A fourth of U.S. health visits now delivered by non-physicians

1) Uniterested, slapdash care from an MD with 12+ years of training and no ability to listen or empathize but eager to make the money s/he went into medicine to make

2) The same from an assistant of some kind who uses ever-degrading search engines to look up not-your-problem and give you potentially dangerous suggestions

The future will undoubtedly be worse. As someone mentioned below, we'll pay current premiums (+inflation) for a touchscreen interface to Chat-whatever-it-will-be.

I'm a critical care paramedic, have several friends who are (perhaps unsurprisingly) generally emergency medicine physicians and related (surgeons, anesthesiology, nurses, etc.).

I see the spectrum too. Extremely competent PAs who have long and detailed in depth discussions with physicians as "peers", on one side, and then I see horror shows from people who went from zero to ARNP in programs with "accelerated RN" where they are not functioning providers with far less schooling and clinical experience than even a PA (which is then galling to the PAs, as why are NPs independent practitioners, and PAs not?).

I do think a lot of the issue is in the education and certification process. The AMA is only recently making the slightest inroads into well, not admitting they went too far in restricting physician flow, but maybe acknowledging that there is a problem there. Nature abhors a vacuum, and all.

I had a friend, extremely intelligent, in a BSN program. Called me one day to ask about flow rates for various oxygen adjuncts (nothing fancy, just like "what do you typically run your nasal cannulas at? What about NRBs?") and I was blown away. "Oh yeah, somehow that got overlooked. I know how to set them up, add humidifiers, etc., etc. - they just assume, I suppose, that someone at some point will say some magic numbers to us".

And I'll also say that you see the same pre-hospital too. In PNW, while there are valid criticisms that can be leveled against two of the pre-eminent paramedic programs (UW Harborview, and Tacoma Community), there are far, far, too many "strip mall schools" in other states that will take you from "zero to hero" in 4 or 5 months (of 6 days a week, 8 hours a day, of just class time), and dump you out on the world with just enough retained knowledge to pass your NREMT and the barest amount of ride time to meet DOT mandated minimums. It's scary, to be blunt. These people go out with no clinical experience and are now expected not just to work as a team on a 911 call, but to lead it.

It's the medical equivalent of high school > college > MBA > management position without a day of work experience in your life beforehand. Except now there are literally (at least occasionally) lives at stake.

What, besides surgery, really requires 12 years of training? I've found I have a greater success rate with self diagnosis and treatment than I have with seeing my physician, and I've found a very good internist. An hour spent with ChatGPT and Google and I always find a couple options that fit what I'm experiencing as well as detailed descriptions on how to narrow it down. And since I'm the one experiencing the symptoms, there's no chance of a communications breakdown between me and the doctor who is trying to diagnose me.

It means that:

- you are expected to learn way too much and only have a surface understanding of a lot of things (see tick example from sibling comment)

- your time is very valuable so you can’t put any time effort into patients at all to try to deeply understand anything that doesn’t pass your “known expertise” classifier.

My son has back pain that most closely matches descriptions of sciatica.

The 3 MDs he has been given a cumulative exposure time of maybe 15 minutes to have resulted in prescriptions for various muscle relaxers and steroids based on a single xray. No attempt to look at any soft tissues and none of it has helped.

The industry is an absolute dumpster fire of ineffective care unless you land in the top 20 issues for each sub category.

No offense, but the job of diagnosing one of the thousands of possible issues should not be yours. This is what computers are ripe to disrupt. ChatGPT isn’t there yet but something like it that can just crunch data and known results for every obscure thing is going to blow you out of the water. We can both only hope…

Brings the rest of the equation into focus, at least for me.

Both of them just reinforced my sense that the degree pretty much doesn't matter anymore. In one case I saw several physicians of different specialties, and none of them had any idea what was going on. My own initial hunch ended up being correct, and I kind of ended up fixing it myself (complicated to explain, nothing illegal or inappropriate; ironically the first physican I saw was also correct, the only one who got it right, but he dismissed it and convinced himself it was wrong). In the other case, the best care we got was from a PA. The physicians were all specialists who were financially motivated to give care that was totally useless but very expensive (we figured this out by looking in the primary scientific literature and realizing that all the procedures they were heavily pushing were no better than waitlist controls). The PA was the only one recommending things that were actually useful.

I've seen useful MDs as well, especially with pediatricians and radiologists. I'm not saying MDs are bad or useless. But I'm increasingly convinced that different educational and training paths do not necessarily mean inferior or superior care; that a lot of services could be provided through different providers or mechanisms; and a lot of what people see providers for could be obtained without any provider as a middleman.

Keyword-driven differentials should be, if anything, the baseline, bottom rung, pattern matching to inspire and drive critical thinking, focused assessment, and diagnostic skills. Not to "easy mode" the path of least resistance.

The receptionist _ran_ to the back to get a doctor. The doctor, in an exam room, very careful, and with significant compassion, explained that they don't have the ability to treat me at that location -- but would I accept an ambulance if they called it?

I took an Uber to the ER, where the admitting nurse gave me a flat stare and said "That's not a hallucination," but still put me at the front of the line to have an attending doctor and a bunch of students stare into my eyeballs before confirming that it was a headacheless migraine.

To this day, I use that experience as an example of a lay person and a professional completely failing to understand each others' word choice.

Not my experience. Every time I've gone to urgent care I am always seen by a MD.

This is the problem with all of these systems that try to violate the laws of physics (aka: free market economics). They invariably results in substandard care, if you receive care at all. Keeping people alive isn't the same thing as actually solving problems with quality care.

This is my big gripe with the ACA (Obamacare) in the US. It's a shit system that was sold as a quality system. There are so many things wrong with it I am sick of listing them.

My wife is a doctor, so I've been privy to behind the scenes effects. If you think your doctor gives a shit about you when you come to the office with one of the stupid plans, enjoy the fantasy.

Doctors do care. However, they can't see thousands of patients at a loss. They have bills to pay, just like anyone else. More than anyone else, actually. And do, what happens in a lot of practices, is that doctors are forced to become numb to their caring impulse upon realizing that there's a dividing line between quality care and going broke. And so, they churn through patients at a rapid rate because the only way to make it is quantity.

My wife was telling me that the office next to hers has four PA's. They each see 40 to 50 people per day. That's an average of 10 minutes per patient. That's not care. That's medical professionals being forced by a shit system to push on the cash register button as quickly as they are able to just to make it.

It is important to keep context in mind when thinking about some of these things. Imagine an office with a couple of MD's, a few PA's, a few medical assistants and one or two administrators. Collectively, this is a group of people with somewhere around, say, $1.5 million dollars in student loans to repay. They each have homes, cars, kids and other bills to support.

That sets-up a situation where it is impossible for that medical practice to exist below a certain revenue threshold. More accurately, below a certain profit level. If the insurance system they have to work with is shit, they have two options: Close the doors and everyone becomes an Uber driver or keep them open and run as many people as possible through the doors with a $10 to $50 per person gross profit probability per person.

No, do the math. Don't just react to this through emotion. People have to get paid for their work, just like you.

So, let's assume $50 per person average profit (not sure that's a good assumption, it depends on the practice). What I mean by "profit" here is what you get paid (not what you bill, because sometimes you don't get what you bill) vs. what it costs for a medical professional (say, a PA) to provide that service.

Now assume you can churn through 100 people per day. That means $5,000 per day in gross profit. If you are open 20 days per month, the gross profit is $100K per month.

You now have to pay, say $25K per month for rent, utilities, insurance and various other expenses. That means $80K per month. Let's say two MD's own the practice and each gets paid $25K per month salary. You are left with $30K in the bank. You likely have other expenses that will easily consume half of that, cleaning, legal, accounting, software licenses, IT, etc. You are now down to $15K. Which is a formula for going bankrupt.

What do you do? Well, you have to crunch through more people per day and try to maintain the same cost structure per patient. So, you try to see 150 to 200 people per day --if you can, not all practices can do that-- and pump them through as fast as possible. In other words, you cannot prioritize quality care.

Anyone thinking "Just provide better care and bill for it". It doesn't work that way. Say you decide to see only 50 patients per day. Obamacare shit plans are not going to magically pay you double for taking someone's pressure and temperature or going through a basic diagnostic check. The limit function here is that these plans are shit, they don't pay for quality care, they pay for delivering the fantasy of having medical care.

Not to mention the horrible problems of Medicaid/Medicare. That's another half dozen paragraphs.

Yes, everyone should have access to *quality* healthcare at a reasonable cost. No, that isn't possible if imbeciles in government make the decisions. These are the same people who, through incompetence and mismanagement can't seem to give us a world without war and misery. What makes anyone think they can actually deliver solid quality healthcare?

BTW, my wife and her partners finally had enough. They launched a boutique medical care office. They provide high quality care at a reasonable price. Patients are well taken care of, employees make a sustainable salary and nobody has to engage in the soul-crushing practice of treating patients like cattle.

Not sure what line of work you are in, but are you willing to answer endless emails and or voice mails from customers, all for free? I know I am not - and while you personally may only ask one question a year, a typical MD may have a panel size of 1000 to 3000 patients (at least the ones I know); multiply one question per patient by 2000 patients, and all of a sudden you find out you worked for free for most of the year.

Maybe if insurance companies had a billing model that allowed the MDs for charge for this type of 'support', that made them some money it would be workable - but I can't blame them for not wanting to give out free care this way.

Also for SSRIs there's nothing to test, you just try them under medical supervision and if they help they help. There is an experimental DNA test that might be able to narrow down the antidepressant options but unless you're struggling to find one that works for you it's usually not worth bothering.

Medicine is crazy advanced in some specific areas but for the long tail we're not that far from leeches.

At the risk of over-simplifying - and certainly not justifying blasé, ambivalent answers... the brain is a very complex organism. And we have barely scratched the surface of how it actually works. Most of it, we just don't know.

So, from this to psychiatric drugs - SSRIs, MAOIs, SNRIs. Read the drug information sheet in the packet. Not just the "standard" paragraphs on side effects and warnings. All prescription drugs are required to specify "how" the drug works.

For a startlingly high number of these drugs, this paragraph starts with the words:

> It is not understood precisely how [drug] works. It is believed that it does X, Y and Z...

(emphasis mine).

We know that they can work for some people and not others. But while we can perhaps make decent educated guesses, a lot of the time, we can't, because, hell, we don't really know how it even actually works, so we can't know it will work for you.

Disclaimer: while I am medically educated and work as a prehospital provider, I'm not a MHP, despite my use of 'we' in the previous para.

What tests did you get? Only thing I can think of when you say “everything looks great” is an otoscope exam.

But if they did audiometry, CT temporal bones, MRI IAC and those are normal? Then those are tough breaks because they can’t fix a problem they can’t see.

Only thing I can think of is maybe a subtle/occult ossicular chain disruption. Is there a little incudomalleal diastases?

Anyways I give up that’ll be $500 see ya