Several interesting (and complex) discussions in this episode! Input on end of life discussions: it is clear to me that the entire process as it stands now is inefficient, chaotic, and generally does not seem to be working well. As a primary care doc, I have LOTS of end of life discussions and as Adam rightly states, these discussions are often complex and even with modifying your approach to the patient, don't always go as well as we'd like. The hospitalists are clearly overwhelmed by the task of having this discussion, on the fly, with every person entering the hospital. It is also clear to me that not every clinician even understands the POLST form/discussion process and who should really have these. Differentiating POLST from advanced directives is even an issue.

To me, the bottom line is our aging population and the fact that elderly with multiple comorbidities are living longer - these are the people who end up in the hospital in great numbers and are overwhelming the system. The hospitalists are desperately trying to limit ultra aggressive measures on people for whom these are just not appropriate interventions.

Rather than "quality measures" to make sure PCP has had an "end of life discussion" with patients, we need a more broad, medical and societal approach and agreement on who potentially benefits from CPR and who does not. I have a 95 y/o patient who refuses to complete a POLST form! And even if a person has had discussion with their PCP, the hospitalist has to ask every person at every admission whether they want CPR. It is an overwhelming task. These are bigger societal issues, that medicine should take the lead on addressing.

As the "silver Tsunami" is just starting (the oldest baby boomers are only 79 years old - true frailty sets in for most people at around 85 y/o) - the wave is only just beginning. Our system will be overwhelmed by doing inappropriately aggressive treatments on the frail elderly unless we come up with more broad ways to manage care. I know this gets into discussions of "ageism" and "rationing care", but it is a fact we have to face. I think the system will break over the next 20 years. Unless we have a more organized, societal approach, the current process will remain (and get increasingly) chaotic and inefficient. Quality check-boxes are not the answer! I'd love to see the medical profession take the lead on how things should evolve over the next decade.

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Have to say as an Australian med school grad, that I think work/life balance should be first up. It is not normal for doctors (or anyone else) to work 80 or more hours a week. Other countries train perfectly good physicians on a 40-hour work week. There is nothing noble about trying to take care of a patient while sleep deprived in a country that spends 20% of its GDP on healthcare. Patients deserve better and so do we.

Similarly, I wouldn't select for students who are driven by the day to day of medicine. Who's to say what the day to day will look like in twenty years? Will radiology be replaced by AI? Will ER docs be replaced by PA's? I think the value of diversifying one's skill set beyond medicine goes up the greater these uncertainties. We may all end up designing algorithms and supervising midlevels. I see primary care physicians running away from clinical jobs. Picking med students who want to do the thing that the average American physician wouldn't recommend their own child do seems like it's setting them up to fail.

Also notice that there was no discussion of the upcoming Supreme Court decision, but if affirmative action falls, that will have massive effects on med school admissions. I'd like to see a blinded admissions process where the initial reviewers don't know the demographics of the applicant.

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Biomarker as the primary endpoint (which is barely statistically significant) and evidence of significant side effects = new guidelines. Evidence-Based Medicine? Guidelines are becoming just a marketing strategy. Doctors are losing their autonomy to push back. Patients are going broke. Pharma is flourishing.

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