to help tutor kids (at least a decade ago) and what they were taught was so screwed up… the teacher wanted the process and didn’t care of the product was correct.

        • Would you believe there’s a school of thought in business that as long as you know how to manage, you don’t need to know anything about the actual business you’re managing? (And yes, it works about as well as it does for teachers.)

      • And even if you have a PhD in a subject, you are not allowed to teach in a public school UNLESS you also have an education degree and pass the state exams (for states that have such). Or you go back and get an ed degree and take the exams . . . A relative of mine was punished by their university’s ed department for getting a subject degree along with a BA in education.

      • K.P. Caudell – I just read this TODAY. I could find something like this every day and post it, if I took the time and energy away from my writing to do it. You do know, don’t you, that in the United States, education majors have the lowest SAT scores, some of the easiest grading, and the least rigorous classes, of any “profession”. We still end up with some good teachers, and even a few EXCELLENT ones, but it’s luck, not skill. Most “teaching” programs in the United States are progressive indoctrination programs, not education. http://blogs.scientificamerican.com/budding-scientist/2012/07/13/math-teachers-feel-theyre-poorly-prepared/

        I’ve known a few excellent lawyers, both professionally and personally. I’ve also run into quite a few that I’d rather have taken out and shot. There is a large percentage of people getting law degrees so they can run for public office, not because they plan to practice law (I’ve talked to a few, they and I both know of more).

        The American Bar Association used to police their membership. Today, they’re just another lobbying group with about as much moral fiber as a garden slug. The American Medical Association isn’t much better. The National Education Associating, the prime teachers’ union, is there to fleece the general public, not to police their membership. ALL of them are far more interested in protecting their personal little racket than they are in actually allowing their members to do their job, and holding them accountable for success or failure.

        • It has been asserted by people who should know (former teachers; look into J. T. Gatto, twice NY city & state Teacher of the Year) that the schools of education are designed to drive out anybody capable of actual thought. Boring, demeaning, repetitive classwork tends to ensure a consistent, uniform product.

      • It might interest you to know that I cannot be anything more than a substitute teacher in any school system in the country, despite having 4 science degrees and 20+ years of experience applying it. Why? None of those degrees is in EDUCATION. However, as a tutor I did quite well in helping students (whether in AP classes or falling behind the curve) learn what the teachers in the classroom could NOT teach.

        • And therein lies the problem. Education principles could be taught in a 16-week course. A person who is going to teach a subject should have a degree in the subject matter they are going to teach, THEN go get the teaching cert. Many school systems require a MASTER’S degree in order to be hired, but that’s not really necessary to teach any except the most advanced of Advanced Placement classes up to and through High School.

          • Wayne, it doesn’t take that long. The Air Force runs (or did, things may have changed) a CORRESPONDENCE COURSE to prepare NCOs to teach and/or mentor classroom work. I took it in 1969, and finished it in three weeks, working full-time with a family. I’ve taught in the Air Force and in Industry, and mentored or tutored more than a dozen students, especially in the areas of my expertise. Schools of “Education” are all about power and control, not about teaching.

      • I’ve been taught by those who were “taught to teach” in public school. I’ve been taught by those who know about the subject they’re teaching, having had at least ten years of actually working in the field or a related one, in the Navy.

        One can be replaced by a teacher’s edition of a book in the hands of someone who is decent at human interaction; one might have a lack of interpersonal skills but can answer questions that aren’t in the book, and stay on subject.

        When it came to getting a good grasp of the subject matter into a high percentage of young minds with maximum efficiency, even the best of my public school teachers were great babysitters.

        • Sigh. This used to frustrate me. You have to understand if I could have taught, I’d probably never have written but as a hobby. Yes, I LIKE it that much. And I’m that good at it. BUT I couldn’t endure the thought of going back for certification (which back then was multiple year even if you had a degree) and besides Dan and I couldn’t afford it when I was young enough I might have done it. And I’m good at my subject (several, actually) and I’m GOOD at teaching. It’s a gift. Maybe one in fifty people have it. And most of them aren’t teaching in schools these days.

          • When The Daughter was in the final year of grade school I started tutoring at risk kindergartners. The teacher I had been assigned to was skeptical as she knew The Daughter and felt I might not be able to deal with these very different children.

            I also continued to volunteer extensively in The Daughter’s class. (Admittedly this was, in part, to keep aware of what was going on and who was who. That year I felt it was important as the teacher she had that year was a great teacher, but not a good match temperamentally or philosophically for The Daughter.)

            By the end of the year I was being told by both of these teacher that I should teach. I was told that the local university had one of the ‘best’ teaching programs. Knowing the prevailing zeitgeist in teaching I shuddered to think about playing the game to get a certificate only to face navigating the system’s dictates. The advantage of volunteering is that I was generally allowed to do what you found worked for the child in question.

            • That’s how I know I CAN teach. I taught and tutored Gifted Emotionally whatever they call “Unstable” now. I also taught normal kids. Not only do I like it, the kids like it. (Only I do best with older kids — the teen years.)

              • My hubby is a teacher – but he is only good with adults. He used to teach electronics in the Army and then the Navy. I noticed the other day when he was explaining packet radio that a couple who act like teenagers (they are in their 60s) were giggling and not listening. Plus they assumed that we would fix their stuff so they could get on the air. Typical typical hippie types.

                He was NOT good with them. I guess it is hard for him to deal with the folks who don’t actually want to learn, but want you to fix it for them. I have been frustrated with this couple for a long time. Your insights have helped me to understand them. I still don’t find them acceptable though.

                • This gets to why I really enjoyed teaching academically gifted 10 year old boys, whatever their emotional issues. They were curious, had gained enough information to ask really great questions and they had not yet become jaded by their experience in the system. They were also surprisingly responsive to someone who actually listened to them.

                  (I have often felt that much of how we do school now, particularly middle school, is designed to convince children that learning is stoopid, and that you should only do what is necessary to get by.)

                  • Complete off topic, but I need to vent. When trying to name a new planet or continent or race, etc… IS EVERY DAMNED COOL-SOUNDING WORD I COME UP TODAY WITH ALREADY SOMEONE’S NAME, SONG TITLE, OR BUSINESS NAME???

                    For crying out loud…my muse must be online today, googling away and I’m just getting the bleed-through.

                    • I am not sure it is entirely off topic.

                      It is unfortunate that your imagination is so effected that what comes out is so closely effected by what is already out there. I think that naming must be one of the greatest challenges. The name needs to fit, to strike a cord in the readers mind. At the same time, if it is an non-human world it would be unlikely to share our mythos or manner of naming. Interesting to think about. Sets up good questions.

                      I do like your image of your muse playing on the Internet and googling, so you haven’t lost it entirely. ;-)

                    • Thanks CACS. The flip side of that same coin, admittedly, is that when you find one that not only strikes a “coolness” chord and is likewise greetings with “No results found for…” the relief is palpable and probably worth all the frustration.

                    • Three questions, Scott. Is the name given to the planet from aliens or humans? If it’s humans, what subset of the human race? Humans aren’t brilliant with their name choices. They tend to name places for their “home”. Just look at the New World place-names, for example (New Sweden, New Amsterdam, Nova Scotia, Newfoundland), or after people that have greatly influenced the new colony, such as Pennsylvania, Washington, Georgia, etc.). Finally, how badly can you mangle that and still have people KNOW what you’re talking about?

                      Remember, when you’re naming a planet using an alien tongue, ANYTHING GOES. Just don’t do anything that would be an inadvertent pun, or something someone else will think is dirty! 8^)

                    • Named by themselves, but they’re human and not of Earth origin. How’s that for turning it back around on you :) Oh, and I have to do that six times.

                      Honestly, I’ve made a LOT of headway with it. If I’m in a flow and something needing a name comes up, I’ve taken to going with a working name italicized or a (insert ship name here) sort of thing.

                      I try to avoid normal English sounds like “th” and such, as well as obvious human language-based prefixes and suffixes. Things that look Latin-ie or Oriental are outright right out. Usually, I can fumble around with a Thesaurus for a while and come up with something that doesn’t return a wealth of hits on google, but today, they’re just not singing.

                    • I have heard that ESSO spent a fortune to come up with EXXON because it turned out that in some language their former name was either ‘fightin’ words’, prime insult, or unspeakable in polite company filth … never can remember which.

                    • One of the things that always kills me is some alien race calling themselves, oh, Parthians from the planet Partha, for instance. We’re the only known example of an actual sophont species and we aren’t Humans from Humania. A made up word for “home” or “ground” or “world” works, but that’s the easy way out.

                    • ppaulshoward

                      Hey Scott, you mean you don’t believe in “Earthmen” from Earth or “Terrans” from Terra? [Wink]

                      Seriously, one of my alien species (from unwritten works) calls themselves by a cultural name and call their homeworld “Homeworld”.

                      Mind you, “Homeworld” only got called that after the aliens had spread over several star systems.

                      Before, it was called something like “the world”.

                    • The issue of a planet giving a name to it’s inhabitants seems more akin to our use of Asians, or Scots. It seems to presume a ‘one world’ society.

                      There is the precedent for one answer, many groups tend to refer to themselves at the equivalent of ‘the people’ and others as ‘the strangers’. (um, The Spouse has spoken of the set where there is ‘the people’, and others fall into such following catagories: those to trade with, those to fight, those to use for service …)

                    • I think that’s a good point. A planet’s name would grow organically out of a background like that and, eventually, the dominant culture would have the final say.

                      I think tinkering in “organic” equivalents gives a wholly contrived world layered authenticity, but it’s got to make sense with minimal explanation…unless, of course, the entire point of your book is why they are fighting over what to call their planet. Still, it may be helpful to panster a brief world history.

                      For mine, I actually sat down with a new game of Civilization V, chose the settings for the world I wanted (huge map, 5 billion years old, ie, less mountainous, temperate, arid) and played through very slowly. The simple act of playing a randomly generated world like that, along with the terrain features the eventual meeting of other cultures, lent itself to a wealth of off the cuff creativity.

                      Yeah, it’s hokey, but it worked.

                    • I have less of a problem with something like your example, Scott (Parthians from Partha), because it’s a fairly simple way of referring to yourselves to other races. What bothers me more is so many stories with aliens seeming to have species-wide cultural norms, or at least singular monolithic governments, often except for a small number of “renegades” who help out the humans.

                    • I think that’s a typical view of sci-fi aliens in general and we see it all the time. This is why I’m going through so much trouble to layer up my antagonists…or maybe they’re protagonists…or maybe just dupes…

                      We only get to touch down on Earth and one of the other six worlds, but I need that sixth place to be a living, breathing world. The human society there has been around for as long as ours, but there are innate differences that make them vastly different in both outlook and societal makeup…ESPECIALLY societal makeup.

                    • worlds with a mono-climate. :)

                    • Explained away with near zero axial tilt and not natural satellite.

                    • Free-range Oyster
                    • We’ve kind of hijacked this thread, and that’s a shame. The original thread is a good one. This, too, is a good topic, actually deserving its own thread.

                      I created a world in one of my books that is peopled by migratory clans in more or less a nomadic existence. They call their planet a name that means “our world”, and themselves as “the people of our world”. That’s pretty much true of every people I know on THIS world – they use a word that means, basically, “here”, or “our home”. In some languages the word may also mean “home” or even “dirt”. When you’re creating an entirely new culture, new language, and new social norms, which science fiction writers do frequently, it helps to think about what WE do here on this planet, and why it would be done differently somewhere else. The logic of “why” has to be believable, but it doesn’t necessarily have to be PERFECT. The only thing I try to stay away from is any names that might be construed as being “borrowed” from someone else.

                    • In this group it should never surprise that even our bunny trails have bunny trails.

                      There would be a couple of reasons to choose referential name, but it should be done with care. One is to simply honor an author and work that proceeded. Another is to tip a hat and lay a clue about the world and/or story itself.

                      It is an unfortunate truth that if the aliens were too alien to us we would probably find their way of thinking incomprehensible. (I think Sarah has already observed this.) We see this hinted in some of the cross-cultural misunderstandings on this planet. The Daughter and I had the experience of trying to explain a recurrent horror trope from Asia to a not unintelligent friend. The friend kept, in trying to understand, attempting to relate it to something she knew. Yes they were similar, but the difference between them made all the difference. Such problems would be even more extreme when you are dealing cross planetary.

                  • CACS – another example of incomprehensibility is trying to explain our humor to a German. It is funny. And yes, we have tried it.

                    • Some years ago the Washington Post published an article which The Spouse believes was titled Take my Samurai Please). The author relates that he had discovered that the Japanese had a sense of humor! By this point The Daughter’s choice of the Anime Club for a family activity had turned into the mother-daughter activity. I took the article with us to club and we had a grand laugh.

                    • Oh, also, the Germans, I believe, did not get the Care Bears either. Bears are not pink, blue, sunshine yellow or what have you. Bears are brown, black, tan, white — you know natural colors.

                    • I remember that on Babylon 5, Penn & Teller were in one episode, and they had made a point of going around and learning about any culture they were going to perform for ahead of time, so that they could adjust their humor elements to that culture. When Penn told Delenn a joke, she thought it was hilarious, but the commander didn’t get it at all.

          • From what I understand, you would have never been able to get through certification, a process designed to break aspirant teachers to harness. If you succeed as a writer (commercially, not artistically) you will eventually teach far more folk than you ever could have reached in a classroom.

            Beloved Spouse & I often giggle over the lessons about trusting government bureaucrats and mainstream media that J. K. Rowling has conveyed, in spite of her being Labourite. How many people has Heinlein taught, and how deeply, without ever entering a classroom?

          • *laughs* You’ll notice I didn’t mention inherent skill anywhere there! Someone who is a good teacher is a different animal– but it’s something you have to have. You can nurture the skill, but not create it. Same way I’ll never be a world class basketball player, though much less obvious, and style can play into how well it works, too.

            But you can’t count on the notion of “everybody who is here will actually have a skill for the job” when designing a system like this….

  4. When my brother was looking at med school, a med school in Tulsa said he could be admitted if my parents made a hefty contribution to the university. My brother ended up pursuing life as a research scientist, not a doctor. And I understand the same type of admittance rules exist for veterinary school.

    • Oh, yes “big money” will always get in. Idiot me, not selling like J. K. Rowling.
      And remember that doctor used to be a “licensed” and “apprenticed” profession. Yes, I know it’s got way more complex, but in a way it’s simpler too — we have more tests that give easier-to-pin-down results. I’m not going to lie: I’m not sure we shouldn’t have an apprenticeship and certification-test (written and practicum) system. Perhaps not for full MDs but for the people you need to see when you have a cold, etc. Kind of like between nurse practicioners and the doctors we have now. Yes, I want a specialist to be VERY versed in what he does. BUT ninety percent of the time, when I go to the doctor it’s for a cold, a rash or an ear infection. Those could totally be dealt with by “doctor second class” who learned by watching another doctor and passed an exam, and who then sends you “higher up” when you don’t react as expected.

      • When I was in, the military got around this by having Physician’s Assistants – they basically did the routine gotta-cold,rash, ear-infection, and referred you to the doctor for anything that appeared the least bit more serious than that. Quite often also, they had nurses that had trained as PA’s, also. I always felt in pretty good hands with them …
        except for the year that I wound up having to go to an Army Troop Clinic for sick call … but that’s another story.

        • The only problem I’ve ever had with the Physicians Assistants from the Air Force was the year I had five different primary care doctors in eight months. I have three fairly serious LIFETIME medical problems. Having to start over with a new doctor every couple of months was maddening. I chose (and was allowed!) to have a civilian primary care physician – who is a Nurse practitioner trained by the Army!

          I will pray that Robert makes it through Medical school and becomes a doctor. On the outside chance he doesn’t, have him look into the PA training program run by the military. He might also look into military scholarship programs for MDs. They pay medical school expenses, he interns at a military hospital, and then serves for 6-10 years to pay back the expenses (as a military officer, at full pay and allowances, with the chance for advancement). If he can fake the PC crap, he can learn to adjust to the military.

          • He’s minoring in chemical engineering, so he does have other options. And there’s always a Phd in medicine and research and/or medical engineering. I mean, the options are open — but he WANTS to be a doctor and he has the grades and the temperament (who else would ENJOY volunteering at the hospital, even in 8h shifts? And he does.) so I hope he makes it.

            • Your boy has options for medical training outside the US. Or in the US military. This morning in church I sat next to the guy who’s in charge of heart transplants in town. He’s an ex-military doc.

              And my son was talking to the son of another doctor who trained someplace nice in the Caribbean. She had to jump through hoops when she got back to the States, but she did it. And don’t be afraid to apply to Oxford or another “name” school that intimidates the Harvard/Yale guys.

              Moreover he can always practice medicine outside the US, too. There’s no Berlin Wall (yet) keeping the boy from going someplace else to pursue his dream. I always regard “no” as damage and seek ways to route around it.

          • I pray for your Robert too – BTW when I became ill with Wegener’s Granulomatosis, my hubby and I were in Germany near Landstuhl hospital. Three months we played this deadly game until finally when my kidneys failed, my doctor sent me off to a German hospital. The German doctors after two weeks of hospital care, diagnosed and started treating me for my disease. Because I had a fast-acting form, if they hadn’t sent me to a German hospital (teaching hospital btw), I would have died. In fact a head nurse in the Landstuhl hospital told me to prepare for death.

            It was very bad…. Also there are only a few doctors in the world who treat my disease. It hurts to know that someone who would be a talented doctor might not get in because of political correctness. However, if this happens please encourage him to become a medical researcher for new medications and treatments for disease. We need that type of person just as badly.

          • The United States Armed Forces has a program for people that want to become nurses and doctors. It is possible to get a medical education, all expenses paid in return for enlisting for a seven year commitment after you are done with medical school. It is a program established by Congress in 1972, and it entered its first class in 1976. It is called the F. Edward Hebert University School of Medicine, and it is the place where the majority of doctors that serve in the United States Armed forces begin their training.

            http://www.usmilitary.com/4245/armed-forces-medical-school-education/

        • I had problems with this system because I was having continuous UTIs and kidney infections and they kept giving me antibiotics instead of sending me up to the next level. It was also in Panama which has every infection known to man going through that Canal. Having to deal with the medical (mostly army) was not fun.

      • I would say, “What about if you have something more serious, but it’s something that appears to be something simple, and a less qualified person didn’t notice the indicators that would tell them that it was the more serious thing?”

        Then I asked myself if I had been smoking crack or something, because even many of the doctors who are supposedly hyper-qualified will miss them. People get into routine, and start to miss things that aren’t quite what they are expecting.

        • Wayne – look into the symptoms and descriptions of Vasculitis disease. It is so easy to misdiagnose this illness because it mimics so many diseases, and even sinus infection. There are a few other fatal diseases that do the same. So yes, it is happening all the time.

          • Actually, Cyn, I kind of had you in mind when I wrote that. I keep forgetting that my textual sarcasm is weak. I meant to imply that having an intermediary level of doctor would not necessarily be a good thing, because the professionals (who are supposed to be the cream of the crop) still get it wrong.

            I have a suggestion for them, but if they tried to implement it, it would be done so far wrong that it would become worse than the way things are now, and that would be to have a backup Expert System software system, which the doctor’s office would enter the symptoms into (not necessarily even while the patient is there, but possibly could be done later), which would suggest possible alternatives, along with clarifying questions. But I’m sure it would be ultimately presented as a First-tier solution, and that would be bad.

        • Let’s not overthink this. Life is not an episode of House. One of the most effective means of reducing mortality in hospital operating rooms is a freaking checklist! The problem is establishing protocols to triage and escalate issues to the appropriate practitioners.

          • So true – if you know that it looks like an auto-immune disease, send the person to a rheumatologist and so forth -

            • and in my case – don’t say you need to go to a psychiatrist when you really need a rhuematologist… which is the first dx for most Vasculitis patients (sorry but that one is a sore point for me).

              • H*ll. I ended up in the intensive care unit for eleven days because for two months they told me tiredness and feeling ill were psychological. No. It was INTERCELULAR pneumonia. By the time they did the blood oxygen test, I didn’t register. Could have solved with antibiotics at the beginning. BUT see, I wasn’t coughing. So it was all in my head.

                • Sarah – YOU UNDERSTAND – they tell us we are hypochondriacs until a major system is involved. In my case it was the kidneys. In other people it is the lungs or sinuses (sometimes the brain). Any organ can be affected. AND many times it takes years to be dx’d. I was the lucky one at three months. Many of us die waiting for a dx because dang it, they won’t treat if they don’t have a firm dx even if they suspect.

                  • We are now having younger Vasculitis patients diagnose themselves and taking it to the doctor. *snort AND being right w/o a medical degree because they are good at researching medical symptoms.

                  • Many of us die waiting for a dx because dang it, they won’t treat if they don’t have a firm dx even if they suspect.

                    Bingo. My wife has Muscular dystrophy. She has all the symptoms, and all the tests they’ve run have come back saying “yes”. BUT it takes an MRI these days to confirm the diagnosis. My wife has a platinum implant in her right ear. She can’t have an MRI until he has ear surgery to replace the platinum with something non-ferrous, such as titanium. BUT they don’t make titanium implants for otosclerosis. We’ve done everything we can, and everything the doctor has recommended, but she’s still non-functional two days out of seven. That’s ROUGH when you have a seven-year-old to take care of.

                • I spent 3 hrs in a dr’s ofc, knowing that I had had flu that had gone into bronchitis and that I was susceptible to pneumonia, having had it several times since an infant. But because this dr. knew my background and wanted to prove he was smarter than me, he ran me through every test in the book (and did some of them wrong, like leaving me on the asthma inhaler machine for TWENTY MINUTES INSTEAD OF FIVE – I was shaking like a drunk with the DTs when I got off it) and in the end diagnosed me with “unspecified decreased lung capacity” – then prescribed antibiotics targeted to pneumonia.

                  Same guy never caught the Mutant Cyst from Hell, just told me I needed to work out harder in the gym. 1) I was lifting entire weight stacks on some of the machines, 2) I looked like I was 7-8 mo. pregnant by the time I switched doctors.

                  And he was an internist. A specialist.

            • My friend the ER doc, who I’ve mentioned in another part of this thread, has enough experience with travel outside the US (he often goes on short-term missions trips, or gives free physicals to other people going on short-term missions trips) that he always checks for malaria if he hears a certain set of symptoms. Well, first he asks, “Have you been traveling recently?” Then if the answer is yes, he draws blood and tests for malaria. He’s told me that most other docs he knows have only worked in the US and don’t tend to think of “exotic” diseases like malaria (scare quotes because malaria isn’t at all “exotic” in most of the world, of course).

              • I’ve worked with guys with malaria (once you have it, you have it for life, and will occasionally have relapses). Enough people have came back from Vietnam and other places with it over the years that I am surprised it hasn’t taken off here in the states.

              • I should mention the best doctors are ER doctors. Why? THEY HAVE TO BE. If you find a doctor that mostly does ER, stick with him. When I went into ER with pneumonia, he diagnosed… pneumonia, gave me antibiotics. IF the pulmonologist hadn’t wanted me to have something exotic and exciting and taken me off antibiotics and wanted me to have steroids — which I refused, thank G-d because given the infection I was fighting it would have killed me. Now I think about it, the dermatologist also thinks steroids solve everything even though ten minutes of googling showed my issue was an infection, not eczema (which I also have and doesn’t react to antibiotics.) and which has been resolved by two courses of amox. I wonder where the got the idea steroids are a cure-all — if the high and mighty specialist had JUST kept me on antibiotics, I would have walked out of that hospital in 3 days. Instead, he took me off antibiotics and started running crazy tests — including one for a fungus that grows in the caves of Brazil… where I’ve never been. I guess the fact I spoke Portuguese at one time was enough? — and Dan had to threaten lawyers by the time they put me back on antibiotics. By that time I was in ICU on oxygen. They put me back on antibiotics. Three days later I wasn’t sick enough for them to keep any longer. I left with pulmonologist saying I would be back in a week and that I’d be on oxygen the rest of my life. Instead, I continued the antibiotics and got over pneumonia and went on with life.
                So, our careful selection process is designed to produce… crazy people? Crazy people who latch on to ONE solution “STEROIDS” and try to give it to everyone?
                Oh, in the middle of this, they did a laparoscopy. To relax my throat they used atropine. Look, I read Agatha Christie. I said “Are you sure? You told me my heart is enlarged and I’m tachychardic is atropine safe.” I got told “Don’t worry your pretty head about it, deary. It’s perfectly safe.” So, they administered it… And I went into cardiac arrest. THIS WAS NOT DIFFICULT INFORMATION TO FIND.
                Robert said given how I feel about doctors, why would I let him become one. I told him “Because you’re not an idiot. And if you become one, I’ll beat you.”

                • *shudder* I’ll have to say that most of the doctors in our area have been very competent. It was even the dermatologist who discovered my wife’s breast cancer (she had missed a few mammograms) – the lump in the breast was hard to find, but it had gotten into the lymph nodes under her arm, and the dermatologist felt that and told her to go get checked. My wife had felt it under her arm, but since she has another condition called hidradenitis suppurativa, which produces boil-like welts in places like under the arms, under the breasts, and between the legs, she thought it was just related to that. The mammogram, however, revealed two 3-cm lumps, so to the oncologist we went.

                  Every single one of the doctors (oncologist, radiologist, oncology surgeon, and plastic surgeon) and nurses have been the most wonderful and helpful people. They explained everything in clear, layman-understandable detail, yet without any hint of condescension when explaining difficult things. While undergoing chemo, they treated her like a person rather than a number, and minimized the discomfort as much as humanly possible.

                  Sadly, I have been told by others, even a woman I know who was a nursing student, said that this is not the rule. I wish it were.

    • Hmmm did they get that demand for donations in writing? Does it count as soliciting a bribe? Was it a public university or a private one? I bet that would make the bribe solicitation legalities even more interesting.

  5. Then why the heck have so many of the doctors I’ve been to over the years been completely incompetent???
    Tell me my child has sleep apnea – after which we spend a year trying to get the kid to use the cpap machine (she never manages) – after which they do another sleep test and tell us she doesn’t have it. WTF??
    Tell my friend his wife has early Alzheimer’s, tell him there is no hope of a cure – and then he finds out she has Lyme disease??? Which explains all the symptoms and is eminently treatable?
    Tell me I need more back surgery – and it is the only way to get rid of pain and incapacity to walk. I spend a year doing yoga and learning about pain (which goes away very close to the beginning), and all the symptoms they said could only be resolved by surgery, period, are gone???
    If this is what we get from a restrictive system, they need to do something – I’m not sure what. And half the doctors covered by my medical plan don’t speak English well enough to understand them (I don’t care where they were trained if they do their job) and can’t seem to do the patient care – the part where they get the patient informed enough and onboard enough to execute the ‘plan,’ and can’t write it clearly enough on the prescription plan so you could actually read it and know what is being prescribed – in Mexico where I grew up the DOCTOR (gasp!) personally types the prescription to make SURE it is legible. Yup, on a typewriter on his desk.
    And now, to get back to our real topic for the day: “99% of those are determined by the LAYDOWN?” Are you kidding me? Is is really that bad? Talk about your self-fulfilling prophecy. Is this true for ALL NYT bestsellers? Where do you get your data – I’d love to see some of it. Is this true for fiction? Mainstream fiction?
    Thanks for bringing the topic up – and I am praying your son, brought up by such a mother, will survive the winnowing process you describe – to become a good doctor.
    I am also going to be asking some questions of the top engineering school my youngest attends – it costs way too much money if you are right about “the number of classes graded on a curve where a majority of the class would fail – the program was designed to weed out, eventually, 90% of the engineering majors, and it succeeded at that.” (Skip’s post, above). Kid is having a bit of a hard time – but we always thought it was kid’s fault. If it is the school’s, I am going to be pretty furious. It is a stupid system.

    • As for the NYTimes BS List and Laydown.

      1) the list is based off only certain stores, figure out what they are and you can game the system more effectively
      2) The more of something on a shelf the more it is seen and the more it sells, that last lone copy sitting spine out almost never sells to browsers. And a nice big book dump at the front of the store (paid for by the publisher) helps as well.
      3) From reports many midlist books take days or weeks (or never) to be unpacked from the delivery boxes in the backroom of the store. They might just get the cover ripped off and returned for a full refund while the pages get pulped without ever hitting a shelf a reader could see them on. A paid for book dump or endcap WILL get unpacked and probably on the right day. Contract violations otherwise and publishers getting grumpy about paying to CoOp to buy they later. If your book never made it to the shelf in the first place its imposable for someone to find…
      4) there are a about 750 B&N in the country and thousands of other bookstores both chain and independent. If the publisher only prints 5K copies of the book (typical for a midlist books as I understand it) you aren’t going to have more than couple of copies in any one store.

      So publisher decides that Generic Book will be BIG! and should hit the NYT BS List. Therefore they print LOTS of copies so all the stores can have a bunch. They pay for CoOp for endcaps and bookdumps at the front of the store. If they can figure out what stores are in the NYT reporting stores list they concentrate on those stores. They set a strict street date so the books don’t get sold early and the maximum get sold in one reporting week.

    • Are you kidding me? Is is really that bad? Talk about your self-fulfilling prophecy. Is this true for ALL NYT bestsellers? Where do you get your data – I’d love to see some of it. Is this true for fiction? Mainstream fiction?

      Abe,

      If you’ve only recently discovered Sarah’s blog, you may not have seen her post from about a year ago, He Beats Me But He’s My Publisher. It won’t answer all the questions you just asked, but it will answer some of them. I highly recommend reading it (and the “According to Hoyt” posts listed in its pingback section, near the bottom of the comments). Then start reading Sarah’s older posts from 2011 or so, by using the following trick: start with the link http://accordingtohoyt.com/2011/01 and read all the posts therein (which will be the January 2011 archive). Then edit the link to read http://accordingtohoyt.com/2011/02 and read the Feburary 2011 posts. And so on. Sarah wrote lots of good stuff on the state of the publishing industry in the past year and a half, but since there’s no good Archives link on the front page, you’ll have to use the URL trick to find them.

      Incidentally: Sarah? That’s an easy way you could make it easier for people to find your old posts: include an Archive link on the front page. I didn’t realize until recently that the URL trick, which I’ve used on other blogs, would work on your blog too. There’s probably a lot you’ve written on the publishing industry that I haven’t found (and I’ve been looking!) because I didn’t know about that trick. An Archive link would have let me find it last year when I first discovered your blog.

      • Thank you for the instructions on how to read older stuff – I’d rather read Sarah’s old stuff than a lot of the new stuff I end up reading when I’m trying to get my head into writing mode. As you guessed, I’m relatively new reading here, but love it – and am sometimes moved to join the fun. And feed the kitty.

    • Doctors — because they’re picking YES men. Medicine — given the variety of human physiology will ALWAYS be an art. My issue with doctors — younger ones. Older ones are fine — is that they try to fit me in “box a” even if I don’t, then act like it’s my fault when it doesn’t work.

      I’m sure it’s the school. Most classes in the first two years are designed to weed-out.

      Laydown — it’s an open secret in the industry. No one even disputes it. Except now it’s not working as well, because of Amazon. The smarter bookstores are stocking by Amazon sales, so some of us are creeping slowly out of the midlist. And the big publishers HATE it. I don’t think Baen does this — hence probably not “all” — if nothing else because it costs the Earth.

      • One of the little heralded bu … features of Obamacare is the stablishment of standards of care whereby doct … phys … supervisory medical personnel will have to follow centrally prescribed treatments for subj … patients Meaning once they have a diagnosis the treatment is “by the book.”

        I don’t think “YES men” adequately covers that. For one thing, they are only “male” by plumbing and DNA, the least important measurements of manliness … being a <mensch is not limited to “gender.”

        • Absolutely and completely off-topic, but, when I was in last week renewing my vehicle licensing I idly asked the lady at the counter how much the specialty license plates cost. Idaho has a large number of specialty plates; wildlife plates, agricultural, snowmobiling, downhill skiing, POW-MIA, support our troops, Rotary Club, Lions Club, NRA, etc. They cost an additional amount to buy, and then an additional charge on each renewal, some of this money goes to the DMV, but a portion goes to whatever group or organization the plate endorses. This is when I was informed that the NRA plates had been discontinued, because Obamacare forbid them.

          I guess you have to come up with something to fill 2400 pages of law /sarc/

  6. What about the military route? It’s been a loooong time since I’ve looked into it, but the DoD was hot to trot for MD’s. You get to go in as an officer and a healthy chunk of your tuition is covered.

    If that’s still the case, have ‘em go Air Force. All the trappings, none of the PT.

    • I would suggest that one too – AF though instead of the other branches.

      • I’d also recommend the Air Force. They also seem to have the largest number of slots available. I’m also kind of prejudiced, being an Air Force vet… 8^)

        My nephew was a recruiter for xxx number of years. I’ll give him a shout and see if there’s anything that might help, if he decided to go that route. The major difference between Air Force and Army is that the Army “gets” to deal with a lot of more exotic diseases.

        If he decides to go Air Force, and his eyesight is good enough, have him apply for flight medicine. That’s an area where the need is greatest, and the requirements aren’t being met closely enough. He’ll also get to fly! 8^)

        • The AF (I’m also a bluesuit vet) is ALWAYS looking to fill open flight medicine slots. However, that can entail deployments and actually playing “military”. If he wants the MD but doesn’t want the hassle, ie, work regular hours and play a lot of golf, have him go standard MD and try to get Eglin AFB, FL. Best. Assignment. Ever.

        • My husband currently works in a recruiting office for the AF, too.

          Another echo on suggesting them– I like the Navy, but if it’s just a matter of getting to become a doctor while avoiding most of the political BS, go AF. Navy as a second choice. I don’t know enough about army to be intelligent.

      • I know that I am a turncoat (Navy), but if he goes hospital corpsman, which is enlisted, with the Navy, he ends up playing military with the Marine Corps. The Army and AF imho have the best medical slots. Army doctors do deal with a lot of trauma (soldiers who have lost limbs, etc.)

        AF has a lot of good places. Navy also have hospital ships with doctors assigned. Navy deploys a lot.

    • Ah yes, the Air Force, civilians in uniform as they used to say at Fort Meade.

      • Well, Steve, this particular “civilian in uniform” did a lot of NASTY things in my 26 years, and got shot at more than once. There are a dozen places where the Air Force could outsource work to civilians and save money, but that’s another long battle. Imagery intelligence is interesting, but it’s also filled with a lot of little “gotcha’s” you have to learn to accept.

        • Don’t take that as disrespect. I rather liked the fact that the Air Force guys were a lot more laid back about uniforms and stuff than the Navy guys. I have every confidence you knew which end of the barrel the round came out of.

    • There is an “all services” medical school in Bethesda, Maryland (yes, it is in MD) where the services “bid” for the graduates. (The Daughtorial Unit has her sights on this.) Not only do graduates get tuition covered and are officers, they are already accruing time in service toward their pension.

      At least, so I’ve been told.

  7. I’ve got to admit my first reaction to this was WTF? Limiting doctors?

    Then I did some googling and found a bunch of data on why. Apparently a while back the AMA thought they’d have a surplus and tried to prevent it. Naturally, now they’re realizing that’s not good and trying to get funding increased.

    The prime problem appears to be that Medicare funds most residency slots, and they cap their funding pretty tightly. Since no residency = no doctor, that acts as a limit to the number of new doctors entering the system.

    Based on this article it looks like a series of decisions that all seemed like good ideas at the time got us into this mess.

    • Ditto the Whiskey Tango Foxtrot reaction there. Will have to read the NIH article you found — thanks for that.

      Wonder why the AMA thought a surplus of doctors would be a bad thing. Bad for the poor sap who gets into medicine thinking he’ll make $BIGNUM per year and ends up making $SMALLNUM instead due to oversupply of his profession, perhaps… but bad for the general public? Or was the AMA acting as a guild representing only the interests of their profession, and not the interests of the public, in that decision? (I lean towards the latter explanation, but I’ve only given it a few seconds’ thought so I could easily be wrong.)

      Also, while we’re on the subject of medicine: malpractice insurance, I’m given to understand by a good friend who’s an ER doc, costs ridiculous amounts of money right now, which is one part of why costs are so high. (Many other factors involved as well, of course.) Part of why insurance costs are so high is the insurance companies tend to settle malpractice suits before they go to court, regardless of whether the suit is at all well-founded. For example, my friend was once sued for something a different doctor did. He had examined a child who needed a specific kind of surgery, said, “This hospital doesn’t have that kind of surgeon, I’m transferring you to a hospital that does,” and that was the end of his involvement. The family wasn’t happy with the surgeon — allegedly he left a visible scar on the child’s face — and they sued for malpractice, suing not only the surgeon, but also my friend who’d transferred the child to the other hospital. My friend never got a say in whether the case was fought or settled: the insurance company decided unilaterally to settle. My friend had two choices: go along with the settlement (which went on his permanent record, and now every time he applies to work at a new hospital he has to explain why “he” settled a malpractice suit out of court) or have the insurance company drop him, which would mean that he would have NO malpractice insurance from that point forward (what insurance company is going to touch a “difficult” doctor?), which is just Not An Option for anyone who wants to be able to pay for their kids’ college tuitions.

      TL;DR: Medical costs too high? Blame John Edwards. (Did you know he used to be a malpractice lawyer before becoming a politician? As if he wasn’t unlikeable enough already…)

      • US Tort law has been broken for a generation. It serves as a lottery to enrich ambulance chasers who pursue one-in-a-million chance of winning cases for ten-million sized payoffs. Insurance companies look at the expected cost (penalty times probability plus legal fees) versus settlement amount and their actuaries choose the smaller number. After ObamaCare is repealed, more doctors and tort reforms will be low-hanging fruit for the GOP.

    • Repeat after me: Central Planning Means More Efficient, More Humane Societies. Central Planning Means More Efficient, More Humane Societies. Central Planning Means More Efficient, More Humane Societies.

      Now go spread that around your rose bushes.

      • RES, what do you have against rose bushes? ANYTHING related to central planning is a killer. Even for roses. Mine are doing fine with some rose food and a banana peel every once in a while.

  8. The NYT Bestseller thing becomes a self-sustaining cycle – it goes on the list, so people assume it’s the best and buy more, so it moves up the list and people assume it’s the best…

  9. Your opening at the DMV reminded me of something I learned after I started writing, “Don’t get mad. It’s all story material.”

  10. Wayne Borean aka The Mad Hatter

    A free society is ALWAYS a function of informed citizens.

    And that’s why the American Government, the Canadian Government, the British Government, etc. are so down on their staff actually talking to the public. They don’t want an informed public. It makes it too hard for Government to follow through on things that the public wouldn’t like.

    Yes, I’m a cynical old bastard.

    Wayne

    • none of them are particularly hot on freedom here. Has anyone else noticed the “China lust”?

      • Wayne Borean aka The Mad Hatter

        Been to China. We don’t have as many soldier wandering around in uniform, keeping things under control.

        Yet.

        Wayne

      • Yes, and I always wonder what crack they’re smoking. You can legitimately go to China and like the people, or get interested in the ancient history and exotic landscape. But the government or the rest of the system? Any ordinary Westerner hates it, or at best finds it not quite as tyrannical in certain issues as a tyrannical government could be. (But it’s much more tyrannical in other areas than even Nazis or Stalin, so it all evens out.)

  11. 57 comments already, and I got nuthin’ — not even time to read before getting on the mailing list!

  12. Fact Sheet – TruthSite.org by Don Smith
    truthsite.org/HealthCare/FactsAboutHealthCare.pdf
    File Format: PDF/Adobe Acrobat – Quick View
    central role of private insurers (Annals of Health. Research). 15. Less than one-third of doctors belong to the. AMA, and 42% of those favored single-payer reform …

    Or just Google “AMA represents” for yourself.

    Draw your own conclusions.

  13. Well, I seem to be the lone M.D. here. I will make a few comments.
    1. Good luck to Robert. If he doesn’t get in, I suggest reapplying. One woman applied to McMaster 8 times, got interviewed on the 4th & 8th times, and finally got in. Or going overseas/military is also an option. It is not impossible to get in. I did it, and my (Caucasian, English-speaking SIL) just graduated from medical school.
    2. Doctors, NP’s, and PA’s are doing the best we can. It’s easy to point out our misdiagnoses and errors. Much harder to do the actual work.
    3. International residents don’t take away residency spots in Canada. They are an add-on, but do pay huge tuition to the universities for the privilege. The ones I work with spoke good English and were, with only one exception, hard-working (better work ethic than the Canadians, oversall).

    • 2. Doctors, NP’s, and PA’s are doing the best we can. It’s easy to point out our misdiagnoses and errors. Much harder to do the actual work.

      Just one point, in case you’re feeling like this is a particularly negative comment thread for doctors: While I cannot speak for anyone else, I don’t really see any blanket criticisms here – the majority of them have been that, for a profession that seems to be set up to promote only the best qualified, the number of incidents of functionally incompetent doctors is frightening.

      Then there is the tendency, as I mentioned above, for people to get into a routine, a rut, if you prefer, where they see the same things over and over, and stop thinking that a certain set of symptoms can ALSO be indicators of something else, and if the patient forgets to bring it up, or feels it is too embarrassing, or just doesn’t feel like it’s related, they get misdiagnosed because the doctor doesn’t follow up with leading questions (I say leading questions, because a simple, “Is there anything else?” is insufficient, because many people need specific prompts. For example, if I were not healthy as an ox, I would probably die, because I would not remember to tell my doctor everything). This is not an indictment of doctors, it’s just human nature, and the limitations that Sarah described make them worse, by increasing workloads, especially in high-population-density areas.

      • That’s part of it. Also, I think Melissa is in Canada, which is again different, but in the states a lot of it is law-suititis. They’re so afraid of law suits they want a specific test.

    • sigh. Yeah, he’ll try twice, he says. After that, he wants to have a job.
      2 — look, throughout the mess with my non-pneumonia, we want it to be exotic misdiagnosis (while it was pneumonia all along) my husband was on the phone to my SIL in Portugal — which is why he finally demanded they give me antibiotics now. Some of the things they wanted to do, like steroids, would have killed me. My SIL isn’t a genius — though she’s smarter than the average bear — with superfantastic abilities, but she called it right up front. As did the ER doc. So, why did the “specialists” try to pursue something more “interesting” — I don’t know. I think it’s a combination of wanting to be better than the people in ER and the “generalists” and the fact that I have an accent — and what seems to be atypical reactions to practically anything. BUT there seems to be good bit of “make people think on standard lines, and if it’s not standard lines, it’s the patient’s fault.” The dermatologist prescribed eczema creams for everything, though I told him the stuff on my hands got worse with the eczema cream and btw I’d already tried all of those creams. Twice. They don’t do anything for the eczema, and they made THE OTHER STUFF worse. (The cream I used in Portugal, which worked, is not licensed in the US for use in humans. Yes, there is a compounding pharmacy, but the genius told me he’d give me something “better” and then gave me something I’d already tried, which had already failed and insisted I use it again.) When NONE of this worked, he got mad at me. This is insane. And I think betrays training in rote thinking.
      Honestly, I think in Portugal because sophisticated tests are not available — and they take anyone with high enough grades to enter med school, regardless of personality? — people still have to think creatively.

    • Melissa Clouthier is an MD in Houston, and also a blogger (not here, though). She frequently gets angry with other MD’s, and reads them out online (without identifying them).

      Most MD’s I’ve met are good people, and do their best. I had one, though, that although I’d been taking a particular pain medication for several years, at a specific dose, and it worked, wouldn’t give me that dosage because he might get labeled as being a pill-pusher. I needed that medication, and I needed it in the dosage I’d been taking. It took almost a year to find a doctor that was more willing to provide the treatment I needed than to be “politically correct”. (Not Oxycontin, but Ultram/Tramadol, 2x 60/50mg tablets up to four times a day for chronic pain from a bad back/osteoarthritis/neuropathy. Kidney tests every six months.)

      The orthopedic surgeon that did both surgeries I had in the last two years was super. One of his partners is equally as good, and if I have to go back for more treatment, I’ll ask for him. My surgeon, unfortunately, slammed into a tree, skiing in Canada, and is no longer with us.

  14. To be fair – I had a good Rhuematologist in Las Vegas until he lost his partner and had to pick up his patients. Then it was ten to fifteen minutes for each patient and we ALL suffered.

    The rheumy I have here has 20-30 minutes per customer. When they expand they add another doctor (there are three now). We go over my labs, we talk about my symptoms, and then I tell him anything knew. If I have to have an operation like that extraction, I make sure he knows.

    My primary care physician is also good. I know he won’t pooh-pooh what I have to say. Both doctors are NOT spring chickens. It is a relief.

    I have to say that the German doctors were the ones who saved my life though when I first became ill. So there is good here… BUT there is also a lot of bad.

    • I had a WONDERFUL doctor twenty years ago. The insurance kept dinging him for ordering “too many strange tests”. he eventually had had enough and retired.

      And before we say “Ah, insurance” I said, yep, let’s eliminate third part payers INCLUDING the government. If I want to be tested for brucitis of the cleaning ladies knees and my doctor thinks I’m crazy but will do it, and I pay for it, who would care? And I say if you remove third payer and stop limiting doctor supply the prices WILL come down.

      • Oh, yeah, the reason I say that is ECONOMICS. I LOVE economics.

      • Unfortunately my PCP is talking about retiring. I am so bummed. He doesn’t want to be a doctor under the new health rules. The new set-up is that they have to put all the symptoms in the computer and some one in Washington will say if they can do that test or make the dx. UGH… Talk about centralizing medicine.

        My doctor was getting dinged because he didn’t want to put our paper records into the computer system. He said he didn’t know who would have eyes on them even with the new (hippa i think?) laws. Privacy laws anyway.

  15. Someone above expressed the cynical view that government doesn’t want an informed populace. That brings up the question: why is the government so vicious?

    Think about it: our government is made up entirely of citizens of the nation, none of them with aristocratic titles. Why then is it so hostile to the common man?

    Partially, it’s the tendency of Washington politicians to “go native.” However, we see the same thing in state governments, and most of those are in small cities that theoretically ought to bring politicians closer to the populace.

    I think a bigger reason is the gerrymandering that tends to be implemented in political systems that use area representation, aka the first-past-the-post system. Everyone knows that politicians shape their districts to protect their own incumbency. They may even think things out to the point of realizing that they are more likely to protect the districts of members of the dominant party who don’t rock the boat.

    What most people don’t realize is that gerrymandering also picks the politicians who will represent the junior party. When you’re a Republican legislator in a Democrat-dominated state, you literally owe your job to the Democrats in the legislature. As a result, you will generally do all you can to avoid toppling the Democrat majority and will generally service your Republican constituents with platitudes.

    Did you ever wonder why there are so many liberal Republican politicians from southern states, such as Lindsey Graham, Bob Ingliss, John Warner, etc.? Why is as conservative a region as the South electing members of the conservative party who are indistinguishable from moderate to liberal Democrats? The reason is that the Southern states took several decades to go from being fed up with the national Democrat party to actually voting for Republicans at home. The state Democrat party thus was able to pick and choose which Republicans would be represented in legislatures and Congress–and, indirectly, the Senate (since most Senators start out in the House or state legislatures) and the Presidency (since most Presidents are governors who are successful at dealing with state legislatures). Voila, the George W. Bush administration.

    In an area representation system, in the absence of popular pushback against gerrymandering, over time a two-party system tends to become a de facto one-party system. This didn’t really matter in the old days, since the individual states each had their own systems–and, often, the local governments were powerful enough to offset the state governments and make area-based two-party systems in the state. Nowadays, with the federal government as big as it is, it can largely get the state governments singing the same tune. As for local governments, city (i.e., Democrat) governments are stronger than ever, while rural local governments (usually Republican) have to compete with federal government projects which can sway people to the Democrats.

    This is not to say we need to do away with area representation–proportional representation is much worse. AR tends to lead to a de facto one party system that is powerful at home and abroad, whereas PR leads to multiple powerful parties that can spend the country into bankruptcy and not do much else. What is needed is pushback against gerrymandering and the establishment of more or less randomly drawn districts. This is more possible now due to the Internet, and we already see a little bit of it; witness the defeat of liberal Republican Senator Richard Lugar in Indiana by a grassroots campaign. But we need more of it.

    My guess is that in the absence of gerrymandering, you’d see a Republican party that would be slightly dominant, and would be essentially a sort of activist libertarian party, more radical on issues like taxes and spending or the 2nd amendment than is currently the case, but less interested in the moral panics du jour. The Democrats, I expect, would be much more moderate than currently is the case, sort of like Clinton in 1997 without gun control or hyperpartisanship (but probably still with the sex scandals).

    • It’s because the vast majority of people holding public office are &^&$#%^$#$^5 LAWYERS who think their defecations aren’t odiferous (trying to be polite here). I would personally love to see a Constitutional amendment that stated that there can be no law that benefits a sitting congresscritter, either now or in the future, and that anyone who practices law cannot be allowed to make law (conflict of interest).

      • Lawyers are part of the problem — their training conditions them to a) believe that laws, regulations and rules are necessary and b) that laws, regulations and rules can be gotten around.

        But the problems would be equally vile if our congress-critters were majority real-estate developers, used car dealers or professional writers. Only a congress comprised of accountants* can be relied upon to draft laws that are data-based and beneficial to the society as a whole.

        *Contact me for investment opportunities in dot.com businesses, foreclosed properties and Nigerian bank vice-presidents.

        • Oh boy – let me tell you stories of what happened when the bean-counters got a hold of the Navy supply system. It wasn’t pretty. ;-)

        • Personally I think we need congress-critters that were farm laborers, at least then when handed a shovel they would know what to do with all the ‘stuff’ left behind by the former occupants of their office.

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