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Comment: Re:Oversimplification (Score 4, Informative) 336

by jeffporcaro (#44425595) Attached to: How Outdated Data Distorts Doctors' Pay
Mod parent up - insightful. I'm a cardiologist, and while I'm making more money than a Wal-Mart greeter, the days of doctors getting rich, and the days of hospitals making a profit, are essentially over, despite the large numbers thrown around. The costs associated with providing high-level, subspecialty medical and surgical care are enormous, and the reimbursement is continually declining. Congress continually nibbles away at the margins, dictating the rules of the game, and then acts shocked when the rules they implement don't result in free care.

The time and money that I've spent in training has value. The specific skills I have as a result of that time and money are significant, and useful to many people. I'm happy to use my skills to help people - it has intrinsic reward. However, the current climate requires that I do so 10 hours a day, plus nights, plus weekends, always with a smile, every 15 minutes, and job satisfaction has mostly gone the way of the dodo.

4 years of college. 4 years of medical school. 3 years of residency training. 3 years of cardiology fellowship training (gastroenterology, the example from the article, is also a 3 year fellowship). College & med school leave most of us with >$200k of debt. Residency and fellowship pay essentially minimum wage when you account for the insane hours, all the while collecting interest on our college and med school debt. I didn't have kids until I was in my late 30's because we didn't think it was fair to raise them without seeing their father.

We all have this same conversation when discussing the issue of money in medicine. In the beginning, there was a binary relationship - patient, doctor. The doctor provided services, the patient provided cash. These facts haven't changed, except now the care provided is better, the patient spends much more, the doctor gets paid much less, and everyone else in the system siphons away the money without the hours or the liability we incur.

In any event, you're not paying for 15 minutes of colonoscopy time, you're paying for the 14 years of training necessary for the doctor to do the colonoscopy.

Not to mention the cost of the colonoscope and its upkeep, the techs, the sedatives and management of their associated risks, the endoscopy suite constructed and maintained to restrictive code standards, cleaning of the endoscopy suite between each case, archiving and storage of the images, time to interpret and create a report from the colonoscopy, conversations with the patient, the patient's family, the patient's primary physician, time lost from providing other services (office and hospital visits - people are always clamoring for more availability), the enormous billing apparatus, a significant cut to the insurance company, maintenance of certification & credentialing (which requires many hours a year away from the office in a hotel conference room watching Powerpoint slides, at great expense), etc.

What's it worth to you?

Comment: Re:Faraday cage (Score 1) 924

by jeffporcaro (#44155843) Attached to: The Average Movie Theater Has Hundreds of Screens
I'm a cardiologist in real life, when I'm not lurking here, and this is not correct. I've taken call in 4 different systems, and in none of them was there ever a "backup" person. If the person on-call isn't reachable, either patients try again later, go to the ER, or die. FWIW, I don't go to movies when I'm on call (typical call would be one night out of 4, and one weekend out of 4 so not a tragedy). I also didn't bring my kids to restaurants until they were old enough to behave (and we left if they didn't behave). I used to smoke, and I never smoked by the only entrance or exit from a building. I'm completely comfortable asking people to stop talking and using their phone in movies, and I find I need to do that frequently. I'm jealous that there are apparently places where people don't confuse the movie theater with their living room.

Comment: Re:Seriously? (Score 1) 152

by jeffporcaro (#41609223) Attached to: Pandora Shares Artist Payment Figures

BTW, have you ever played an instrument. 2 hours solid on a guitar would leave your fingers shredded, 4 hours you wont feel them for a week (by solid I mean practically no breaks, playing hard for 55 minutes an hour). I have a lot of respect for people who can do this.

I was a music major in college, and 6-8 hours a day on your instrument, between practicing and rehearsing, wasn't particularly out of the ordinary. Not sure where the destructive guitar meme comes from, but for anyone who plays regularly, finger shredding just isn't an issue. If I remember correctly, Bruce Springsteen just did a 4 hour show, and I'm pretty sure there were no finger-related hospitalizations necessary afterwards.

Comment: Re:Don't quit your day job (Score 1) 687

by jeffporcaro (#41608801) Attached to: A Day in Your Life, Fifteen Years From Now
Why the Soulskill hating? I've been here a few years, and it seems that every once in a while, this editor or that editor is deemed an incompetent moron by some sort of acclamation, and I have never been able to find any rhyme or reason to it. Other than essentially saying "I don't like Soulskill," this comment doesn't really add anything to the conversation.

Comment: Re:learn? (Score 3, Insightful) 229

by jeffporcaro (#38425806) Attached to: Ask Slashdot: Transitioning From Developer To Executive?

I recently had to make a similar change - from being in training to becoming one of two cardiologists running a private office, which means I'm responsible for employees.

Making technical decisions is the easy part - managing people is the hard part. You're simply treated differently when you have the ability to make decisions that can change people's livelihood and lives. The best resources I found on this were "Getting to Yes" and "Getting Past No," both touchy-feely pop-style books, but both with semi-useful information in them.

Friends gave me management books, like "The Essential Drucker" and a subscription to the Harvard Business Review - I found all this stuff to be almost useless. I've found that if I spend a few minutes every once in a while checking in with people, and trying to listen to the answers, that things work out well.

good luck...

Comment: Re:Once Again... (Score 4, Informative) 815

by jeffporcaro (#38120262) Attached to: In the EU, Water Doesn't (Officially) Prevent Dehydration

Sorry to re-post - all the carriage returns were stripped. I forgot to add HTML. It reads better with some whitespace.

I'm going to try to to untangle some if the above...

Some guy somewhere once said that you need to drink 8 glasses of water a day to maintain health. Turns out to be nonsense. For those of us with intact thirst centers in the brain (pretty much everyone reading this, for example), drinking when you are thirsty is all you need. Your body will tell you when you need more liquid by using the thirst mechanism. There are exceptions, as there is a lag before thirst is triggered, so on a hot day when you're exercising aggressively, you can get "dehydrated" and not get thirsty in time to do anything about it, but this is rare, and recent evidence tells us that hydrating aggressively, even in marathons, is overkill.

The jumble of hyponatremia, hypernatremia, hypertonic, hypotonic, hypovolemia, hypervolemia, isotonia, etc is maybe worth clearing up, although this will be interesting to precisely nobody. Some of the concepts are almost right.

"hyper" = too much, "hypo" = too little, "iso" = equal.
"volume" is the quantity of fluid (any fluid, technically) in the system.
"natr*" = sodium in the system.
"-emia" = in the blood.
"tonia" = concentration.

So, hypovolemia = low volume of fluid in the blood (hypo, vol, emia) Isotonia = equal concentration (in the medical context, meaning concentrations of a solute equivalent to those found naturally in blood). If you drink excessive fluids over an extended time, you overwhelm the kidneys' ability to maintain normal sodium concentrations in the blood, and you end up with hyponatremia. Drinking excessive fluids is usually called "psychogenic polydipsia," which is med-speak for drinking too much water because your brain is bad. The hyponatremia is potentially fatal, and often causes confusion, among other symptoms. Note that it does not cause (at least immediately) hypovolemia - the quantity of fluid in the system is adequate or high, it's the composition of that fluid that's troublesome.

In this case, one could say that the composition of the blood is hypotonic - there are fewer solutes (particularly sodium) in the blood than normal. This is treated by limiting fluids (reducing solvent, and allowing the kidneys to recover and restore balance), &/or by increasing sodium intake. Pepperoni pizza is a great solution (not kidding - my favorite nephrology professor used to prescribe exactly that). Hypertonic saline is reserved for emergencies. The blood is usually about 0.9% sodium, so a 3x concentrated version of that - typically 3% saline - can be given parenterally (via IV [intravenous], for those of us scoring at home). This is a dangerous treatment, as the brain is susceptible to dangerous/fatal swelling if hyponatremia is corrected too quickly ("cerebropontine myelinolysis," if I remember correctly - I'm a cardiologist, and I haven't thought about this stuff in a long time).

Not drinking enough fluid results in hypovolemia (commonly called "dehydration"). Usually the sodium levels in the blood measure high ("hypernatremia"), although it's not due to too much solute - it's due to too little solvent. The treatment is to replete fluids (volume), either with a a straw and some water, or with IV hydration. Usually 1/2 NS (saline that's hypotonic compared to normal blood, in this case 0.45%) or even normal (isotonic, 0.9%) saline.

The rest of the parent's post is mostly on target. Sorry for pedantry.

Comment: Re:Once Again... (Score 2) 815

by jeffporcaro (#38120174) Attached to: In the EU, Water Doesn't (Officially) Prevent Dehydration
I'm going to try to to untangle some if the above... Some guy somewhere once said that you need to drink 8 glasses of water a day to maintain health. Turns out to be nonsense. For those of us with intact thirst centers in the brain (pretty much everyone reading this, for example), drinking when you are thirsty is all you need. Your body will tell you when you need more liquid by using the thirst mechanism. There are exceptions, as there is a lag before thirst is triggered, so on a hot day when you're exercising aggressively, you can get "dehydrated" and not get thirsty in time to do anything about it, but this is rare, and recent evidence tells us that hydrating aggressively, even in marathons, is overkill. The jumble of hyponatremia, hypernatremia, hypertonic, hypotonic, hypovolemia, hypervolemia, isotonia, etc is maybe worth clearing up, although this will be interesting to precisely nobody. Some of the concepts are almost right. "hyper" = too much, "hypo" = too little, "iso" = equal. "volume" is the quantity of fluid (any fluid, technically) in the system. "natr*" = sodium in the system. "-emia" = in the blood. "tonia" = concentration. So, hypovolemia = low volume of fluid in the blood (hypo, vol, emia) Isotonia = equal concentration (in the medical context, meaning concentrations of a solute equivalent to those found naturally in blood). If you drink excessive fluids over an extended time, you overwhelm the kidneys' ability to maintain normal sodium concentrations in the blood, and you end up with hyponatremia. Drinking excessive fluids is usually called "psychogenic polydipsia," which is med-speak for drinking too much water because your brain is bad. The hyponatremia is potentially fatal, and often causes confusion, among other symptoms. Note that it does not cause (at least immediately) hypovolemia - the quantity of fluid in the system is adequate or high, it's the composition of that fluid that's troublesome. In this case, one could say that the composition of the blood is hypotonic - there are fewer solutes (particularly sodium) in the blood than normal. This is treated by limiting fluids (reducing solvent, and allowing the kidneys to recover and restore balance), &/or by increasing sodium intake. Pepperoni pizza is a great solution (not kidding - my favorite nephrology professor used to prescribe exactly that). Hypertonic saline is reserved for emergencies. The blood is usually about 0.9% sodium, so a 3x concentrated version of that - typically 3% saline - can be given parenterally (via IV [intravenous], for those of us scoring at home). This is a dangerous treatment, as the brain is susceptible to dangerous/fatal swelling if hyponatremia is corrected too quickly ("cerebropontine myelinolysis," if I remember correctly - I'm a cardiologist, and I haven't thought about this stuff in a long time). Not drinking enough fluid results in hypovolemia (commonly called "dehydration"). Usually the sodium levels in the blood measure high ("hypernatremia"), although it's not due to too much solute - it's due to too little solvent. The treatment is to replete fluids (volume), either with a a straw and some water, or with IV hydration. Usually 1/2 NS (saline that's hypotonic compared to normal blood, in this case 0.45%) or even normal (isotonic, 0.9%) saline. The rest of the parent's post is mostly on target. Sorry for pedantry.

Comment: Re:My anecdote disagrees (Score 1) 606

by jeffporcaro (#36211802) Attached to: Professor Questions Sink-Or-Swim Intro To CS Courses

Just a quibble on the Berklee comment - Berklee famously accepts anyone who will pay them - there are no entry barriers other than ability to pay. The music students who come with no musical experience do not last long, do not play in the higher level groups, and do not end up making an impact in the music industry. For this reason, many of us with experience in music education (I'm a graduate of the University of North Texas, so I'm biased) find the statement that "Berklee...is one of the most renowned institutes on the planet" to be - well - inaccurate.

In fact, one might say that Berklee is a great illustration of the topic of this post, by way of analogy. Because it is a famous (I'll make a distinction vs "renowned"), many talented and experienced musicians do enroll, and they go on to have successful and important careers in music. So the experience the students bring to the college are (at least anecdotally) the primary factor in their success. Much like the programming students.

Trying to make inexperienced Berklee students play in the orchestra in 15 weeks (or 4 years, for that matter) is ridiculous.

Comment: Re:Kind of agree... (Score 1) 566

by jeffporcaro (#36059146) Attached to: Doctors Are Creating Too Many Patients
I'm a practicing cardiologist and see my fair share of comments on topics like this, and my responses range from sadness to amusement. The trial showing benefit from normal LDL and elevated CRP was called the JUPITER trial, and wasn't created by doctors or lawyers - it was funded by AstraZeneca, who were "doing their duty" to their shareholders by creating demand for their product, Crestor. The way drug companies do that is by funding studies, which sometimes benefits us (patients), although in my experience, that's not usually the outcome. In any event, the problem in the summary is that it misses the point. Assuming that the results of the JUPITER trial are accurate, and by giving Crestor to 100 people with normal LDL but high CRP, I could eliminate 1 "outcome" (stroke, heart attack, or death - a composite outcome often used in trials like this), the question isn't "am I harming 99 to save 1" - the question is "am I helping this population overall." The harm was minimal, the benefit was impressive. The real harm comes in the form of monetary cost (as well as the rare risk of "adverse events," including muscle injury or liver injury). So what is an acceptable cost of avoiding one outcome? I don't know, but that's where the conversation should be. The way I think of it, there are two rooms - one with people who get the best evidence-based treatment, and the other with people who don't. The truth is that people in the first room live longer, on average, than people in the second room. Being in the first room does not guarantee a better outcome to any individual occupant, but overall, more people will be healthier in that room than in the other, over time. So my job, in a sense, is to get people in that first room. Right now, incentives don't stand in my way, so I'm insulated from the question of cost, to some extent (this is changing for better and for worse, and is the subject of a much much longer post some other day maybe). I spend enormous amounts of time trying to stay current, attending conferences, reading journals, conferring with colleagues. That's hard to argue against, I would hope. Some evidence leads to recommendations that are easy to lampoon (expensive drugs for people without diseases - what will they think of next to steal from us!), but you pay me to walk around knowing things, and to apply that knowledge to you when you walk into my office. As a side note - we've moved on from JUPITER, which later turned out to be less promising than it initially appeared. In fact, I never put anyone on Crestor simply because of high HDL - and current research has backed me up - we are "late adopters" in my practice, which I would highly recommend if I were a patient. This didn't stop dozens of patients from asking me for/about it after it was summarized in the NY Times in a much more flattering light than the summary above.

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