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Comment by teeray | Hacker News Reader

> But the boom angers some doctors, who argue that circumventing their offices can lead to questionable remedies, misdiagnosis or delayed medical care.

Yes, we’ll get you scheduled for that initial consult in a couple weeks, then a few weeks after that we can probably get you a test appointment, then a follow-up consultation a few weeks later. We might have to repeat that cycle a few times to get all the tests. The epitome of speedy treatment (/s)—but only if you’re an existing patient. If you’re a new patient, then bump that up a few months.

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Don't forget it's gonna cost you a fortune for each step of that process, plus the overhead of making sure you stay in network.

I legit avoid some stuff I should probably go to a doctor about not because of monetary cost but because it’d be five minutes with an old-school country doctor (I’m filling in a trope for illustration’s sake) but it’ll be like three damn hours of my time (or more) with the current medical system, factoring in multiple appointments because family doctors don’t actually do anything but prescribe antibiotics and issue referrals anymore, generate a dozen pieces of mail I have to deal with, et c. And that’s assuming no insurance fuckery that eats a ton of my time making them do what they’re supposed to.

And much of that time will need to be during weekdays during work hours, over multiple week days probably, and with so many unknowns about how much time it’ll actually take. I dunno how people without semi-flexible white collar work situations do anything with the healthcare system at all. I guess they either don’t, or they just have no vacation time left for actual vacation, ever. Especially if they have kids they need to guide through the same time-wasting bullshit.

Interacting with doctors takes me like 45-60 minutes for every five minutes of doctor time, at best. It’s fucking miserable. That’s the actual main benefit of things like telehealth, at least I can get a referral spending only 2-3x as much of my own time’s as the doctor’s, and all I have to do is give up all the benefits of having an actual family doctor who knows my history and also a good chance of just being told to see a GP anyway.

> I dunno how people without semi-flexible white collar work situations do anything with the healthcare system at all. I guess they either don’t, or they just have no vacation time left for actual vacation, ever.

Insurance company, starry-eyed: “You mean they can’t make many claims and we keep all the money?”

Employer, salivating: “and they won’t be able to take leave for more than a few hours at a time?!”

I believe insurance company profit is limited as a percentage of their revenues by the ACA. That's why some people get checks from their health insurance provider; the provider collected too much in premiums, and was left with more than their allowed profit.

They want you to use the insurance, so they can raise premiums and that % profit they're allowed to have is a larger absolute dollar amount.

That’s not really true. Insurance companies use intercompany eliminations to bypass the rules. Look at United Healthcare’s record-breaking profit.https://www.axios.com/2021/07/16/unitedhealth-optum-provider...

There aren’t enough doctors or specialists. So what to do? The answer for most shouldn’t be “alternative medicine” where any whacko “treatment” is an appropriate stand in.

But the answer is also not “the traditional system is perfect, just under-provisioned.” The additional doctors aren’t coming. They’re too expensive to train and they don’t want to be primary care doctors when they can finally practice. We need self-service means to augment the few doctors we have so that the system can continue to function.

The primary care doctor role is in the process of being supplanted by nurse practitioners and physician assistants.

I got an appointment at a pharmacy "instant clinic" when I was traveling because I had a persistent cough I couldn't see to throw. COVID test was negative but that doesn't necessarily mean much these days.

Got an appointment in less than a day. The nurse practitioner probably gave me a more thorough look over (absent labs) than my primary care would have. Gave me an inhaler prescription probably as much to do something other than tell me to just continue the OTC medication I was already taking.

Sure, in an ideal world, we'd probably have a next-day MD appointment for everyone. But there's a ton of stuff when an ER or physician isn't really called for.

Not sure what your point is. It sounds like the instant clinic was functionally no different than doing nothing at all.

You don't see any benefit to having a trained/licensed professional taking vitals and making a diagnosis--even if that diagnosis is basically "you'll get better"? And the inhaler was actually helpful. And if the other option was to spend the day in a NYC ER I'd probably have passed.

I'm not a hypochondriac and maybe in a pre-COVID world I'd just have assumed I was "fine" but having a second opinion seemed warranted given the option.

I've also been in an ER when the diagnosis from an infectious disease specialist (after some really bad lab work and high fever) was basically go home, rest, and drink plenty of fluids when his assessment (of a fairly serious tropical disease) took a month to be confirmed from a lab in Paris.

So we just basically self-diagnose and assume it will all just get better?

A wrong diagnosis may be more harmful than you realize - if they are wrong (and they often are) it can lead to death/permanent disability.

I'm not sure what point you're making.

In one case, it would have been pretty ridiculous for me to have gone to the ER given that I didn't otherwise have COVID or other serious symptoms.

In the other case, in spite of a pretty high fever, I'm quite confident that had I gone into the local rural ER at the time they would have had zero idea about the tropical disease I had and, even after I got home with a fairly persistent mild fever, my very experienced primary care MD just knew that my blood work looked bad and it took an on-call infectious disease specialist to know what was going on.

You're not always going to have an expert specialist available.

Not that it mattered in either case because there wasn't really anything they could do other than let my body do its thing.

Anecdotes are mixed. Here's one from me: See multiple PA's at E endocrinology office, test results indicate hyperthyroidism, they all say no that's just barely above normal (it was actually significantly higher), wait months between appointments, after nearly a year force an appointment with the actual doctor, "yep you have hyperthyroidism, let's get the drugs you need to live, I don't know how they missed that". Mind you the PAs worked under that same doctor. So had it not been for patient effort to read and interpret test results, things would still be getting worse. Some PAs are great, some are not. Same as doctors, same as patients self testing and diagnosing.

And a nurse practitioner who has years of varied hospital experience including ER is different from one who doesn't.

And France places an ER doctor in emergency response ambulances - apparently that has value (and they sometimes park themselves while the doctor works to stabilize the patient rather than try to bounce around to the ER.)

Same for France and urgent care. If the phone screen goes in the right direction, a doctor driving around from patient to patient will get to you quickly (~ 20 minutes last time for me.) Even if you don't have local insurance, and for a surprisingly low price.

None of this is impossible - as the US med professions want you to believe.

Ah yes, the perpetual margin chasing enshitification of healthcare.

And while we're at it, companies should probably only hire PhDs from elite schools as developers because you never know when that sort of (supposed) expertise might be needed.

Hiring doctors is exactly what the local hospital needs, and can no longer do after being bought out by a megacorp.

NP: "if it gets worse go to the ER" Thanks...I guess.

There's no shortage of whacko treatments in mainstream medicine nowadays. Very unfortunate and dangerous.

One thing you plausibly could do is attempt medical tourism, if nothing else, your perspective will improve.

This is why I don't understand the AI hate. We literally don't have enough people becoming doctors, AI-assisted Healthcare would be stealing jobs from basically nobody

It would detract from any real answer, like making medical/care work more attractive. This might be a very European perspective from me but the people I know who work anywhere close to medicine are doing so despite the pay and working conditions. At the exception of the top of the pyramid, typically occupied by old white men with a horrifically antiquated world view and inflated egos.

Why isn't it a "real answer". Any time our civilization had a shortage of something, we increased efficiency by offloading work to machines.

Blood count tests used to be done by people actually counting cells. Now, it's all machines, likely even in a very poor countries.

"white men"

Please don't add racial and gender resentments into an already bad problem.

Neither the US nor Europe has enough medical professionals to drag arbitrary racial and gender demands into the mix.

And without old doctors in general being willing to work even though they could enjoy their retirement, many places in Europe would have no healthcare left. Which doesn't bode well for 2040 or 2050.

What is the process for making AI acceptably reliable for medical use? Is it just drastically reducing the standard of "reliable"? Who is liable for AI medical errors?

When you can choose between a well rested and competent doctor, everyone would choose that.

But when you have to choose between a overworked and exhausted doctor, who gives you 10 seconds of slight attention, then I might choose the AI, mixed with my own judgement.

Anyway, why not more of both? Better AI tools and more doctors?

The shortage of doctors is an artificial guild monopoly.

Why aren't there enough doctors or specialists? Especially in America it seems like a very profitable profession. Is it artificially limited?

Yes, by the guild of doctors.

Becoming a medical professional is very expensive; tuition often going into the six-figures. Becoming a physician takes a good decade or more of your life. The entry process is very competitive and limited, with majority of applicants being rejected. IIRC the acceptance rates are below 50%. Once a person clears those hurdles however, they are now faced with a torrential abuse of corruption, racism, fraud, elitism, favoritism, etc. that they must overcome.

Much of the medical field is like this unfortunately, it's not just doctors. Take for example this article about Duke's Nursing School and racism: https://archive.is/DIJ98. From what I've heard through third-party, corruption at Duke is at an all-time high. This is just the stuff we hear about too, so I'm sure these problems affect all of the top-tier colleges that nobody reports so they don't get ejected from these programs.

4 years college taking some of the toughest courses there are to be ready for 4 years of medical school. After that 8 years of schooling then you have to go through the hazing ritual they call "residency". Residency varies depending on your specialty, from 3 to 7 more years[1] - during which time you're working 60-80 hour weeks [2].

So baseline if you're smart and hard working, you need to take the hardest college track from ages 18-22, medical school (22-26). Then work two jobs worth of hours as a trainee making well under 100k starting at age 27 and into your early 30s [3] so you can't save or pay down any of your debt from getting here.

So if you choose to be a doctor, you have to: (a) dedicate to working your ass off at 18, (b) keep at it until you're in your early 30s, (c) start with massive debt

I think it's actually pretty amazing that we have as many doctors as we do.

[1] https://medschoolinsiders.com/medical-student/how-long-is-re... [2] https://www.ama-assn.org/medical-students/preparing-residenc... [3] https://www.inspiraadvantage.com/blog/how-much-do-medical-re...

But what's the actual rate limiting factor? I remember liking at University entrance requirements in my country and the minimum requirements were low compared to what you actually needed because of the insane competition.

Why not just expand the amount of spots and train more doctors? Surely they don't take everyone that applies and then filter them out (even CS doesn't do that).

The limiting factor, as I understand it, is residency slots. Residency slots are, for some reason, principally funded by Medicare, so they are funded by Congress, which has for the past several decades not increased that allocation. Apparently that's starting to change?

In my opinion though, I can't see why the number of doctors should be something that is principally controlled by congress at all, and ideally some other method should come about.

Until that happens though, it's up to Congress to fix this.

I've read about it and came upon the same answer as you just gave, but I'm not satisfied with it.

Looking around the world, it seems to me that most developed countries (if not all) suffer from the same problem of lack of doctors. Some mask it by pulling doctors from poorer countries (including poorer developed countries), but it seems like there's a lack of doctors everywhere. If that's the case then Congress can't really be the only limiting factor.

Why are there no developed countries that have far too many doctors? The only countries that I can think of that export doctors are Cuba and third world countries.

You need to be smart, hard working, dedicated, and interested in medicine. That’s going to be a limiting factor. Add in high tuition and a public that hates you, and it’s hard to motivate.

Complete destruction of price signals due to the symbiotic relationship between "providers" and "insurance" cooperating to defraud patients. This is backed up by whatever corrupt laws allow "providers" to send arbitrary post-facto bills and even presumably enforce such nonsense "debts", rather than getting prosecuted for said fraud.

Unfortunately most people taking notice of how broken the system is end up get fixated on the large figures on those fraudulent bills, and think single payer can do something to fix at least part of the system. But systematically, at best single payer would be tying the garbage bag off for tidy disposal, when what we actually need is for the sheer majority of medical care to have a functioning market that allows for patient agency.

Having a test done is not a treatment. It is vital information about your own body. Better yet, if you have an issue and no doctor is listening to you and are willing to pay for the test, then your usage of the system simply means you're not doctor shopping. If you turn out to be right, then you can take the result and go to a doctor and get treatment. Otherwise, you can be satisfied.

The artificial scarcity created by doctors gatekeeping is unnecessary.

For example, I successfully diagnosed my own anemia disorder (thalassemia) this way. It's a simple test. I paid for it. The results are unequivocal. We can now stop giving me iron, thank you very much.

I would worry as much about kicking off a 'cascade of care'[1] where test findings cause more problems then they avert.

1: https://www.npr.org/sections/health-shots/2022/06/13/1104141...

We are capable software engineers.

We can learn new domains, assess risk, and evaluate trade-offs.

This is our health. Self-research is love. It's advocating on your behalf.

> We are capable software engineers

That is completely meaningless in this context.

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