Extra: Pitfalls of Modern Medical Training and the Dr/Primary Care Shortage

[00:00:00] Howdy Howdy. Today we're going to talk a little bit more about medical training, kind of outline

[00:00:05] the path to becoming a physician and talk about some of the cultural problems associated with

[00:00:12] medical school and residency. We'll talk a little bit about the cost, a little bit about the

[00:00:18] primary care shortage that we see in the United States, which is the worst of any country

[00:00:24] in the world by a lot. This is also one of the first recordings that we did with Rob,

[00:00:32] my audio engineer and friend. So you'll hear him a little bit on the discussion as well as

[00:00:38] a good friend of mine and former co-resident Ariel Blythresky. She is a delight to be around,

[00:00:46] is very intelligent, high energy, eccentric, cares a lot about her patients, has a really

[00:00:51] good bedside manner and is a good critical thinker, which is much needed in the field of psychiatry.

[00:00:58] Her and I together are maybe a little bit unhinged at times, but it should make for an

[00:01:04] interesting discussion. And if you like this more informal discussion format,

[00:01:10] please reach out to us, let us know at Renegade Psych on all social media platforms

[00:01:15] or RenegadePsych at gmail.com. Hope you enjoy. Somebody get this guy some help.

[00:01:31] Let's just kind of outline in a little bit more depth the path to becoming a physician

[00:01:36] in the United States. In your undergraduate years, you've got to pick a major. Usually it's

[00:01:42] something like a pre-medical or biology or chemistry, building a resume, trying to make

[00:01:48] some connections within the field. And you're preparing for the MCAT, which is the intro

[00:01:54] to medical school test, eight or nine hour test. If you're lucky enough to get entrance into

[00:01:59] medical school, you do roughly two years that are focused more on academic and you're just

[00:02:05] head in the book learning everything there is to know. And then you do two more years

[00:02:09] of clinical work where you're on the wards, you're in the hospital, you're in the clinic

[00:02:15] all the while you're taking tests for everything, tests on tests on tests. You can only fail a

[00:02:20] couple of them within your medical school. You're taking national standardized exams,

[00:02:26] step one and step two. You have to pass those to continue moving along in the process.

[00:02:33] Then in your fourth year, you start doing all these interviews and figure out where you

[00:02:37] want to spend the next four years doing your residency. Orders are $1,600, $1,700, but you've

[00:02:44] got to get it. Boards are $1,600? You've got to get a prep course along with it. But you spent

[00:02:50] like $3,000 on tests before you started making money. This is coming out of negative money.

[00:02:56] For step two, did you have to go to another city? I did step two. Yes. So you did. I went to LA.

[00:03:03] So after your third year at medical school, you have the standardized test at step two,

[00:03:07] nine hour multiple choice test. And then they used to make you go to one of five different cities

[00:03:15] in the country. You had to travel there and you see 12 different standardized patients or fake

[00:03:22] patients. And they all give you a grade. And you have to pass that too. And that was like

[00:03:27] a $1,200 thing. The test alone and the plane ticket, the hotel, you had to pay for all people took

[00:03:34] loads of drinks afterwards. Well, obviously that's another $1,200. At least how much time do you have

[00:03:41] to get a job outside of medical school? None. I tried to have a job five, 10 hours a week,

[00:03:48] but then I failed my first two tests. Oh my God. First two anatomy tests. So medical schools

[00:03:52] make you sign a contract that you're not allowed to have a position outside of med school.

[00:03:57] And even if you wanted to, there's no time because of all the me turn into a rote memorization machine.

[00:04:04] That's your full-time job. Residency is anywhere from three years for something like family medicine

[00:04:10] or emergency medicine up to seven years. If you want to be a neurosurgeon, you've got to take

[00:04:15] another what's called a step exam or a national standardized test. You got all kinds of performance

[00:04:21] reviews. You got to keep studying, keep expanding your knowledge. And then when you finally hopefully

[00:04:27] graduate from your residency program and don't fuck anything up for that four-year period,

[00:04:33] hopefully then you pass your boards to where you are now an officially certified psychiatrist or

[00:04:40] family doctor, etc., etc. If you are a primary care physician, you're talking about at least

[00:04:45] 11 years. If you are a neurosurgeon, you're talking about 15 years. Then there's fellowships on top

[00:04:53] of that. If you want to be the guy who takes out some rare gallbladder tumor or treats some rare

[00:05:01] pancreatic cancer or something, then it's another couple of years doing that exclusively.

[00:05:06] And then you have to take tests every 10 years. A lot of the European countries when

[00:05:13] people want to go into medicine, they will go to college and start their medical track.

[00:05:18] A lot of them started med school outside of high school and did six to seven years of

[00:05:23] dedicated medical training as opposed to our four years of horseshit. One entire year of basic

[00:05:30] sciences where we learned the crap cycle multiple times. And I've saved a lot of lives with that.

[00:05:36] And then just really two dedicated years of learning medicine for real.

[00:05:43] That's the problem where you do two years of just your heads in a book.

[00:05:47] And that stuff's important. Answering multiple choice questions is important

[00:05:51] because you do have to exhibit that you can retain a bunch of information and pull it out

[00:05:56] when you need it. And learning biochemistry is important if you want to know how the

[00:05:59] medications work. I think it's easier to remember mechanisms of action that become

[00:06:04] relevant to you and your practice if you know the biochemistry behind them. But you're never

[00:06:10] going to use the steps of gluconeogenesis or glycolysis. Why can't there be a little bit more

[00:06:17] balance in those first couple of years of school? You're going to do four weeks of head in the

[00:06:21] book and memorizing information, but then you're going to do a week or two where you're

[00:06:26] in the hospital. You're working on some service that is relevant to what you've been learning

[00:06:30] and you are actually providing something to that team that they've probably all forgotten.

[00:06:36] You learned through experience. You touched on not even knowing that I wanted to touch on it

[00:06:42] is this rote memorization. Find the right answer, be able to pick A, B, C, D or E on a multiple choice

[00:06:49] exam enough times. Wish life were multiple choice at this point because that's how I think

[00:06:55] anymore. I understand the point of rote memorization to a degree, but having been to medical school,

[00:07:03] I know I was never dumber and less interesting than when I was in medical school because as

[00:07:10] you're aware what they teach you how to do is regurgitate facts and not necessarily critically

[00:07:18] think. Medical school turns out all these cookie cutter doctors who have a lot of facts,

[00:07:26] but don't really know how to use them and don't know how to think. It's so frustrating and I

[00:07:31] number among those physicians you have to relearn how to think critically. I think layered onto

[00:07:37] that just imagine back in first year of medical school and you're sitting in class and the

[00:07:43] professor's talking about something that you don't fully understand, but you're in this ultra

[00:07:48] competitive. Everybody is so smart and they want to let you know how smart they are and so how

[00:07:54] comfortable did you feel raising your hand to ask a dumb question? Also for a woman who probably

[00:08:01] has an anxiety disorder I have to preface every question I ask with this might be a stupid

[00:08:06] question. You don't want to come off stupid but if you don't want to come off stupid not

[00:08:10] knowing that you come off stupid. You're constantly in this dick measuring contest with other physicians

[00:08:17] if you did not ever have a dose of humility you would in med school and you would learn that

[00:08:23] humility is a suppository. And so you get two kinds of physicians. You get people who were so

[00:08:32] stampeded by the system that they are apologetic and have so little confidence

[00:08:38] and then you get people who are the opposite. They're completely unapologetic because they need

[00:08:44] to project this air of total confidence in order to feel like someone who knows what they're doing.

[00:08:51] They have to project that they do but they don't take any input and so you get these ultra competitive

[00:08:57] shutting every other opinion out physicians. It closes doors it closes so many doors for

[00:09:02] your own understanding and your own growth. The medical training of course it's essential

[00:09:08] to your development as a physician you have to get it. There's so much information that you

[00:09:13] learn in med school that you need to know but if you were going to be a good doctor you were

[00:09:18] going to do it despite your medical training because your medical training it teaches

[00:09:22] you what you need to know to be a good doctor not how to be a good doctor. It breeds this

[00:09:27] desire to have the right answer. You spend so much time taking tests not just the five or six national

[00:09:35] standardized exams that you got to take but all your tests within your medical school and

[00:09:40] undergraduate so it really gets drilled in. Find out how to pick the right answer of these

[00:09:45] four to six options for every question. It's like a whole different game in its own.

[00:09:51] Yeah and so you do that for eight years maybe ten years and then you start seeing patients

[00:09:58] and it's like you're ingrained in this philosophy of I've got to find the right answer here but

[00:10:04] we're talking about human beings. We're talking about like super complex organisms. One of the

[00:10:09] reasons that we thrive is because we are so diverse every human being is like a snowflake

[00:10:16] unique and different and that carries with it a lot of evolutionary benefit if

[00:10:23] some virus comes through and hits us hard then it's not going to kill everybody because everybody's

[00:10:29] immune systems work a little bit differently. This system prioritizes knowing the right answer.

[00:10:35] It's a whole different like learning the answer they want to pick versus finding the answer

[00:10:40] in a person they don't necessarily like correlate. Right and if you come into the doctor and

[00:10:45] you're like oh I have this headache and then a little bit nauseous and I just try to find the

[00:10:52] right answer. If I miss it on the test then you know that's one point that I missed on the test

[00:10:57] but if I miss it in the context of your life then the consequences are a little bit more severe.

[00:11:04] The number of doctors that come out every year is a relatively stable and predictable number

[00:11:11] because there's only so many medical schools that have so many positions available.

[00:11:17] The bigger thing is there's only so many residency slots. That is when you're finished you graduate

[00:11:23] medical school and you go through this whole match process to try to find a place that matches with

[00:11:30] you. So the match occurs in March. You apply in your fourth year of medical school you send

[00:11:36] out a bunch of applications. You get letters of recommendation you send in all your test scores

[00:11:42] then around September, October they send out an interview request to you. Hey you want to come

[00:11:49] to Boston? They used to be all in person adding to the amount of money that you have to spend

[00:11:55] for flights and hotel and most of the residency programs don't cover you.

[00:12:02] Everybody's been interviewed by a bunch of programs. All the residency programs have a

[00:12:07] rank list. All the graduating medical students have a rank list and then this computer algorithm

[00:12:14] just goes ham and matches everybody to their program. It's a fucking computer? Yeah it's

[00:12:21] based on the rank list. If you had Yale as your number one school and Yale has nine spots

[00:12:29] and you're the tenth person and the other nine all wanted to go to Yale then you would not be able

[00:12:34] to go to Yale. That's the simplest way to describe it. All right so there's three different types of

[00:12:40] graduates that will apply for these positions. International foreign medical graduates people

[00:12:46] who went to what are called DO schools more homeopathic type of medicine more holistic

[00:12:53] but have the same amount of training as MDs. The American graduates do pretty well.

[00:12:59] The DOs and the MDs 85 to 95 percent match of the foreign medical graduates. This could be somebody

[00:13:06] who has already completed medical training in another country and is practicing there.

[00:13:12] They're right around 50 percent. Let me give you some numbers here. So 21, 2021 and 2022

[00:13:19] you had about 85,000 medical school graduates and they applied for 71,500 first year residency

[00:13:28] positions. So right there you've got a surplus of people who could enter into a residency position

[00:13:36] of 13,500. You've already got the people who want to pursue it and again a lot of those are

[00:13:44] international medical graduates but you're still talking about it roughly a thousand

[00:13:48] US graduates who have gone through the whole system in the United States and jumped through all the

[00:13:53] hoops and stuff. So that's 84 percent of medical school graduates who by the way have an average

[00:14:00] debt of 200 to 250,000 dollars match into a residency position. If you take out IMGs you're

[00:14:08] still talking about six to 10 percent of United States MD and DO graduates that don't enter into a

[00:14:15] residency position once they graduate. The number of residency spots that are funded primarily

[00:14:22] through what's called GME or Graduate Medical Education which is funded by Medicare and

[00:14:29] a little bit of the Veterans Affairs or the VA they control the number of residency positions.

[00:14:36] So literally every year there are thousands of students who don't match into a residency position.

[00:14:46] So then they made it all that way and they're just like well fuck?

[00:14:50] Yeah if they made it to that spot where they actually graduated medical school,

[00:14:54] they passed all their standardized exams, they did well enough in their classes to pass those

[00:14:59] actual medical school tests. You could end up not having a place to continue your more relevant

[00:15:07] clinical training and all it would take is to expand the number of funded positions.

[00:15:16] In the 70s and 80s the government was worried about a doctor surplus.

[00:15:21] A doctor surplus? Yeah. Hilarious. They're worried that there was gonna be too many

[00:15:25] docs and then for docs to be able to make the amount of money that they would need to make to

[00:15:29] offset the costs of school and residency, they would be doing all these unnecessary procedures

[00:15:35] and necessary tests and killing people for their organs. Exactly. That quickly fell out

[00:15:42] of popular opinion. We realized that we don't have nearly enough primary care docs to service

[00:15:47] our population. In 1997 this act passed in Congress called the Balance Budget Act and

[00:15:53] because Congress and the federal government subsidizes 90 something percent of the residency

[00:16:00] positions, in order to balance the budget they said no more increase in residency positions

[00:16:06] year over year for the next at least five years. Even though our population continues to increase.

[00:16:13] 2007 Congress put out this bill called the National Resident Physician Shortage Act.

[00:16:21] We don't have enough doctors to treat our population so we're gonna try to push this

[00:16:27] bill through that's gonna add 15,000 residency positions over a five year period. Start to

[00:16:33] address the problem. Well election cycle comes and goes and then all of a sudden that 2007

[00:16:40] National Resident Physician Shortage Act just kind of disappears doesn't get signed into law.

[00:16:46] A couple years later there's the second edition of the National Resident Physician Shortage Act

[00:16:54] and the exact same thing happens. There have been 12 or 13 of these acts nothing ever happens with

[00:17:01] them. They all propose to increase the number of residency positions to meet the shortage.

[00:17:08] They know how many we need over what period of time and then it fizzles out right after

[00:17:14] the election cycle. Yeah like every promise that requires money. Exactly it's literally just a scheme

[00:17:20] to help with reelection. Hey look at what we're doing. Only recently did anything get done. The

[00:17:27] one from 2021 didn't get passed. The only thing that's happened is there was another bill

[00:17:32] that gave us a thousand more residency positions just like a one-time thing. That's not nearly

[00:17:39] enough. Obviously the financial impact excludes a huge proportion of people that might want to do

[00:17:45] medicine, might be smart enough to do medicine and most importantly I think have the right mindset

[00:17:51] or the right reason for being there. There's an even more pressing problem in terms of what people

[00:18:00] who graduate from medical school do after that. This was staggering to me. You take 100

[00:18:06] physicians who graduate from medical school in the United States there will be roughly 12 of those

[00:18:12] who go into primary care. The person who's supposed to have an understanding of your whole health and

[00:18:18] well-being. I'm not surprised that's why there's a primary care shortage and that's why they're

[00:18:25] trying to bridge the shortage with mid levels whether they be MPs or PAs. The second lowest

[00:18:31] number is 23 percent in Germany. It's pretty tragic. 2.6 physicians in the United States per

[00:18:39] 1,000 people. If you break that down even further 0.3 primary care physicians for 1,000 people if

[00:18:46] everyone was to see an MD or a DO as their primary care doc those primary care docs would have to

[00:18:52] be seeing 3,300 patients a year but beyond that first I want to touch on how the culture within

[00:19:02] medical school treats people who want to do primary care. I went to University of Minnesota

[00:19:08] one of the top 10 schools in the country for recruiting primary care physicians. There was

[00:19:12] a lot of encouragement to go into primary care and a few people that I knew even had

[00:19:17] full-ride scholarships for people interested in primary care. The scholarship would pay

[00:19:23] as long as you were committed to a primary care specialty. That sounds like a solution.

[00:19:28] It is a solution. What was the attitude at UofL? It was like oh you want to do primary care,

[00:19:34] you're not very cool, no no no the cool kids are doing primary care and you must not be very

[00:19:39] smart. Okay that's so interesting that was not my experience really because of where I went

[00:19:44] to school and because of what they're trying to do is recruit more people. So I think the school

[00:19:48] attracted more people who are interested in primary care. Yeah we graduated more primary

[00:19:53] care doctors so because you went to a school that did not encourage matching in a primary care

[00:19:58] residency I'm interested to hear why you think people don't go. My guess is primarily the

[00:20:06] money for people who don't know primary care specialties are among the worst paid. I

[00:20:10] think pediatrics is by far the least compensated and again it sounds really insensitive if you're

[00:20:15] hearing this as someone who's not a physician to hear a physician say these doctors don't make much

[00:20:22] money but for the amount of education. And again I'm excluding teachers and social workers,

[00:20:29] you guys are excluded from this because you go through a ton of education and you get paid

[00:20:33] jack shit. You get paid jack shit exactly. For people who went through 11 or 12 years of education

[00:20:40] they get paid very poorly. I don't think that's the case in other countries that don't get

[00:20:45] compensated as well for specialties as they do in the United States. Yeah and you're talking about

[00:20:52] being very realistically a million dollars behind from where you could be. In Minnesota which

[00:20:59] where I went to med school I heard a statistic that by the age of 60 the average family medicine

[00:21:06] physician will be worth as much as the average teacher. In a state that is one of the best in

[00:21:13] the country for physician compensation. The remaining number like not going into primary care

[00:21:19] were they doing. In the United States everybody specializes it's usually a little bit longer

[00:21:25] training but there's more money. So it's kind of like you've come that far you might as well do

[00:21:31] the other couple years to specialize in something and it's well worth it financially because you're

[00:21:37] fucking a million dollars in debt. The shortage lies in primary care. Drastic shortage. I remember

[00:21:44] starting medical school there were maybe 120, 130 people in my class and 40 of them that were

[00:21:51] going to be orthopedic surgeons. Yeah yeah. And another dozen who are going to be neurosurgeons.

[00:21:56] Emergency medicine was tits when I was going to school. OB attracted a lot of people. Yeah

[00:22:04] Orthopods are everywhere. Orthopods are everywhere. Yeah and the orthopods are those jacked guys who

[00:22:08] are getting up at 5 a.m. to go work out. Honestly I knew one guy in my class who was interested

[00:22:14] in orthopedics and he was one of the best students in our class who like gave a shit.

[00:22:18] He probably couldn't bench press very much then. Add your step one score to your bench press and it's

[00:22:23] got to be over 500. So what are you bench man? So you better either be really smart or you better

[00:22:30] be jacked. Those are your options. Yeah that's correct. When you are in medical school you're

[00:22:36] talking about a bunch of Taipei people who've always gotten the best grades and been the

[00:22:41] smartest. You put them all together. Bunch of egos. What do you think people talk about

[00:22:46] going into in their first couple of years of medical school? What would you want to be?

[00:22:51] Fucking surgeon. Right I want to be an orthopedic surgeon. Oh I get what you're saying. The ego and

[00:22:57] like why would you sell yourself short and say I'm gonna be a primary care person. Yeah you've

[00:23:01] got this whole environment that is all about getting high test scores, knowing the right answer

[00:23:10] and in terms of like standardized national exams that all the medical students across the country

[00:23:17] take you get a score. When you go into residency years later these scores really matter. In order to

[00:23:26] do orthopedic surgery you better be in that 70th, 80th, 90th percentile of test scores.

[00:23:34] That produces this ultra competitive atmosphere and nobody's competing for the primary care spots.

[00:23:41] Oh it's like fucking playing baseball and being like I want to play for the

[00:23:45] Louisville bats when I grow up. Right even though in reality if you're talking about

[00:23:49] who is going to make the biggest impact on somebody's life? Primary care. Primary care

[00:23:55] absolutely. Intellectually you can see a bunch of different stuff, treat a bunch of different

[00:24:01] conditions. You can be like the old time doctors or critically think about something, use all this

[00:24:08] knowledge that they have but not in a memorized way. This is all obviously driven by like future

[00:24:15] salary for the most part unless you're very passionate about it. It's not just money

[00:24:20] though it's also the prestige. In your fourth year of medical school you have what's called

[00:24:26] match day where everybody figures out if they match into a residency spot and where at the same time

[00:24:32] which is kind of wild. And that's like getting picked for the team. Exactly. Exactly. If I can show up in your names not on the sheet.

[00:24:39] Yeah or you show up and it's like oh I got my 12th selection out of 13. I've got to go down to

[00:24:48] bumfuck Kansas and do primary care. It's put us in this situation in our country where

[00:24:54] we're graduating all these doctors not even enough doctors but we're all specialists. Yeah 89% of us are

[00:25:03] in some specialty. There is so much prestige attached to becoming an orthopedic surgeon or

[00:25:10] a neuro radiologist, a pediatric oncologist. There's so many people that want to do those

[00:25:17] things and there's limited numbers of spots for those. So there's a lot of people who don't

[00:25:21] match into those more specialized positions. Then there's what's called the supplemental match

[00:25:27] or the soap. This week period all these residency programs that didn't fill spots

[00:25:34] are reaching out to you because they know you're in the match but that you didn't match in any of

[00:25:39] those specialties. So most of those positions are going to be in primary care and unless

[00:25:44] you're willing to go into primary care where you will almost assuredly find a spot to

[00:25:49] scramble into your other option is to wait until the next year and figure out something to do in

[00:25:55] that year between that will build your resume or connect you to some specific program. There's

[00:26:01] a lot of people just doing it almost against their will that are even doing it like nobody

[00:26:05] wants to fucking do this. Exactly competitively who is landing in those positions? The people

[00:26:12] that don't want to be there and the people who generally had bad test scores or bad interviews

[00:26:18] or just bad candidates. You don't have the people even if they maybe like inherently really want to

[00:26:25] be the old timey family doctor they wanted to do that and then they get to medical school

[00:26:30] and for four years they're kind of told without being told this only people who couldn't match

[00:26:35] into these other more prestigious positions going to primary care. Yeah it's prestigious to talk

[00:26:42] about but if they were paying less then I don't know that we would still have the perception that

[00:26:48] they were so prestigious even though it's a specialized. I mean if you think about it these

[00:26:53] guys are one trick ponies you know a lot about this one thing well the primary health guy needs to

[00:26:58] know a lot about everything yes so that's like a more valuable. On a societal level absolutely

[00:27:05] always think about what if there was an apocalypse nobody really cares if you're really good at

[00:27:11] taking out a hankerous and avoiding the common bile duct and not nicking the aorta and I don't

[00:27:18] want the guy that's only been you know looking at baby dicks for in 10 years or do I want the guy

[00:27:24] that's seen it all had more for that guy everybody needs a primary health care everyone needs their

[00:27:30] you know their doctor. They picked out one year of all ambulatory care visits which is just

[00:27:36] anytime that you go out somewhere to get care whether it's in a clinic or a hospital 50% of

[00:27:43] them are primary care related problems and yet we only have 11% of us that go into primary care.

[00:27:50] How can you incentivize people to do what we need them to do? That is part of the solution

[00:27:57] This is the average BMI of the patient population in Bowling Green Kentucky and this is the average

[00:28:06] BMI of your patients. This was the profile of this patient before they came to see you. This is the

[00:28:12] profile of this patient after they came to see you just like getting a general medical

[00:28:16] checkup or a general medical checkup. This is the average BMI of your patients. This was the

[00:28:23] profile of this patient after they came to see you just like getting a general health screening.

[00:28:28] You are likely to have prevented some outcome therefore government will incentivize you in

[00:28:35] some way as opposed to the way that our system works now which is hey we'll incentivize you

[00:28:41] for seeing as many people as you can in the allotted amount of time and you just prescribe

[00:28:45] them all an oral and send them out of the way. Exactly so I guess we conclude that

[00:28:51] medical school in the United States is flawed in a lot of ways. It should be more experiential.

[00:28:56] It should encourage critical thinking, overwrote memorization. We didn't even talk about that

[00:29:02] like in terms of how you could test that. Even just having a multiple choice test and having

[00:29:07] the ability to ask questions about a question will show how much you know or don't know. I don't

[00:29:12] know how we change this or if it's possible or if every other country has the same culture

[00:29:18] as we do but the culture of medicine where you are not allowed to not know and you cannot

[00:29:25] demonstrate, you cannot betray ignorance which lends itself to either just a complete lack of

[00:29:33] confidence or a facade of overconfidence that is dangerous. We need to be able to ask questions

[00:29:41] without being made fun of or disregarded. You go to your doctor, you want your doctor to know

[00:29:48] what they're doing but I think I have more respect for a practitioner who tells me that

[00:29:52] they don't know but they'll figure it out than somebody who tells me that they know and they

[00:29:56] actually don't. This is reflected in medical school culture probably adopted from society in general.

[00:30:05] People have very high expectations for their physicians that they need to be acting a certain

[00:30:10] way, that they need to wear some tweed or something. They need to look professional. They

[00:30:15] can't have tattoos. They can't have colored hair. They need to look a specific way and they need to

[00:30:21] always comport themselves in a specific way and they can't fucking swear

[00:30:26] and they need to know and dedicate their lives to knowledge and not do anything else and that

[00:30:32] makes for a person that nobody wants to be around and nobody wants to take it. Nobody

[00:30:36] wants taking care of them. Yeah and none of that even touches on the impact that the industry

[00:30:43] has in our field and especially in America. We didn't ever talk about that. We didn't talk about

[00:30:48] having to document a certain way not in order to protect yourself legally. Definitely talked about

[00:30:54] that but in terms of making sure that shit gets paid for by the patient's insurance company,

[00:30:59] you are diagnosing them with the right condition not with what they actually have necessarily

[00:31:04] but with something that their insurance company will pay for. Yes. Will pay for the medicine.

[00:31:09] You got to have a certain number of symptoms described based on a diagnostic statistical manual

[00:31:16] that has been long ago debunked as not accurately portraying what mental illness is. Oh yeah.

[00:31:23] You've got big pharma reps who are coming in and educating you despite them having no clinical

[00:31:30] experience or education on how to use a medicine. And insurance is dictating

[00:31:35] what care you can or cannot provide for your patient. Yeah those are aspects that we need to

[00:31:42] have knowledge of before we get to our position where it makes you feel burnt out. It makes you

[00:31:46] feel like you cannot affect the system in a measurable way. It leads people to say I'm just going

[00:31:52] to be apathetic and what do you want? Oh you want a benzos or I don't care. You want a

[00:31:57] necessary eye. Okay yeah these are the side effects that I know about. I am going to tell

[00:32:02] you that this is going to help but I don't really know what's true about the long term.

[00:32:06] We've got to recognize like our role in these societal trends, our role in the opiate epidemic

[00:32:13] that started in medical school that saying we're under treating pain,

[00:32:16] the benzo epidemic up and down throughout the last 60 70 years because we're under

[00:32:22] treating anxiety etc etc. We need more government funding for residency positions. We've got

[00:32:28] to get people to go out into the rural community. We need people to go into primary care. Yas. We need

[00:32:33] more fucking humans to be in medicine. God bless but we need people. We need people. Not to Dr.

[00:32:41] Botts. Exactly not algorithms. Yes exactly. Somebody get this guy some help.

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[00:33:23] The information provided in this podcast and related materials are meant only to educate.

[00:33:26] This information is not intended as a substitute for professional medical advice.

[00:33:29] While I am a medical doctor and many of my guests have extensive medical training and experience.

[00:33:32] Nothing stated in this podcast nor materials related to this podcast, including recommended

[00:33:36] websites, texts, graphics, images or any other materials should be treated as a substitute for

[00:33:40] professional medical or psychological advice diagnosis or treatment. All listeners should

[00:33:43] consult with a medical professional licensed mental health provider or other healthcare

[00:33:47] provider if seeking medical advice diagnosis or treatment or put more simply need help like

[00:33:51] this guy. Call your own doctor.