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Comment by dimal | Hacker News Reader

I get the feeling that doctors aren’t really trained for more than half of the stuff they need to know. Trauma informed care is a joke, yet a huge proportion of people have a history of multiple adverse childhood experiences, and these have very real effects on health. And any chronic illness that doesn’t have an easy biomarker is a complete unknown to most doctors. They just throw up their hands and say the bloodwork is normal, you must be fine.

I don’t know how doctors can be trained for twelve years and have so little understanding of health. And yet they have such confidence in their abilities.

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Part of the challenge of bringing mental health into physical health, I think, is that it introduces a vast number of non-verifiable variables into an already incredibly complex system. While it might be a good idea, it asks a tremendous amount from a practice which often can’t keep up with demands as it is.

I know a paradigm shift and rethinking could resolve that to a degree, but it’s quite antithetical to western medicine.

It’s like asking programmers to embrace non-deterministic programming languages when you’re already deploying to non-deterministic platforms. It would seem like total chaos, I think.

I don’t think it’s antithetical to Western medicine. It’s antithetical to mass produced, industrialized medicine. Those aren’t the same thing. I only want them to use the scientific method on each individual patient. That’s all. They don’t seem interested in it though. They don’t seem to be able to think for themselves and reason on their own. They like acute diseases and disorders. Here’s a virus, and we kill it with this medicine. Here's a bacteria and we kill it with this medicine. Here’s a tumor and we cut it out. Anything more complex and they don’t have any interest in it. If they want to treat the patients they actually have, they need to learn how to do this other work.

The other option is we just accept that they don’t have any interest in this type of complexity, and say OK, that’s fine, but they no longer have a monopoly on medicine. We find other ways of certifying other branches of science to treat people with these things. There are a lot of people who are already treating these things well. I go to a nutritionist who is amazing and has helped me more than any other doctor. She’s not anti-science or using crackpot theories. She’s still scientific. But my insurance won’t cover the because the MDs have a monopoly on that.

As you've said, the human body is complex. We don't always know what's wrong - of course we do our best with the tests we have, but often we're ruling things out and are left without a clear answer. When I try to tell patients that "I don't know", they're frustrated with me. And frequently, it's the patients that are mad that I don't have a pill or procedure that can fix it immediately.

You say that doctors like diseases that we can treat...well, of course we do. I want to help people! Why would I enjoy having to tell someone they're feeling badly but I can't figure out why with my current available tests and data? It doesn't mean that the symptoms aren't real, I just don't know what's causing them.

People think modern medicine means we have all the answers, but that's not the case by a long shot and the vast majority of human experience and condition is still unknown, and I do wish people understood that more.

(And, side note, insurances put up a fight with a ton of doctor-prescribed orders as well, it's a huge problem in the system. I'm sure all healthcare workers would love universal dietitian coverage.)

> When I try to tell patients that "I don't know", they're frustrated with me. And frequently, it's the patients that are mad that I don't have a pill or procedure that can fix it immediately.

One of my best experiences with a doctor was when he told me he believed my symptoms were real, but he didn’t know what caused them. After being told I was healthy repeatedly even though I had very real symptoms, just being believed was a relief.

Different patients want different things. Some want a quick fix. I don’t. I want to get to the bottom of it. Maybe try to ask some questions up front to gauge which type of person they are, so you can know how to give them bad news?

The other problem I was referring to was not that doctors like diseases that they can treat. That’s a misrepresentation of what I said. I was talking about how they seem to only like diseases with a VERY clear-cut diagnosis and standard treatment, where they can run one test, then write a prescription and solve the problem. Boom. Next! But anything that’s slightly more complex than that or has any grey area, and they don’t have the patience or mindset to troubleshoot the problem.

As a software engineer, I find doctors’ lack of curiosity very difficult to deal with. You get the strong sense that they’re just looking up a flow chart, but when things don’t fit the flow chart they have no method for dealing with that uncertainty, so they give up. I guess part of the problem is that easy fixes are the only thing that can fit into a twenty minute visit. Seems like there’s no time to be curious.

I don’t expect miracles. I know that modern medicine still doesn’t have anything close to all the answers. I suppose I just want doctors to get more comfortable with uncertainty and learn how to manage that uncertainty better. Don’t act certain about things they can’t be certain about, and be more curious when the patient in front of them doesn’t fit the diagnostic flow chart.

I understand that you’re all in a difficult situation though. Dealing with insurance B.S., difficult patients, legal risks, hundreds of thousands of dollars in school loans… I don’t envy you at all. But I can’t act like the current situation is working. It’s not.

What would it mean to use the scientific method on each individual patient? You can't run a valid RCT or even an observational study with an n=1 sample size.

You can form hypotheses and test them though. That is what they do when they run the "standard" tests, but once those tests are done most doctors don't seem to be good at and/or interested in coming up with further hypotheses.

You're mixing up unrelated issues. Anyone can call themselves a "nutritionist"; it's essentially a meaningless term.

MDs don't have a monopoly on receiving medical insurance payments. Insurers will pay for many non-medical allied health services including registered dieticians (RD) in cases where those meet coverage rules based on scientific evidence.

> Insurers will pay for many non-medical allied health services including registered dieticians (RD) in cases where those meet coverage rules based on scientific evidence.

Saying they will pay out in their brochure and actually paying out are two very different things. Anyone who has spent any time trying to get reimbursed for medical expenses knows the maze of dark patterns that insurance companies will use to avoid paying out. They wear you down with broken websites and “lost” form submissions until you give up. Medical insurance companies don’t make money by providing healthcare. They make money by collecting premiums and not providing healthcare. And actual scientific evidence has very little effect on what’s covered easily and what gets the runaround.

“so little understanding of health” - compared to, for example, you? Whats your method of developing this understanding and does the state and society in which you live recognize your tremendous ‘understanding of health” and allow you to prescribe medications or perform surgery on other humans? If not, why not?

Or are you just frustrated by how little we know about human health compared to what we wish we knew? (which I agree with but have made my peace with)

I think medical research has progressed far beyond what clinicians are capable of using. I won’t claim to have any great understanding of health myself. But I’ve had issues where qualified doctors told me there was nothing to be done about my health issues, yet with some research I was able to find evidence-based interventions that I tried on my own, that helped. A Google search by an engineer should not outperform twelve years of rigorous medical training, but it did on multiple occasions. And many people have these types of experiences. It’s not unusual at all for people with chronic health issues. There’s something very wrong with that.

But also, I agree that our understanding of health is still very limited, and I am ok with that. But MDs seem to think that their knowledge is much greater than it is. They tend to have a certainty in their assessments that is unwarranted. For example, instead of saying “Your bloodwork is within the normal range, so I’m not sure what’s causing your symptoms,” they will say “Your bloodwork is normal. You’re healthy.” Those are two very different statements. One shows empathy with their patient and allows for further investigation, and the other one says, “I did my job. You’re on your own now.”

While I don't know anything about medicine, I have some experience in curriculum design. My rule of thumb is that you can learn two things in a year. That doesn't mean people can't learn more. It means that you should describe the learning objectives you expect the students to meet at that level of granularity.

Anything that gets substantially less than half a year of full-time study is uncertain. Students may encounter it but fail to learn it, or they may learn it and later forget it.

12 years is enough time to learn 24 things. While there are more things you would like every doctor to know, you can't reasonably expect them to know all of that after just 12 years of training.

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