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Comment by goodluckchuck | Hacker News Reader

The underlying point of the manifesto is that insurers have corrupted medicine itself. Regardless of whether the care would be covered, the doctors were trained to diagnose and treat in a way that isn’t designed to cure, but to “care.” Sure, she had visits and specialists and diagnoses and it was largely incompetent, because incompetent doctors are cheap in a system where inaction has no real consequence.

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Which is total nonsense. There is certainly plenty of room for improvement in the healthcare system. But the average competence level of doctors is higher now than ever before. If you think we have problems now than look how many quacks there were a century ago, before health insurance even really existed.

I think both views are partially right. Yes, medicine has advanced. There are many areas where the treatments simply didn’t exist, even 20 years ago. There are different people involved with different incentives. However, that doesn’t mean that insurance hasn’t also had a negative effect on quality of care. The example that comes to mind the standard of care for back injuries. Treatment begins maybe with an x-ray to check for fractures, but then NSAIDs. If that doesn’t work, then physical therapy a couple times a week for a few weeks. Then patients may get an MRI a couple months later… after it’s too late to see bruising to the spinal cord. So, there’s almost never direct evidence that a herniation is work-related, and thus it isn’t covered by workers compensation. The path of escalation is designed to reduce costs, but starting with an MRI on day one is decidedly better for patient outcomes.

Regardless of insurance issues, are there actually evidence-based medicine guidelines to support an immediate MRI for back injuries? By injury do you mean some kind of specific trauma, or any serious back pain regardless of suspected cause? Many patients do recover with OTC analgesics, proper physical therapy, and time.

https://peterattiamd.com/stuartmcgill/

What you'll find with imaging for those structures is that many patients appear to have abnormalities or apparent pathologies, including patients who don't have any pain. So while MRI can be helpful for diagnosis and treatment it isn't necessarily definitive.

There is always going to be a resource allocation and care rationing issue with expensive services like MRI. Other countries with socialized healthcare often have long queues for non-emergency MRIs. In fact, we often see affluent Canadians coming to the USA as medical tourists to skip the queues.

Medicine, like engineering, is a domain of trade-offs.

You could order MRIs for every back pain complaint, which would improve outcomes for some % of patients, while probably worsening outcomes for others (due to red herring findings that lead to unnecessary treatments), but at what cost? Who will bear this cost? Regardless of health care system, someone will have to. Most back pain self-resolves with home care, so it makes sense to try that first, unless you have reason to suspect severe trauma that needs immediate treatment (e.g. the patient just fell off a ladder).

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