Google almost convinced me to spend $400 on useless laser treatments
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This characterization makes it sound like a good thing. In reality, the doctor’s responsibility is being pushed to the patient because they are overbooked in the name of economic efficiency.
As a patient with complex, non-specific medical condition, I can tell you how miserable this is.
I can’t count on doctors _at all_ to move the process forward. It’s always me, reading articles on PubMed and coming up with ideas.
I’m not medically trained nor am I scientist. It’s a lot of legwork for me normally, but the ways that being sick limits me make it much harder.
Further, the emotional and intellectual overhead required to negotiate with medical professionals is high.
Back when I could afford to, I saw a neurologist at an office that didn’t accept insurance. She choose to see fewer patients and give them more time, as well as spend time doing research to look for new clues and ideas.
This worked really well and I made progress with her.
The rest of the American medical system? Gatekeepers that block access to potential treatment pathways until you can convince them it’s worth a try.
The United States' healthcare system is fundamentally broken. As it stands, it's probably completely irreparable, as well.
Patients who are proactive in their own treatment are a positive, not a negative.
I agree we should be able to rely on them more, but the point is to get a better outcome, and to do that, being an active participant in your treatment is a great option.
The risk I guess is that being informed might make me want to overrule the experts. On a population scale the advice might be bad. Depends on how good the experts are.
In my opinion if you disagree or have doubts about treatment you should definitely bring those up with your doctor, see what they say about your reservations, and either get convinced or find some second opinion to increase trust in the expert opinion vs your own research. One thing I've learned from living with a doctor for several years is that an informed curious person on a very specific subject knows more than a doctor that has to know about a million things and probably isn't up on medical research papers. Your duty should be to bring up that research to your doctor and bring them up to speed. Once they read those they'll understand them better than you, but before... not a given.
Discussion is always better than no discussion. Engineers get thing wrong all the time, but code reviews help. You should help your doctor to minimize mistakes rather than just accepting everything.
Not only that, medical history is often wrong. I've often corrected previous notes to a new doctor - learning only then that the previous one hadn't actually understood what I had shared. There's a million ways in which your active involvement and care improve your outcomes.
Another time I asked about several aberrations in an x-ray after a surgery, and the doctor admitted there had been a slight mistake during the surgery that chipped a bone, but that it wouldn't have negative consequences. He didn't bring it up until I asked.
We're all dunking on doctors in this thread, but look at it from their perspective: They're probably sick and tired of patients coming in to their office saying "The TV told me: Ask your doctor about Provalanix!" And patients who googled "How to get your doctor to proscribe SSRI medication". And patients who insist they should go with their aunt's Healing Crystal Therapy. And patients who asked HN for medical advice[1] !! If you want to really do research, go get a medical degree and then do actual research in an actual academic institution.
Yes, have a discussion with your doctor. Yes, ask him or her if you have concerns. Maybe even get a second opinion (from another real doctor). But don't think your keyboard is going to bring you to The Truth That Doctors Dont Want You To Know.
1: https://news.ycombinator.com/item?id=31098263
EDIT: Right, the comment is not directed in particular towards its immediate parent, more in general at the entire thread.
- reading medical research papers
- bringing detailed information about your symptoms
- mentioning things you ruled out and things you've tried
- having a good understanding of your medical history
I didn't mention ads on tv, youtube videos or HN comments. Perhaps you should reserve your outrage for the proper place.
If someone gets information from video format they should be ignored?
If someone came in and wanted to have a conversation about a medical product they recently heard about they shouldn't go to their doctor with questions?
Sounds like someone is close to retirement or leaving the field with that attitude. Those are all valid concerns the general public may have. That's your job as a gp (to schedule appointments while patients tell you things you suggest your ideas).
PubMed is a great resource. Of course, it takes a lot of effort to really get something useful from those papers, since you need to try to understand the experiment they did, and not just read the conclusion (scientists have biases as well, and will often read what they want into the results).
But depending on how bad your condition is, it could absolutely be worth the time.
> But don't think your keyboard is going to bring you to The Truth That Doctors Dont Want You To Know.
Neither do I. I expect instead it might bring you to The Truth That Doctors Don't Know.
If a doctor breaks your body irreparably, it would seem there's a high probability that you have no recourse other than in rare situations you might get a settlement for some cash. Cash that won't fix your problem.
My main point is that the risks aren't comparable at all.
My experience with "experts" has been almost universally underwhelming. The only notable exceptions I've had is with a couple of veterinarians.
It's not a great but a necessary option, unfortunately.
Better would be if they gave you a % of their salary in that case.
You assume they actually know what needs to be done. In my experience, you can see they don't have a clue and aren't willing to do research to learn. They just hand out their usual prescriptions, etc and sometimes hope an exam will give them an obvious answer.
On top of that, most doctors only have a very narrow understanding of the human body and don't know when to refer you to some other doctor they will be better equipped to help you.
But you don't... that's the whole problem with the American Healthcare industry!
Which is to say: standard-of-care treatments can cost far too much relative to other countries; but also, if you’re willing to throw millions of dollars at private clinics, you can opt your own way into experimental treatments that don’t exist anywhere else in the world.
They have a system where you get evaluated by a general practitioner (or someone more relevant), and then they schedule you to see however many specialists you might need to see - all within a day or two.
It's not perfect, and I've found it's still hard to get them to drill deep on anything not life threatening or obviously testable. That said, I very much doubt that system exists anywhere with socialized medicine. You don't need a referral or anything else to go. You just call and make an appointment.
Within 45 minutes of arrival they had figured out what was immediately wrong and had me hooked up to an IV drip of stuff to fix it. An hour later, a specialist for my issue came and talked to me about the problem and had an idea for a root cause. I was held overnight for observation and had several more tests run; by the time I left the next morning I had a root-cause diagnosis and a prescription to fix it.
Those antibiotics, man. They work.
I see these comments all the time on Reddit and HN but never see the reverse from US posters. They just come across as insecure and snooty.
Then the financial problem is fixed, and Homer carries one of them, all the while spouting about the European health system, to the garbage can. He says "Time to take out the Eurotrash."
And considering that you can find a dentist to do a root canal for $300 without too much trouble, I'm surprised anyone would be able to fly to Croatia and get treated for that little.
I'm transgender, and everything the top-level poster said about incompetent doctors, gatekeeping, and having to read literature and teach yourself about your own medical condition absolutely 100% applies to me and nearly every other trans person I've talked to (I remember printing out the Endocrine Society guidelines and taking a highlighter to them in order to convince a doctor that what I'm asking for is standard practice). I also have friends who have other chronic medical conditions, and their experience with doctors is pretty much the same as my experience and the experiences of other trans people.
And everything I've heard from people in Europe is that over there, it's even worse. At least in the US it's possible to doctor-shop and find someone who knows what they're doing—or who at the very least is willing to listen—but in European countries with single-payer healthcare you are entirely at the mercy of whatever doctor gets assigned to your case (yes, this isn't as bad in multi-payer countries such as France as it is in single-payer countries like the Nordics). And in some cases, the barriers aren't even the competencies of your individual doctors but institutional requirements doctors are legally required to follow even if an individual doctor is competent. Mind you, there are some exceptions: in parts of Spain and in much of Southeast Asia, for example, a good amount of medications that are Rx-only in most other countries are available over-the-counter, so at least you can self-med if you've put in the exhausting effort to research your own condition and figure out what you need (and even then, good luck getting blood tests to confirm your dosage is appropriate).
This isn't an endorsement of the US healthcare system, just an acknowledgement that the shit sandwich offered in the US has slightly less fecal content than the shit sandwiches offered in many other countries.
The quality of the actual doctor varies on whether the doctor is a lifelong learner, a deep thinker, a good listener, is good at extracting information from people who are bad at introspecting how they feel, and communicating with people whose language skills and mental capacity are far below or above their own. They also leave out their personal biases about "what" the person they're treating might be (drug seeker, hypochondriac, malingerer, etc.).
If you visit a doctor and they don't have the ability or time to execute those non-medical training qualities, then you get a bad doctor.
The main issue is that the good doctors usually go to desirable places to live. This is often not in rural or even suburban areas of the country, and that's typically where the bad stories come from (adjusted for population density anyway - lots of stories from cities too but there are more people in cities).
They are not paid by outcome they are paid by referrals, tests, drugs sold and consulting
I am an American who has lived in several countries and had experience several medical systems.
The US has the best care… if you have access to it. This access can be limited by geography, insurance, money, awareness of the specific doctor, etc.
In a random provincial area with no university medical school nearby, the treatment will often be quite sketchy.
In other countries I’ve lived in, the best medical care was still in the large cities, but the standard in provincial areas was to a much higher standard (imho) than in provincial areas in the US.
If your lucky enough to have an accessible primary care physician who personally knows specialist and lives where there is a University hospital center, the system is awesome. If you don't, the system appears to be a special kind of administrative hell.
Are we talking about doctors, not nurse practitioners? It's hard to understand how a doctor with 4 years of medical school and 3-7 years of residency would have a "very narrow understanding" of the human body.
Also, my experience has been that I have always been referred to a specialist when there was any uncertainty about diagnosis or treatment. My trouble has come from them not following up when an RX is denied by insurance, and making it difficult to schedule a doctor's appointment due to not being able to transfer my previous information.
For instance I have an endocrinologist (at Stanford, not to name drop but to signal this person is really good even among doctors) who only deals with thyroid. I naively figured that an endocrinologist would deal with all kinds of hormone issues but no, she's thyroid and thyroid only -- she has a colleague for testosterone, another for diabetes, etc etc.
I don't know that I'd say GPs "don't know" when to refer you; GPs are gatekeepers who will try conventional solutions to conventional problems and generally unless you push won't often suggest going deeper with a specialist. It's not that they don't know to refer you, it's that they're Level 1 Tech Support for the body and often times unless you make a stink they won't connect you to Level 2.
I suffer from pretty debilitating fatigue. It started when I was 13 or so, which was also a few months after I suffered a bad concussion. I have low testosterone, and treating that helps some. Autoimmune diseases run in my family; my father has lupus, his siblings all have something, and I have a small patch of psoriasis on my head (to which my doctor said "huh.."). My white blood cell count is always moderately low, even after an infection. I get sick extremely easily and stay sick longer than other people. I frequently get chills in my limbs like a person does when they're sick, though the testosterone helps. The chills are a sure thing when I don't get enough sleep. I get cluster headaches, and recently I started getting really frequent eye twitches leading up to when the cluster of headaches start.
Who should I see to try and figure out the root cause of the fatigue? An endocrinologist? Urologist? Sleep doctor? Neurologist? Immunologist? Rheumatologist?
It's hard to know what's relevant to the fatigue. When I was first treated they simply put me on antidepressants. After giving up on those, years later I did some research and had to practically beg just to have my testosterone levels checked along with some other things that were fine.
Quite literally. If a more expensive treatment has a better chance of saving your life, or a more expense test has a better chance of detecting a disease, the Doctor could be sued for malpractice for not ordering it if you die.
In reality, your choice is your responsibility. Even if one could delegate medical power of attorney to a health care provider, it would be unethical for them to hold a dual role.
Chronic conditions that are not well characterized and addressed by medicine are awful and as you said are a combined burden: the condition in of itself and the effort necessary to address the condition. The science and practice cannot progress fast enough to address the long tail of rare disease.
Informed consent is a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care. A healthcare provider is often held to have a responsibility to ensure that the consent that a patient gives is informed, and informed consent can apply to a health care intervention on a person, conducting some form of research on a person, or for disclosing a person's information. Informed consent is, in fact, a fundamental principle in the field of health protection, obviously wanting to mark the very close and unavoidable connection between the need for consent and the inviolability of the right to health.
How does that work if:
A) doctors frequently refuse to provide treatment or tests the patient is asking for
B) If the patient is unconscious, incapacitated, or otherwise unable to make a choice?
B: There are specific provisions for emergency situations typically guided by state law.
Do your best not to end up in a hospital without an advocate (friend, relative) watching out for you. They'll fail to treat you at best, then discharge you with a shrug and a huge bill; and they'll kill you with mistakes, at worst.
Most notably, he suggested we separate diagnosticians and prognosticators from practicians. The former do their best to guess what you have, send you to the right kind of practician, and estimate your possible outcomes (with probability distribution and Bayesian goodness and all). Then whatever practician you chose do their best to treat you.
Separating prognosis from practice allows us to have a system where prognosticators are rewarded for their accuracy and calibration, and practicians are rewarded for their outcomes relative to prognosis. Being good doesn't mean having better outcomes, being good means having better outcomes than predicted.
I'm not sure how well this system would work in practice, and there may be a huge problem with eliminating the short feedback loops we can have between diagnosis and practice when they're the same person. What should be a nice separation of concern may turn into a communication nightmare.
Nevertheless, it is possible that specialised diagnosticians may be better than any expert system.
[0] srsly if I'm understanding some recent hospital records correctly, they still mostly work by verbally dictating at subordinates who transcribe for them. And they spend most of that dictation simply reciting the patient's known condition. Compare with programming where the working set is openly displayed on the screen (modulo scrolling), and then our contribution is only that of making changes.
And then be billed 400-800$. Such an incredible system!
I also gave up going to physicians with a chronic illness. They're in and out in five minutes, and just ramble off the top two treatments from uptodate. If it's a surgeon, they'll try to sell you on surgery or a diagnostic procedure to "re-validate" the diagnosis (conveniently to generate a trivial 10K for the hospital in a few hours). If you want anything beyond that or to have a discussion, good luck.
I only go to doctors for injuries or other clear, specific problems.
I am afraid all this technology is taking away all of our wisdom. Too easy to know things, very hard to understand them.
If anyone is interested, it seems it is partly (mostly?) caused by a Purine nucleoside phosphorylase deficiency. (PNP gene)
Doctors generally see 6 patients an hour, and have 5-7 minutes of paperwork per patient. The remaining 3 minutes gives enough time to diagnose the obvious, but not much else.
But I literally showed my doctor the cutaneous lupus in my ear and she said "Oh, some people just get gunk in their ears" and would not send me to a rheumatologist.
The slow diagnosis is because the specialists are so reluctant to see people. Right now I am on a six month wait to see a rheumatologist. Why? Capitalism.
It's why we have this.
United States – $316,000 Germany – $183,000 United Kingdom – $138,000 France – $98,000 Italy – $70,000 Spain – $57,000 Brazil – $47,000 Mexico – $12,000
This. This is the problem - not the vague spectre of "capitalism" being waved around.
Once capital gets power it uses a government to enforce that power.
We do not have anything close to socialized medicine.
In France for example you can walk into any doctor and they will see you.
Please stop blaming every problem on your ideological pet peeve. Society is too complex for every single issue to be caused by capitalism, financialisation, the patriarchy or systemic racism.
Veterinary care would be much closer to the model of a capitalistic solution.
The interviewee says that the Reagan administration tried to drive down the cost of health care by increasing (as opposed to, say, lifting) the quota on production of doctors, with the idea in mind that more supply of doctors would drive down costs. And he goes on to say that the idea backfired by raising medical costs.
In the interviewee's mind, the problem is that doctors can "make their own work" -- with more doctors around, more medical care can be performed than was possible with fewer doctors, and so the cost of health care went up instead of down, making the policy a mistake. That is the beginning and end of his analysis.
No one asks whether the cost of particular treatments went up or down. If total national spending on health care went up, the policy is supposed to have been a failure.
This remark seems somewhat lacking in rigor. I know bagging on capitalism is a common reflex, particularly in medicine, but something more is almost certainly going on.
The default thought process for a retailer is to move units. A lawyer wants to rack up billable hours. A subscription service wants more subscriptions.
So why would a specialist look for fewer cases? There is almost certainly a perverse incentive involved, because a competitive market would usually prompt a service provider to accept business and grow with demand.
However, failing to communicate to a patient that a diagnosis is provisional might serve to undermine their faith in the healthcare system leading to periods of fatigue wherein one doesn't have the self-efficacy to continue seeking care if things haven't improved even if quality of life is severely impacted.
From my limited understanding of the US healthcare system I'd imagine you don't want an excess of cases because each case
1. Is a responsibility, and thus a liability, and 2. every patient your staff needs to accommodate is draining (risk of overwork).
If that would apply to a country with socialized medicine I imagine that Item 1. receives significantly less consideration but that Item 2. is still very much considered. If a unit isn't a first-line care-provider they can in theory be a bit more guarded about who they receive, while first-line just has to bear whatever comes through the doors.
I feel as if I'm shifting to a different point of discussion but I still struggle not to mention the fact that a specialist may not be readily at hand depending on what city you are in.
The way it's supposed to work is that the general practitioner rules out a bunch of stuff, and then starts referring to specialists who can diagnose/treat the rare things.
In practice it's not quite perfect, but it's hard for me to think of a better way to deal with it.
You missed a whole bunch in that progression. You forgot the insurance companies for one thing.
And you are wrong about the diagnosis process for Lupus. My Primary Care gave me the worst test for diagnosis ANA levels for Lupus. It came up negative. Therefore, I could not see a rheumatologist even though I had documented (MRI) spinal arthritis, kidney problems, and all the other symptoms.
When I found out it was a bad test I demanded they did the correct one it came up positive. So you see, when they do not know what is going on, the give up. They do not dig deeper. The process is a failure for people with chronic illnesses.
The better way to deal with it is to have fewer specialist, get rid of insurance companies, and just have more doctors that can spend more time with their patients and learn more in the process. Primary care doctors need to know more and investigate more.
And the only reason specialists time is extremely valuable is because they make sure there are not a lot of them.
A full round of blood tests by a few specialist would’ve saved everyone involved a lot of money.
Wasn’t even a super rare thing. Just 2 somewhat common conditions. One of which is known for being dismissed as anxiety.
There's no magic doctor who would be a flawless diagnostician if he just had more time to spend with the patient and less interference by the insurance companies. And if he did spend hours and hours on your case, and run all the tests, that would be hours he's not spending helping other people and delays in other people's labwork.
Medicine is imperfect, and diagnosis is based in large part on probabilities. Doctors do what their education and experience tells the is most likely to help. Sometimes they are wrong, because people are different, and some doctors aren't as good as others. Sorry your chronic condition was misdiagnosed. It sucks. There's no magic answer.
A hard fight later I started treatment. Dramatic and immediate health improvement. Some of my doctors still refuse to believe I have condition. Process Took 3 years. The average time for diagnosis is 7 years. Had about 30 doctors during this time frame.
Not even a rare condition.
Consider that the AMA is a monopoly enshrined by the government, and their purpose is to limit the supply of doctors, which they do by limiting the seats in medical schools.
It's not capitalism.
See Competition & Monopoly in Medical Care by Frech.
https://www.amazon.com/Competition-Monopoly-Medical-Care-Fre...
Typically that's anti-capitalist: there are very strong government and regulatory limits on who can perform the services, and for self-serving reasons, they maintain shortages of supply. The free-market capitalist solution would be for prices to rise to a point where supply and demand are balanced, either by supply increasing (people switching fields), or reduced demand from prices rising.
Is there a limit to the amount of money you would pay to save your life? Is there a predatry loan you wouldn't take to pay for life-saving surgery for your child?
Has this ever been demonstrated to work in healthcare in the real world, outside free-market fantasy land?
BTW, no government is going to spend unlimited sums to save your life.
When did that happen? If you are thinking Obama care, uhm, no.
> BTW, no government is going to spend unlimited sums to save your life.
You are missing the point. Supply and demand curves break when it comes to life and death matters. That is why prices should not be dictated by a free market. Well, I guess that is fine if you are a sociopath.
Not all at once, but decision by decision. One big change was when the AMA was granted a monopoly over the education of doctors. Then there was when companies got around wage controls in WW2 by tying health insurance to employment. Then in the 1960s there was enormous expansion of the FDA, and then Medicare and Medicaid. Then there were laws that required emergency rooms to treat people for free.
All these measures sound great, but they completely mess with the structure of how markets work. And so we have the very expensive, and often dysfunctional, system today.
> That is why prices should not be dictated by a free market.
The free market doesn't dictate prices. Governments dictate prices, which always leads to shortages.
> I guess that is fine if you are a sociopath.
If you have a case, you should be able to make it without insults.
https://youtube.com/watch?v=3qpLVTbVHnU&t=34s
The people who tend to be the most ardent defenders of private medical care are usually the same people who have had the fewest reasons to actually depend on it. They're also the same people that declare the United States the greatest country in the world despite having never lived anywhere else but the lower 48.
There are, of course, problems with a system like this. "I would pay literally everything to not die, but can't find treatment" is just not one (assuming certain values of everything), because people will take your money. Problems are things like rich people getting better treatment (happens just about no matter what, but we'd rather pretend otherwise), and evaluating treatment performance as a customer/patient (a reason for most supply restrictions.)
No, that is socialism inside capitalism. Let me explain. I assume by "medical aid" you mean insurance, right? What is insurance? It is a bunch of people pooling their money so they can reduce risk and pay for each others health care.
Capice?
Either way, we're talking passed each other because we have different definitions.
You can get a rheumatologist TODAY if you're willing to pay (quite a bit) more (at least here in Uruguay). THAT is free-market capitalism.
If you don't have money, you'll have to wait 2-3 months (quite a lot less than what you're saying), and you'll have it for free (here). That's socialism.
In crony capitalism, you have the worst of both worlds...
Another anecdote, my sister worked at the front desk in some department ( she was an admin and not a nurse) and a patient coded but came back by themselves. Only afterwards did the nurses realize they were marked "do not resucicate" by mistake!
i do not trust hospitals at all.
Spent $500 for a pointless MRI.
I have some specific domain knowledge on my injury (very sport specific) but obviously have not spent 10+ years in school studying hand surgery.
But I did read and send AND tell/ask in my appoint real specifically relevant med publications saying the only way to see what I wanted was an ultra sound under stress.
My PT also said this. But not a 'real md.'
So I had to pay and sit through an uncomfortable MRI for nothing. And never got the ultrasound. Should have just said no thanks.
They're looking to stabilize you and get you able to survive outside the hospital, not to solve a mystery.
Great place to go if you need it, though. Got internal bleeding? Get that taken care of. The risk of a debilitating or fatal hospital error isn't that high, so absolutely go when the risk of not going is high.
TV, though, has trained us to expect to get everything figured out and root causes solved too. Unfortunately, that's just not realistic even if many of the complaints in this thread were solved. There are a lot of nasty rare diseases and conditions, and strange manifestations of conditions, that will still be missed if they have 60 minutes with you instead of 8.
You should also realize that doctor quality varies as much as any other skill. SHOP AROUND. I've had better luck with second, third opinions than I have trying to pester an original doctor into changing their mind. There are doctors out there who appreciate it if you bring up a written self-history of the condition, the strange aspects or other things that may or may not be related, what has or hasn't worked so far, etc.
You can order your own tests right now from LabCorp and Quest, through sites like requestatest.
https://www.ondemand.labcorp.com/ https://questdirect.questdiagnostics.com/
Which are just a wrapper for asking one of their in-house doctors to prescribe you the test you requested, without a real review of your need or the actual potential benefit for you in doing so. So it technically meets the letter of the government requirements for medical tests, but not necessarily the intention behind restrictions around tests.
I hate going to the doctor's office to have them order a panel so that I can go to a labcorp and have the doc call me and say everything is good. It's all free but my time isn't.
Going directly to labcorp bypasses everything and they give me the results to review myself.
I've been through 8 doctors now. I've had 4 specialists in different areas tell me that there was nothing they could do for me, and just leave me hanging, without even giving me an idea of what to look at next. The only reason I've been able to get any help was because my wife just happened to stumble on a couple of doctors (who work together) by researching my symptoms online. Luckily, the last two have identified my problem, confirmed the diagnosis, and one of them just operated on my back a week ago.
During this year, I wasted time, health, and money on a surgery I didn't need, and which the specialist who performed it SHOULD have known wouldn't help. I can't help but think that he saw an opportunity to do a surgery, covered by my full-blown, "Cadillac" insurance plan, that might have helped, and he took it.
Now I've had an experimental surgery (i.e., uncovered by insurance), and two trips to California. I figure I'm running about $30,000 out of pocket on this whole fiasco. The good news is that the surgery seems to have been a success, but I won't know for sure for 3 to 6 months. Maybe even a year.
> I can’t count on doctors _at all_ to move the process forward.
My feelings directly echo this. No one in this process is responsible for my overall HEALTH. I'm old enough to remember that it didn't feel like this. Your PCP would have been the "general contractor" several decades ago. Now, all anyone cares about is selling me a service, and then getting paid. And my PCP is notorious for trying to upsell me (per the FA) and get me to do tests and labs that I don't need.
This has been my experience as well dealing with fatigue. I was 25 when I finally got diagnosed with sleep apnea, after over a decade of symptoms. How something so common could go unnoticed by the adults and professional doctors in my life astonishes me still today.
Eventually, thanks to ego, I questioned the narrative that I was just normal and lazy. Without the internet, I might not have ever learned that sleep studies even exist.
I was more than half-asleep for all of my schooling, college, and early professional years. I've spent the last 5+ years trying to catch up.
Getting insurance to approve the CPAP, though... that is still an open problem. Weeks later, no treatment for diagnosed disease.
It doesnt sound like the situation has improved. Without a friend like you, would she have received treatment?
I think the community has gotten better at addressing the undiagnosed sleep apnea epidemic. When I needed help, there were some discussions about it on forums that I could find with the right search terms. Now, it's become much more common knowledge on the internet that people can spot it in others. which is fantastic.
The Doctors still seem to suck at it. For starters, fatigue is possibly the single most common symptom of disease - and is not something proactively asked about by doctors (in my experience). Every doctor at every check in should be asking "How tired have you been?". The fact that you can notice apnea in your friend before trained professionals even suspect to ask about it is the problem.
And the bigger problem is that even if we address this for apnea, how are we to know how many other issues are going around waiting for the patients to bring it up themselves? I certainly no longer trust that proactive diagnostic due diligence is being done on anything other than blood test result levels.
Doctors rely on patient complaints to govern their behavior. full stop. Check-ins and physicals are way more superficial than most patients understand, imo. Still very helpful, but not nearly enough
I happen to enjoy reading NTSB accident reports in my spare time, and they're always sleep apnea, so it was at the top of mind when I heard things like "headache every morning" and "I randomly fall asleep on my couch". I didn't go to medical school so I'm not sure if those are anxiety/depression symptoms, but a sleep study sounded like it wouldn't hurt. You're absolutely right that doctors should at least be asking these questions ("how tired are you", there is even a scale with more specific questions).
It is far from an ideal solution, but in the 3 months it takes insurance to get their shit together - your friend could have the energy to work a side job to pay off whatever it costs and just be generally happier overall
in my case, i needed to see an orthodontist every 2 weeks to have the mouth piece adjusted. I am not sure how CPAP works to say if it is safe to "plug and play out of the box" so-to-speak
A friend of mine was struggling with a weird disease, 7 years and 5 doctors later he finally found the cause -> vitamin D deficiency.
I can be a PCP check it out - What is the most easily observable "defect" that's tangentially related to your symptoms? What is the most common treatment for that defect? Next patient.
But in general, the counterpoint to that view is that medicine is one of the only professions that never industrialised. You have to put a highly trained MD in front of every patient for every problem. It just doesn't scale. And some patients have the expectation that this MD should also cuddle them, provide emotional support and listen to their life. I am glad when I see a doctor for something and I am in and out within 5 minutes, it makes me feel that I resolved my problem without burdening a precious resource.
1. Super coders: These are the coders who write the algorithms that pave the way for coders below them.
2. Natural coders: Competent coders who take to the craft easily. Can easily learn new things, but probably won't be designing the next great video codec. (I fall here)
3. Amateur coders: that somehow got hired. These are the coders that you curse because you're always cleaning up after them.
...
I have a theory that the same medical professionals have similar categories. This theory was first formed when I once saw a doctor who, on my first visit, regaled me with stories of taking Uber into the city for a night of drinking.
I'd put this guy in the lowest category of medical professionals. He's there to make money by providing a service with little regard for the long term outcomes of his patients.
There is more to the ranking than his crass unprofessional behavior. Upon leaving the appointment, I was given a card with a request that I rate him on some rate-my-doctor.com ... It had the same slimy feeling as one of those "give us 5 stars" cards found inside the box of many product sold on Amazon.
I took this seriously and made some changes. I went back for a follow up I had scheduled for 6 months later. I met with a different doctor this time and she looked at my charts, asked why I was here, I explained I fasted over night and wanted to take a liver function test and I needed her to order one. She argued that "It's fine, you're not even that over the maximum!" and "Do you feel pain? If not you're fine."
From my research there are both completely false statements when it comes to increase in this enzyme at my age range. Everyone said that if they see an increase in 6 months that's a sign of a larger issue and it's worth getting the test since your insurance would cover it (which mine did) just to be safe. After telling her I wasn't leaving until she ordered the test she opened her laptop to enter it into the EMR. I saw her open Google, copy "Hepatic" from "Hepatic Function Test" on my previous labs and then read the popup Google showed me out loud: "Liver.. ok good" and then order the test in the EMR again.
Some doctors haven't got a clue. It's unpopular to say because it's a convenient fiction to think you will get good care from any qualified doctor but when one doesn't know what "Hepatic" means then I don't know what to think.
The doctor decided this was an ulcer and said the ulcer could be bacterial, viral, or idiopathic (meaning without a cause). His solution was to prescribe an anti-bacterial and a steroid and to take both. I asked if there would be any complications or drawbacks to taking both, and he said there would not. I asked if I should take one first and then the other so I could narrow down whether the ulcer was bacterial or viral. The doctor thought this was a good idea and said I could do it if I wanted. I asked if I should take the medications in any specific order and he said it did not matter.
I went home and read up on the two medications he had prescribed. Sure enough, the steroid would make a bacterial infection worse. Following the doctor's advice, without my own research, could have made things worse. Without doing my own diagnosing and testing I would have had a much longer time to treatment too. (Wound up going away with the anti-biotics)
'didn't accept insurance' is interesting -- in the econtalk episode with the surgery center of oklahoma, the guest claims that he's able to offer better medical outcomes by being out of the insurance system, and implies that billing things at a mainstream hospital has become so hard that it consumes more mental cycles than medicine
it seems like the medical system as-is isn't the right service for people who are fighting the system to get a diagnosis; I wonder if there's a different model that would work better
or tbh a specialized concierge doctor that just prescribes things that you ask for
With the system set up like this, game theory basically guarantees we end up with the state as OP describes.
This seems to be the case with most medicine. Doctors in the US don't seem comfortable making suggestions. I recently got appendicitis and at first they only offered an appendectomy as a thing I could do (or not do). I had to specifically ask for a recommendation to get someone actually recommend a path, and this probably is one of the most routine cases in an ER. Can't imagine having something more complex.
It's not just America. We have exactly the same issues here in Australia.
For people that are very good at research, self-advocacy and research is absolutely a night and day difference from just going in to the doctor for 15 minutes and being rushed through the system. If not for that in my own chronic health condition, I'd be on immune suppressants right now vs a much lighter treatment regimen in conjunction with generic/supplements supported in limited academic research abroad (the funding bias in research for patented vs generic/non-patentable treatments is its own topic).
But that's not the majority of people, and far too many think that they are capable of "doing their own research" when they aren't equipped to do so at all.
Particularly when it comes to medicine, that's a dangerous misconception, and Dunning-Kreuger is actively killing people who can't discern between snake oil and a meta-analysis.
So many of the people doctors are dealing with that are Googling ARE idiots who endanger themselves with their 'research.' Which sucks for the people who are actually good researchers and dealing with biases towards self-research.
Though in my experience, typically good doctors very quickly realize you're adequate at research and work with you as a treatment partner, and it's the people like my dad who will fight against actual research efforts in a quest for confirmation bias.
More importantly though, when deferring to "experts" in medical practice, you should ask yourself, "has the amount of money we've spent and 'expert training' these practitioners have gotten, and the 'breakthroughs in medicine' that they claim have occurred over the last 80 years, resulted in a statistically significant and measurable positive patient outcome?" What I'm seeing is, since the advent of hospitalization and deferral to medical 'experts', we've as a society, become much more fragile, non-resilient, addicted, overweight, and unhealthy.
A doctor might spend 5 minutes listening to your symptoms, you have no training on how to recall them correctly or bring up the right ones. Another 5 minutes might be spent discussing treatment. And you life might depend on this
Congratulations, you have earned the achievement “chronic condition”.
Your rewards are as follows.
You have max exhaustion at all hours of the day!
Exercise recovery is bumped from next day to 2 weeks! Your pain level is now on par with dying cancer patients! Everyone now considers you lazy and incompetent! Doctors now blame all symptoms on anxiety!
You gain +1 to medical research ability. But -20 to Reputation.
You now get spontaneous and useless medical advise from people that believe in essential oil.
You are now on timer with your job until sympathy runs out!
Disability now can mock you openly as clearly your faking and don’t have a real condition!
You are now a burden to your family!
+10 sneak score; you quickly learn to hide your suffering! +20 to loneliness! -20 to persuasion! Asking for help gets little from doctor's. +10 Planning! Your kids may be orphans soon, make sure they get taken care of. Read fine print on death benefits. ——- Staying positive when you have a chronic condition is incredibly difficult. Your not going to get through it without losing your mind now and then.
In Norway I've seen documentaries about them sending the same people to multiple dentists, and some of them receive wildly different advice. Some of that can be ascribed to some being in the school of pro-active, so they want to fix your teeth at the first glance of issues. But in the end, most of the things being quoted were unnecessary. They all seemed very intent on removing wisdom teeth, even when they pose no problems.
They re-did the experiment recently, and I think one of the guys they sent got his teeth cleaned and tartar removed from 10 dentists in a week or so. No one stopped to see if it was actually needed, they all just do it by default and charge you for it.
I went to a second dentist, they fixed the broken filling and said my teeth were otherwise fine. I have the paperwork to back this up.
I’d been seeing another dentist for a while and he suddenly wanted to crown 3 of my teeth. Again I got a second opinion, and again they were like “That’s probably not necessary”.
I think a lot of dentistry comes down to how much money they need that month. It certainly doesn’t feel very scientific.
https://www.yelp.com/biz/shamblott-family-dentistry-hopkins?...
https://www.pbs.org/wgbh/frontline/article/patients-pressure...
> Former employees say Aspen Dental trained them in high-pressure sales. Corporate management scrutinizes the production of dentists and staff daily. And internal documents show that dentists get paid bonuses as key production targets are met.
https://www.elpasotimes.com/story/news/health/2018/01/10/koo...
> "Especially when that fraud involves performing unnecessary procedures on kids —here, unnecessary baby root canals and tooth extractions, among other procedures —we will not hesitate to use every tool at our disposal to punish those who break the law," Bash said.
> The accusations against Kool Smiles included prohibiting parents from being present during root canals "to keep hidden the child's suffering" and retaliation against "unproductive" dentists, according to a federal complaint filed in San Antonio in 2013.
So they never got punished?
They typically settle and sometimes pay a fine.
https://ag.ny.gov/press-release/2015/ag-schneiderman-announc...
I suspect they still make more profit than they lose in fines.
And this goes double for setups to make such violations "nobody's fault" like the creation of perverse incentive structures. In the context of blue collar crime, that's called a "conspiracy".
In addition to being a scam organization, we got to see the group of people in the waiting rooms at Aspen vs our current dentist. As you can imagine, the folks waiting in the Aspen waiting room are observably less wealthy and are statistically going to be less able to defend themselves against medical scams.
Evil organization.
Went to a new dentist and everything is fine again.
Dentists are in the sweet spot where they actually are very important and necessary (as opposed to chiropractors, who are universally charlatans and frauds), but they don't get quite the scrutiny and oversight that physicians are used to. And they make as much as some of the top tier physician specialties. PCPs, OBs, ER, etc. all make less than dentists by and large.
I take it you've never thrown your back out and had an adjustment that fixed a lot of pain?
A physical therapist can help you with that long-term back pain you got.
I've gone to chiropractors for manipulations. Some even were able to bill my insurance (yet surprisingly the cash price was the same as my insurance copay, imagine that). But I treat it the same as getting a massage. It feels good, and I might feel better after, but it's absolutely not any sort of medical science.
Are you referring to those charts that say these are the random other symptoms you might have from alignment issues? Those definitely seem shady, and pseudoscience at best.
Edit: Oh, I see. Overloaded term. I was coming from the medical side, but it can be used differently in a Chiropractic sense. https://en.wikipedia.org/wiki/Chiropractic#Vertebral_subluxa...
I'd go to another one again.
A _good_ chiropractor will only perform adjustments, but the foundations of Chiropractic "medicine" is pseudoscience that many still practice to this day. Wikipedia has a good summary on this: https://en.wikipedia.org/wiki/Chiropractic#Pseudoscience_ver...
But, in my opinion, if you're only going to a chiropractor for adjustments you'd be better off finding a Registered Massage Therapist or Physical Therapist (depending on your level of pain).
I hope it makes you laugh as much as it did for me.
Crap, even the old school Kansas cowboy I used to ride with uses them. When his ranch horses start acting sore, he gets a chiro out. The man can do pretty much anything else veterinary himself, and does, but calls in an equine chiro for his working animals.
One thing I will say after having seen ~10 chiros is that the ones who actually x-ray you are the only ones I would place any trust in.
Then there is chronic pain due to some issue like disk breakdown or another illness. They can do little to nothing with these illnesses but they will not admit that. They will bill your insurance for all they can and eventually when insurance will not cover it anymore they will try to get you to pay out of pocket or tell you to kick rocks.
I wish chiropractors would be upfront about this but I've never talked to one that is willing to. I have spoken to several who I know socially who have said this is more or less true in their clinic. At least the part about being able to help some but being useless with chronic pain.
Are they fully charlatans and frauds? No. But they do take advantage of people who they cant help and promise something they cant give.
But on the other end of the scale, you also got ones who don't have that sort of business and are selling new-age crystal moon beam energy healing power and claiming anything and everything they can sell you will cure you of any and all ills which I think most people would consider irresponsible and dangerous.
One side argues for chiropractors because of what they do above on top of being super cheap and affordable for the average labor worker. The other side argues against it because they only see new-age crystal therapy in their areas while also being able to themselves afford better healthcare with a significantly less physically damaging workload.
Technically speaking, if there's any decay in your teeth, that's a cavity. The deeper it is, the faster it'll get worse. When you want to get that filling though, is a judgement call that a lot of dentists make for you sadly. Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned. Can it be delayed though and done later? Almost certainly. Just a bigger filling later. Or maybe a crown if it gets too far gone.
Also, how fast your decay progresses depends on a variety of factors. For some people, it won't be long before those questionable cavities become serious problems. For others, it can be many years if they decay much further at all even. I think it's largely genetic, but also depends on oral care, diet habits, etc.
So, no, I don't think most dentists are just seeing dollar signs and putting fillings onto teeth without cavities. Its not outright fraud or malpractice. But some dentists are sympathetic to your financial situation while others think dental health should be a priority above everything, no matter the cost.
So it's a mix I think, between dentists' values/philosophies about dental care, and the lack of science about how fast tooth decay can vary from person to person (and an inability to measure that).
Fluoride treatments and good dental hygiene can reverse carries. Carries should only be treated if they're large, or if they're still growing after discovery and alerting the patient.
Caries are initiated by direct demineralization of the enamel of teeth due to lactic acid and other organic acids which accumulate in dental plaque. What is tartar?
Heavy staining and calculus deposits exhibited on the lingual surface of the mandibular anterior teeth, along the gumline
Tartar is a form of hardened dental plaque. It is caused by precipitation of minerals from saliva and gingival crevicular fluid in plaque on the teeth. This process of precipitation kills the bacterial cells within dental plaque.
I guess if you could show a study showing that leaving plaque/tartar on teeth leads to better health outcomes I might be interested.
Caries are a sign of an immune disorder or imbalance. As long as dentists only scrape peoples teeth and do not integrate their health into their practice you will keep having plaques and tartar to be remove as your body fight this battle.
https://www.lupus.org/news/people-with-lupus-exhibit-increas...
Or just terrible habits like drinking liters of soda everyday. Besides the diabetes, the mix of sugar and acid is terrible for dental health, and contrary to the myth, brushing your teeth will not save them, at all, if one persists in terrible habits.
https://www.dentaleconomics.com/science-tech/oral-medicine-a...
The idea that intensely cleaning your teeth (and keeping them white) is healthy is an intuitive leap that marketers take advantage of, just like the bad intuition that makes people clean their faces intensely to get rid of skin problems. The reality is more complicated. Clean, pure, healthy, white.
Fossils have better teeth than we do, but we have prettier, less fragrant teeth.
That's because those fossils had way less access to sugar, which is the main reason we need so much more dental hygiene nowadays.
https://www.dentaleconomics.com/science-tech/oral-medicine-a...
It is more probably that the sugar throws off lipid metabolic and that changes the oral microbiome.
Modern science says no, you should apply topical fluoride for most early cavities; and if the teeth use a modern pronamel (cough stuck behind USDA approval) should be able to recover quickly.
This is mostly untrue. Fillings don't last forever, so prematurely filling cavities "starts the clock" on the longevity of the filling. When the dentist is replacing a broken filling, the dentist has to remove more of the tooth. Eventually you will need a root canal and/or crown. So for maximizing your health, the dentist still has to make a judgment call on how early or late to fill.
I say mostly because mercury amalgam fillings do seem like they can last effectively forever (20+ years), but they have fallen out of favor.
I never doubted the dentist I had during my youth, and as far as I know he’s actually just really good at his job, so it was kind of a shock to find that so many of them are just winging it.
I had similar experience as others - one guy wanted to set series of visits (4 hours each) to remove all older fillings. He was doing a fine work otherwise (replacing urgently one that started breaking apart). The detail being, he didn't do an X-ray to check if older fillings actually needed replacement (the idea is, your teeth can handle only few filling replacements depending on situation, so definitely don't fix things that aren't broken).
After that (and few months), went to another dentist who first did full x-ray, found that one filling needed replacement and the rest were fine and I ended up paying 5% of the price of first one. Good dentists are worth gold (same as many other professions for that matter) - if you find a skilled professional who is not ripping you off, you stay there till you die. This quality mix is unfortunately not easy to find.
I notice that even with my NHS dentist and just in how long he recommends leaving it until next time.
When I went back after 18 months (on a recommendation of 12-18) I got a cursory checkup, probably the most glowing 'all fine' I've ever had, a routine X-ray (i.e. that wouldn't be due again for a while) and then he asked to see me in six. I double-took and confirmed, so booked in for six months.
(Then we had a pandemic and it was more than two years before I could get a non-emergent appointment. That went fine too.)
Unlikely that a dentist would ever recommend filling cavities if they didn't believe it was necessary – they're not very profitable for practices. Crowns are sometimes recommended when a filling will suffice, but that's usually because crowns last ~10 years and fillings only delay the inevitable crown for a few years.
All my previous experiences I had minimal issues, and then suddenly at a different dentist I needed several fillings and needed to drill a good tooth to "fix a cavity" in-between my teeth.
I didn't get any of that done.
My next visit at a different dentist a couple years later and I had a single tooth that needed a filling.
When something feels off, it's always good to get a second opinion.
I think if we had the 'pay out of pocket' kind of thing for other health care we would see the same thing.
And by upsell I just mean convincing you the financial burden is worth the proposed extra treatment. Right now as long as I have health insurance I don't care abut the extra cost of extra treatments beyond a health check because I don't directly bear the cost.
I mean pretty much every other health related thing that's not covered by insurance has the same dynamics; eye care, cosmetic surgery.
"Gjessing visited eight dentists.
* Five found no holes.
* One found a hole.
* One found two holes.
* One found three holes.
* Three removed tartar.
* One recommended brace for 2500 kroner and a new appointment.
...
Memo visited six dentists.
* Three thought everything looked good.
* Two recommended replacing fillings.
* One found two holes and said they had to be fixed quickly.
* One took a panoramic x-ray."
Wonder if this is the original I was thinking about, from 10 years ago. Crazy difference in what they get recommended based on the dentist. https://www.aftenposten.no/norge/i/kJqKj/samme-tenner-helt-f...
(It was just a bit of body hair hit by an electrocauterizer that was smouldering, but two doctors in the room told me I was imaginging the heat and smell, while the third rushed to grab a cup of water).
Or the first 9 didn't remove the tartar?
Which is the good option?
In my case they found a tumor in my jaw during a cleaning that even was overlooked in a full set of X-Rays.
Bit of a meaningless distinction if they're in the same office.
https://www.ama-assn.org/delivering-care/ethics/fee-splittin...
Perhaps in the US where they drug you down? Here the dentist just gives you a local anesthetic and pry them out, unless there is something extraordinary. Or perhaps it's a different person? But still the same company getting the money.
Oral surgeons in the US are usually found in larger hospitals; most dentists are just dentists.
It was honestly an awful experience. Trying to pry that thing out while I couldn't feel a thing, but I felt incredibly drained afterward. Not sure if it was from adrenaline/anxiety or if you still respond to the trauma despite no immediate pain or sensation.
Then I had the pleasure of little shards and chips working their way out as I healed over the next several months. It really did take a good 3-4 months before I felt remotely healed back there.
The oral surgeon had to prescribe anti-biotics and follow up with a "debridement", reopening the site, draining and flushing it. No fun at all. Also not something that's normally done at a dentist's office.
No way would I have done lower wisdom tooth removal without total-knockout anesthesia (Propofol). For me it's as much about the sensory input, sounds, and visuals of the hardware tools used. With the Propofol, it was a painless "30-minute time-travel" experience but I still felt exhausted for a couple days after the procedure. It's like my body knew what it went through even though I have no memory of it. Apparently this is a common feeling.
The upper wisdom teeth come out easier and heal faster. I had those out with just local anesthetic injections, nitrous oxide, tightly shut eyes, and headphones blasting music.
The worst part of the entire procedure was that they wouldn't call my prescriptions into the pharmacy in advance, so I could just go home and not run errands after the procedure. I guess people will schedule fake wisdom teeth removal so they can get a 3 day supply of Tylenol with codeine? I remember being very annoyed waiting around for a half hour in some grocery store with my mouth full of gauze and the pain setting in. Would have preferred to be at home in bed. Sigh! At least I don't have any more wisdom teeth.
I went back two years later for another checkup/cleaning. They didn't find any cavities.
Maybe it healed itself? Apparently that's possible via re-mineralization. Either way, if that was possible, then perhaps they shouldn't have been so eager to drill and fill?
Ideally you do want to get even small ones filled as a preventative measure. However IME trustworthy dentists will acknowledge the potential for false positives on less obvious xrays upfront and offer a choice of either probing the area with a very fine drill first or simply defer work altogether and monitor it on each check-up.
Point is, in your case it could be an untrustworthy dental practice (suggesting unnecessary procedures), or the original xray was ambiguous and there was never anything there, or the dentist was poor at interpreting it. Either way if it was that minor they should have made it clear - i'd recommend scepticism next time, feel free to interrogate them, they are doctors and usually welcome it... if they are unconvincing and defensive, go elsewhere.
To add even more confusion, this is mostly untrue. Fillings don't last forever, so prematurely filling "starts the clock" because the filling will eventually fail and every time a filling is made, more healthy tooth must be removed. (I say mostly untrue because mercury amalgam fillings really can last multiple decades, but these have fallen out of favor).
Teeth looks fine and healthy, not much tartar to clean. When was the last time you visited?
Two years ago.
Oh no you should visit at least twice a year (?). Even if all looks fine x-ray is recommended which can reveal some things.
I do the x-ray. All is fine. You don't even have upper wisdom teeth. Lower wisdom teeth are at 90deg so they can pose a risk if they started growing.
Yeah, but I am 40 years old already? My mother is 70 and has the same 90deg wisdom teeth, never started growing?
TBH it really starts to feel "scammy" when they start suggesting procedures for things that might never happen.
Impacted wisdom teeth don't always stay impacted when they start moving too. They can straighten up when they start coming in.
[1] Hupp J, et al. Contemporary Oral and Maxillofacial Surgery. Chapter: Principles of Management of Impacted Teeth. From https://www.animated-teeth.com/wisdom_teeth/t6-wisdom-tooth-...
(Honest question, no agenda. That sounds like something that would make me never go back to the dentist, but maybe that’s just me projecting popular dentist horror.)
When I lived in Spain I knew they offered GA there, but it usually meant paying 100+ EUR more, which is quite a lot. And europe doesn't really have a thing such as dental insurance. In most countries (Not 100% sure) in Europe you pay out of pocket for all the dentist stuff. Maybe you get a free cleaning once a year.
But other than the availability of GA and the money, I have nothing against it and would have obviously preferred that to my experience of medieval dentistry.
So I would believe your surgeon :)
Because everyone is and you can generally afford it when cheaper professionals do it and don't know when expensive ones (doctor, lawyer, etc) do it.
Due to improvements in hygiene, and public health measures such as water fluoridation, children get fewer cavities and adults lose fewer teeth ("having an insufficient number of teeth" was once a major cause of men being rejected from the military draft).
So dentists have had to pivot from providing necessary care, such as fillings and extractions, to more discretionary services such as whitening and other cosmetic procedures (oh how my last dentist used to try to push Invisalign® on me at every visit!)
I suspect the same is true of people getting contract development done. Given the number of horror stories I've heard and the number of terrible code bases I've had to clean up, I'd guess the custom-software industry is no better than dentistry or car repair.
And, the crucial part is the hospital is considered as no 1 hospital in my country.
Why? Capitalism. And I am serious. It is just the need to make a profit that drives them to these places.
from my single data point I can conclude that:
1) dentists will remove wisdom teeth that don't bother you even for no financial gain. 2) never visit your parents practice unless you have a excuse to bail out immediately if they try to get you on the chair.
To get around that, I prefer to get dental work done at dental schools. The faculty at the schools have their own practices within the schools, and you can be sure that they are doing all the up to date stuff that is currently being taught and following sensible practices in terms of treatment plans. Prices are also fair. If you opt for a student dentist its even cheaper and many low income people use this service (although appointments are much longer since everything they do has to be signed off by a faculty member responsible for a floor of students).
People tend to be unfortunately incentivized to find something wrong with you, as they get paid based on treatments performed.
In the US, this produced the idea of Health maintenance organizations (HMOs), where there is a large member count paying a fixed fee. The hope was they'd want to spend on preventative care, and minimize other costs.
Whether or not to drop $400 is not a "high-stakes medical decision". Also, expecting Google to give you high-quality medical advice when your actual, licensed, trained dental hygienest is not is asking a lot of a search engine.
Personally I've found sticking "examine.com" on the end of most results to be very useful for anything supplement-related, and "reddit.com" as a suffix pretty good for anything else.
This just feels out-of-touch. $400 on a medical decision is a MASSIVE choice for many people -- it could be the difference between whether not they eat.
All medical decisions are high stakes, even if they don't end up working. Even without effects and side effects, the confidence from the laser could mean the author stops flossing for example.
Think sugar pills and homeopathy. If you end up trusting that the useless pill prevents cancer, you might stop going to your cancer screening appointments.
It can also become very costly if the procedure is then added to all other appointments. In an economy 64% of the population lives paycheck to paycheck, this can open a can of worms when presented as a mandatory (or strongly encouraged) procedure.
I appreciate your suggestions for improving search results.
This is true.
> and "reddit.com" as a suffix pretty good for anything else.
LOL. Our definitions of "high quality" are apparently different.
To be honest I've only seen this level of "patient-centered" stuff in the US. Never heard the phrase "Ask your doctor about xy" anywhere but on US TV. Sometimes pretty hard drugs like psychotropic drugs. When I first head it my response was "WTF, shouldn't the doctor tell you what you need and not the other way around?"
I guess it comes down to the batshit crazy US healthcare system and people losing trust in doctors that give them 40k$ bills for simple treatments or short hospital stays
The problem here is that it is the medical professional who is pushing the ineffective treatment.
My preference is for the one who I think is being honest with me about how certain they are about what's going on, and when a medical professional seems like they want to appear 100% certain all the time it makes me worry about their judgement.
I think many people have the opposite preference, which seems to me is asking for dishonesty. Seems like an ethically tricky area.
Imagine your grandmother who knows nothing about computers or tech asking you about GPUs and which programming language is best because she's curious about buying Bitcoin vs investing in Ethereum.
For someone who can't tell the difference between a screen saver and a computer virus, the discussion is meaningless, and only the illusion of control exists
Well, you know a phone book? And, you know how if you want to phone someone, you tend to look up their number in a phone book?
"Yes"
Well, computers are the same. They only know numbers, they're computers after all, and DNS maps the names you see for websites, to numbers, so computers can find the website.
"Uh, OK"
The adblocker I am going to install, makes it impossible for the computer to see the numbers for advetisers. It can't find them in its phone book any more. So, no ads!
Now grandma understands how DNS works, and what some adblockers do.
Some things are not as technically complex as we think they are.
Been doing the same thing for lots of paper databases, like address books, and been using indexes in books too.
Not to mention, how the library indexed books in her day.
Zero confusion about DNS after I explained urls to her. None.
They might be an expert, but it's your (literal) skin in the game.
Why? Because the things I personally value in my life and health are not always aligned with the things doctors try to optimize for.
I’ve told the story here a number of times but my tonsils swelled up to the size of grapefruit a number of years ago. After 6 months of steroids and having them drained I wanted them removed. My doctor did not think it was necessary, even though I was living in misery. I ended up just going to a doctor about an hour away and had them out within the week.
I have multiple sclerosis. There’s not a cure but there is highly effective medication. There’s also less effective medications. The highly effective stuff is various degrees of immunosuppressive or has a risk of fatal brain infection that is manageable with proper testing and monitoring. The less effective stuff can seem “safer” because it lacks these particular risks. A regular neurologist might not know very much at all and give outdated advice and treatment plans compared to some specialists and for this reason advocating for oneself is hugely important as long term outcomes can be greatly different based on the treatment choices. The fact is that you can’t just let “medicine happen to you” because the person that cares the most about your medical outcomes is you. Obviously this is an extreme example but it’s one of many.
On the other hand, they're a professional and they've usually spent the majority of their life training to be good at what they're advising you about. I don't demand to be involved in the design of planes I fly on or bridges I cross, because frankly I'd do a worse job than even a pretty bad qualified engineer.
I know the meme de jour is teens diagnosing themselves with ADHD because of TikTok but it's the perfect example of a whole bunch of people being like "holy shit it's not supposed to be this hard all the time? You can actually do something about it?"
That should be the doctor's job. Doctors have too much financial pressure to pump patients through, so they have neither the time to get to know individual patients nor time to keep abreast of current trends in their speciality.
Should MedicineX be allowed to have a website with a FAQ? Yes. Should MedecineX be pushing ads on TV/radio that make it seem like it's a cure for everything that ails you? Nope.
I have really, really bad fatigue. It took me years to figure out everyone else didn't feel that way. I was in high school and was able to skate by on intelligence alone.
https://www.fda.gov/drugs/information-consumers-and-patients...
Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit.
Many physicians thought that DTC ads made their patients more involved in their health care.
Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs.
Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments.
The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
This was the case for many years where it was illegal to have advertisements for prescription medicines. They lifted this like 15 years ago. This was very favorable for the pharmacutical companies as now patients are going to go to doctors and ask exactly that.
What is worse now IMO is these direct to patient ads on social media from Cerebral. They show a lot of common things that people do (Like slack off, not pay attention to something boring), and then encourage them to talk to them for ADHD treatement. While more awareness of mental disorders and health is great, it is a bit scary when people can get convinced they have a disorder that needs pharmaceutical intervention and shop these firms until they get a script.
Maybe it has always been this way, but anecdotally it feels like it has gotten so much worse in the last few years.
The exception to the SEO spam rule seems to be a small subset of “highly trusted sources”, that at least for medical information seem to be biased pretty heavily towards “don’t say anything that can get us sued.”
I don’t know the best solution to all of this, but I really think that content marketing is getting to a point where it has drowned out actual content. I wish Google would put a downvote button on their search results page that I can click to indicate that a highly-SEO’d result was not actually useful for my query.
Then also you need to ask the right question. Googling something like "Toyota RAV4" will give wildly different results than "common problems with Toyota RAV4".
In this particular case the better question should've perhaps been something like:
"scientific evidence effectiveness lazer bacterial reduction"
There are few independent clinics around. Most of them belong to huge corporate conglomerates that push down shady treatments like this, or offer predatory financing for these “treatments”.
I’ve had only two instances of a health professional outright lying to me and telling me I had a health condition that I didn’t have, and both times were dentists. One of those times was also about periodontal disease, so it seems like this is a common thing.
A good heuristic is that if the treatment isn’t covered at all by insurance it very well might be worthless.
Doctors who won't justify themselves can often be avoided at least in medium-sized and larger urban areas.
The main observation is that in medicine you need to be your own advocate. The doctor is used to people who just want an answer or a cure. They're not going to break out the journals for every patient because most patients don't want that. This also goes for dentistry.
I go to an independent office (2 dentists) and I've never felt pressured by them and they've even said things like, "It looks like that may turn into a cavity, but we can wait and see what happens."
Obviously I'm not saying it doesn't happen, but like anything, it's not everywhere.
I would appreciate if google could elevate more “google scholar” results and also have a zone of clearly marked “likely low quality matches” but apart from the howls of outrage from the bullshitters, this would be very hard.
Also note at the end the author pitches their alternative.
==
BTW the laser is a capital investment (or lease) for the provider so the laser manufacturers are always coming up with new ways to use the device and sending them to their customers (mainly dermatologists and dentists — people outside the managed care, and often insurance, infrastructures). These suggestions are typically worded in a way that doesn’t get them in trouble with the FDA.
So even if a dermatologist buys a laser to remove birthmarks, most of the time it will just sit unused in the corner of the room. So they add tattoo removal. Next thing you know it’s a cosmetic liposuction alternative for the area around your mouth.
I personally have a story of a great doctor who went to the effort to try a less-well-known (but still entirely conventional) treatment that resulted in a much better outcome for me. But that just highlighted the fact that great treatment outcomes are a haphazard occurrence in a sea of crud where neither the insurer nor the provider prioritize the patient over maximizing revenue.
What this story illustrates is that paying out of pocket, which presumably put greater market based pressure on health care providers, is even worse.
Not all parts of the economy work bast when least regulated and maximally market driven. Without information from disinterested parties, and without oversight from outside the profit-driven parties, you just get farmed by crooks.
It's hilariously bad, it pulls misleading info out of context. It is probably responsible for more than zero deaths worldwide.
Also reminds my of my experience with my disease "specialist" and my GP. Specialist is concerned about my cholesterol, puts me on meds, schedules regular (now expensive) blood tests. I mention it to my GP and he's says "your cholesterol is fine, don't worry about it"
Who do I trust exactly?
I now have little faith in most doctors ability to solve my medical problems. I recall someone on HN saying they are basically "chat bots", and sadly, I find that to be an accurate description. I've turned mostly to the internet for help. The internet has both helped and harmed me, though I would say overall has been less harmful than the experiences I've had with doctors.
Doing my own research on the internet does make me feel like a "kook", but I would not even have a label for my condition if I had not done so. I can live with some discomfort if I can at least put a label on what I am feeling. It's also comforting to know there's people out there with the same condition as you.
I have access to research and studies online, but if the doctor was not aware of it, they are quick to discredit it.
The one thing I am grateful for about seeing doctors is their ability to rule out the common/serious conditions. That has been helpful, although I have found that simply "getting permission" for a procedure, or to see some specialist, is way too difficult. Often times specialists are booked out for months. It's so discouraging.
So we're left without answers and with an unnecessary prescription for antibiotics, every time. It's pretty frustrating, to say the least. The internet has come up with "interstitial cystitis" as a possible culprit, but it's not much of a diagnosis with an unknown cause, no diagnostic test, and no peer reviewed treatments.
The old thing to do was to get a second opinions. I wonder how that would have fared comparatively in this case.
Is it the place of online platforms to filter out misinformation?
In a much, much narrower sense, we are talking about Google and not an online platform. Google's explicit mission is, “to organize the world's information and make it universally accessible and useful.” Like, filtering out misinformation is literally the thing that Google says is its purpose.
And the answer was that yes, the optimal head shape is known, but since it's not that consequential this is not regulated as other medical stuff and basically everyone does weird shapes just for marketing and differentiation purposes (like colored specks in powder detergent which do nothing)
The head shouldn't be too big, so that it can reach even in the back.
Rubber inserts are not recommended, as they tend to irritate the gum.
Typically the better ones look more plain - no multi colored bristles or spaceship looks. However, since this becomes more known, it becomes a marketing signal in itself - like "plain brown paper package" chocolate, etc.
Usually this stops the service upselling.
My wife sells dental insurance to businesses. These brokers are doing plan designs that specifically exclude certain services to get monthly costs down to the expected competitive floor pricing. Think of it this way, you have 100 people in your group. 5 are willing to pay for implant coverage at $100/mo, but to get that rate, you need 75% participation of the group. 95 people will not participate if it’s more than $20 a month. Your plan design is going to be designed to appeal to the 95 over the 5 and that broker is going to bring in a plan that is as close to $20/mo without going a penny over…and hope like hell that their competition isn’t lower with a similar plan design.
I think it is definelly possible to sort results better (pure engineering problem). But there is really no short term insentive for that. Maybe in long term this will help Google to stay on top but that is not 100% clear: it is hard to predict how content discover will look in the future.
First comes the idea that you can't make health decisions yourself, or treat yourself for health problems. Got a back ache? See (read: pay) a doctor. Got a wart on your toe? Got a sunburn? Go pay a professional for their services, this is the only solution.
Adding to this is the lawsuit addled consumer climate of our society. Best not give anyone any sort of information about anything, lest they sue you for it.
I actually googled a question and an article I read told me to talk to my healthcare team. Team? Each of us has to have an army of highly paid professionals to figure out why our head itches?
You can't google anything health related anymore and actually get information about it. You get a little walkthrough of possible causes of anything followed by a "see your doctor." I just want to know what exercises to do to relieve back pain.
Taking care of yourself shouldn't require you to visit a specialist for anything other than extreme circumstances. The information on how to take care of yourself is available online, hidden behind marketing funnels. Used to be I'd find a bunch of crystal healing blogs and the like, and I'd bitch about it, now I'm wishing for them back because in between the bullshit they're more helpful than being told to pay someone to (maybe) tell me.
So, perhaps we shall do just that
https://www.tepeusa.com/collections/tepe-interdental-brushes...
(The brush is basically applied to the space between teeth and touching the gums, but see a pro please first.)
Also for all our learnings' sake xrays often fall into this category. Dentists will basically demand xrays as often as the insurance will pay. This is not only a waste of money, but contributes to cumulative damage.
Yes, if you have specific exceptional circumstances then the cost/benefit may be greater, but I understand that in the main and for better exceptional cases you every 3 years is fine.
How is this system itself not a cruel and unusual punishment? Now obviously it’s because it isn’t applied as a punishment for a crime, which is I think the letter of the law.
Still, it feels like we live in some Kafka-esque nightmare where a huge number of things the US government ought to take care of are outright cruel… and that the cruelty is the point.
I get tons of Testosterone replacement therapy ads. And also 'adhd' ads.
These are real MDs, but they will give scripts to almost anyone. Many online only.
I'm not judging people who want to use. People will use drugs legal or not and it is far better to get real stuff from real MDs.
But advertising it? The whole point is to create / increase demand. This is not passively allowing safer use.
These ads are misleading; TRT ads of young super fit people or getting people hooked on stims for no reason.
How would people feel if there were FB ads targeting people who listen to EDM with dope or E ads? We are also inundated with alcohol already.
All drugs aren't comparable or similar danger profiles, but just shows how prejudice and assumptions from a prohibition system are imho hypocritical. using a more extreme thought experiment can highlight this.
So it's not just dentists... at least my dermatologist is pretty transparent about all the aesthetic treatments that complement their medical services, though they seem to always find a mole that needs a biopsy and every year it turns out benign. I wonder how many times it was necessary, versus how many times it was just an easy money grab because my insurance covers it and it's very minimal of a procedure. I don't have a problem with for-profit healthcare, but fee-for-service is driving the insane cost inflation in the US
This expresses a lot of my feelings with the modern web experience really well. I feel like I'm constantly in "avoid" mode and it's becoming more and more difficult to get to content of actual substance and you are constantly being bombarded by garbage that is becoming more and more AI generated, making the volume higher and quality/relevancy even worse.
Although to be honest, I was nodding as I was reading. It's not only about medical decision, but with most decisions where you want to buy the best X. Maybe medical decisions are less... selfish? I mean - if I want to buy a toaster, I'll look at Which, and won't splurge on the most expensive one, but will look at what other people are finding useful. With health however, you probably don't want to spare expenses, so the decision making process will be a bit different - we trust people from which we're getting health advice.
I'm not in USA, and don't think this sort of thing is confined to USA
This is also why a weekend on pubmed and similar gives you a better result than a doctor ... who spent 2 minutes reviewing your chart and comes into the room for a few more minutes to talk to you.
They didn’t make it, but the premise was sound / that standard of care is about 30 years behind research (at best).
The mindset I learned there helped me overcome a diagnosis of Bipolar / schizoaffective by doing primary research and rejecting the medications of Standford Psychiatry…
8 years later, with a mix of shamanism, spiral dynamics, mens work, underground mdma therapy, 5meoDMT, somatic therapy, biomythic.com and coaching and I’ve finally got some place to stand within itself, no need for medicines, and no longer dealing w suicidal depression or manic psychosis.
I think of it kinda like a car wash. You can pay extra for the fancy spray on waxes or you can just get a basic wash. How much does wax quickly sprayed on by a machine do for your car in the long run? Not much. But it makes you feel like you're taking care of your ride. Sub in teeth (a part of the body) for a car and they can charge almost whatever they like for shining bright lights in your pie hole.
If the dead internet theory [1] is true a new search engine may eventually emerge which focuses on indexing verifiably human-generated content with high information value. I have no idea what is going on with Google search results.
[1] https://forum.agoraroad.com/index.php?threads/dead-internet-...
I'm not sure that will be possible to implement without the "search engine" being more of a magazine.
I look forward to the day when AI is sophisticated enough to take medical decisions out of the hands of fallible and emotional human beings. (We're not anywhere close to that day)
The reasoning behind flossing makes a lot of sense:
1. You remove food sources for streptococcus mutans
2. You avoid inflammation from teeth shifting
3. You disrupt biofilm (plaque) formation in the joints of your teeth
I imagine the evidence is limited because genetics, diet and other oral hygiene routines significantly impact the outcome. There is a whole microflora system in your mouth, and the advice is to throw everything (floss, scrape tongue, mouthwash, brush) at it for everyone because personalising it is not worth the effort.
If the service was being provided for by the dentist for $1 I don’t think the author would have cared so much about the evidence behind it. Floss is just so incredibly cheap that even with weak evidence behind it it’s worth doing —- having just a 0.1% benefit, even if it’s just placebo, still has it being worthwhile.
This policy is what stopped me from getting a treatment from my dentist that involved grinding down my teeth. Google results were mixed on the benefits. Dentist pushed it very hard. It was like $500 so I said no. Teeth have been fine without it.
Not exactly a strong hand to bet on, but it's better than nothing.
Simple heuristic: All results from the first two search result pages don't provide much/any evidence that LBR is helpful or worth is -> it is not.
This simple heuristic is often quite good.
If it would have been a useful method, I would expect to find some good serious pages, or maybe Wikipedia page on it.
Well I've not heard my recent search results summerised better than that. What a perfect description.
I always Google something and add "Reddit" to it to get better real, less-biased opinions on something.
Or if there is a site dedicated to discussion of the topic (ie. an old school forum or message board), I'll go straight to that and search there.
Dentist almost convinced me to spend $400 on useless laser treatments; Google results of search spam SEO cesspool
Even if it is an advert, it's not a shitty one. It presents scientific arguments and is well-sourced. It's about as a good as an "advert" as you'd ever get. Really, what more do you want from people?
I think that's the real problem with articles like this. The moment I realized it was a commercial piece masquerading as a scholarly meta-article, I have to question all the previous discussion they have. Is it right? What are they trying to sell? What viewpoint are they trying to get me to follow?
Advertising is codified monetary deceit. We've moved long past "Buy my soda cause its yummy", to an ever-present dread of "if you dont have this, you'll be sorry" in a round-about way.
> should articles which point out problems be written completely independently of the people creating solutions to those problems?
If there's a commercial motive to use/buy/rent their shhit, absolutely yes.
> It presents scientific arguments and is well-sourced.
Depends. What are the biases of their arguments that the underlying commercialism is modifying? It now needs its own analysis to see if they were trying to sell me something different on dread or FOMO.
I'm really not sure what you expect. Should articles which point out problems be written completely independently of the people creating solutions to those problems? Cos clearly that is totally unrealistic.
> your insurance won't cover it
So to answer
> So how do most patients make this decision?
0. Insurance won't cover it, so they don't get it ($), or
4. Insurance won't cover it, which is a signal it isn't an evidence-based intervention, so they don't get it.
Orthodontia are a cosmetic procedure with a pretty visible result. It's an exceptional case, not the rule.
And for many people, see step 0.
This is how all the alarm bells went off for me about VPNs as I was forming some OPSEC ideas.
My solution was to look up court cases.
Actually, this is what efforts are attempting to shift in the industry. It goes by the name "value based care" and is a better solution.
That's how this should be fixed - return to those limits. In an online environment that would mean limiting ads to doctors et al. on sites that require password and professional identification/validation. Otherwise information on drugs et al. should be presented only neutrally and scientifically to the broader public - marketing should be banned from the process.
LOL. Seriously? Google the biggest known data whore, worst privacy invader on the Internet, whoring personal data out to any john willing to pay. Yeah. The year starts with 2 and Goog has been pimping your data for 23 years now and people still haven't learned they are not your friend.
You're showing me that the author personally uses google, and that the author thinks the vast majority of people use google (which is true). Nothing about what they said suggests they think Google is ethical.
It would be nice if we could have an omniscient oracle to gate-keep us away from ineffective treatments - but we don't live in that universe. Instead we have (in the US) the FDA, which is staffed by smart, well-intentioned, and very fallible human beings, each with their own (well-intentioned) agenda. At the very least these folks are simply weeding out treatments with major negative outcomes, like killing the patient. So some placebos get through and called 'treatments' like LBR - unless there is some better treatment that you're forgoing, there's really not much harm except for the $400.
The folks that do a lot of research will make better choices than those that don't - but they will also help all those others make better choices over time as they communicate their ideas and results to the masses.
I dislike Google for many reasons and generally avoid their products and services, but are they really to blame here? Google is a general purpose search engine whose business model fundamentally relies on including marketing in its results. It isn't a flaw in the algorithm; it's a feature. It's how they make money - and a lot of it at that[0]. If you want academic results, go to an academic search engine. That's exactly what the author did and it worked out fine. I'm down for an argument that we need academic works to be more accessible and digestible, but that's not really a problem with Google.
The other accused subject was the dentist, but I'm not so sure about that one either. There is a lack of consensus among medical professionals on many treatments and procedures, and this story could simply be another example of that. Medical professionals are humans, each with their own experiences and biases. Besides, it's not like the academic results cited by this article determined that the treatment was snake oil. Maybe the author's dentist had her own experience with the procedure and honestly concluded for herself that it was worth the $400. Maybe she was biased by anecdotal evidence or her own theories. Maybe she doesn't value $400 as highly as the author. Maybe she simply values dental hygiene more than the author. This is a great example of why it's important for medical professionals to act as consultants and for patients to make the final decision.
IMO, the big problem here isn't Google or the dentist. The problem is how much trust people have in those two as sources of accurate, unbiased medical information. If you're making a significant medical decision, you shouldn't accept a single source of information - even if it is academic - and you certainly shouldn't trust marketing material. Get second opinions. Do a little academic research. It's easier than ever before.
That said, if a $400 laser treatment for your gums isn't a "significant medial decision" to you, then feel free to just follow your dentist's advice. That's up to you.
Many years ago I wasn't in the best financial position and went to the dentist. He identified a number cavities needing filled and quoted a hefty sum, and I put off the procedures because I couldn't afford them. I diligently saved for 6 months to pay for them and when I went in for my next checkup, I asked about them. What cavities? No your mouth looks fine.
I've had similar situations with my children, getting quotes for thousands of dollars worth of work. Getting second opinions and using different insurance changes those quotes and scope of work dramatically.
At this point in my life, I don't trust dentists at all. I'm sure they're not all crooks but how do tell?
> This was my motivation for starting GlacierMD: I wanted to give consumers the information they needed to make evidence-based health decisions. And although I lost that battle (spectacularly) I'm still fighting the war! If this is a topic that interests you, I'd urge you to
My wife is an oncology surgeon and it's absolutely mindblowing the things her patients tell her or later post on Facebook. One of her latest winners is someone that flew cross country to California to get things like 3D Bio-Scans.
3D you say? That sounds useful. It's a 3D image of you, your cancer, your organs, etc, right? No. I'm taking this straight from their website:
> It has four FDA-approved technologies in one: Pulse Oximetry, Body Composition, Heart Rate Variability (HRV), and Galvanic Skin Response Devices;
Not a damn one of those is going to tell you anything about cancer. And then there's thermagrams, where they basically check your skin temperature to try and diagnose internal medicine, like cancer, colitis, gluten allergies, etc. And people just buy this shit up.
It really just reminds me of Steve Jobs' quote on television:
When you’re young, you look at television and think, There’s a conspiracy. The networks have conspired to dumb us down. But when you get a little older, you realize that’s not true. The networks are in business to give people exactly what they want. That’s a far more depressing thought. Conspiracy is optimistic! You can shoot the bastards! We can have a revolution! But the networks are really in business to give people what they want. It’s the truth.