Doctors Tell All, and It’s Bad
theatlantic.com
theatlantic.com
A the lowest-level, you have doctors who're just assholes. Unfortunately, they don't do a good job at filtering out abrasive personalities upon entry to medical school. In fact, I'd say in some ways they self-select for that type of person. I've worked with heads of departments at huge hospitals who've openly discussed their salaries with me in patient rooms or brushed off a patient's concerns in a condescendingly paternalistic manner only to laugh with colleagues about it the second they step out of the patient's room. I've argued many times with specialists running their own clinic about their exorbitant fees and clever ICD-coding skills -- that some brag about developing -- to squeeze every penny out of insurers, all justified by "we've got to make a living." Assholes in medicine run rampant.
Up one level and you have the sheer morbid nature of medicine that physicians deal with on a day-to-day basis. I've given chest compressions to trauma patients with self-inflicted gunshot wounds to the head, and cleaned maggots out of a patient's festering diabetic foot. To the outsider, it is all incredibly shocking and gruesome, but as a physician you grow callous to it. Unfortunately, many times that means growing callous to all emotions and stunting your ability to empathize. Mix that with a superiority complex and you get things like Hispanic Hysteria Syndrome.
Go up a level and you've got a huge logistical and resource problem. Hospital physicians, particularly residents at teaching hospitals, are often overloaded with responsibilities and patients. They often feel they cannot give every patient and every obligation full and thorough attention because they are being bombarded by pages for new admissions, calls from other staff, etc. I have seen residents breeze through a list of patients, only giving minimal attention to each, just to avoid being chastised by a superior for not fulfilling all responsibilities in the short time allotted. And when you are severely limited to the number of open beds you have, and you've got a crowded ED, it becomes a game of who can we push out the fastest without killing.
At a higher level, you have a hospital who needs to keep the lights on, needs to pay salaries, needs to maximize profits and yet treat patients as best as they can. Unfortunately, many hospitals are being swindled by suppliers who're working through group buying organizations [1], inflating costs and making it difficult for hospitals to hit their margins.
There's a lot more I could go on about.
Teaching you to make acceptable/the best possible/whatever decisions when you're tired/not at your best for whatever reasons, which will likely happen in the future.
Teaching you how to deal with extreme emergencies, e.g. http://stormdoctor.blogspot.com/2011/06/first-response-mode-..., which may not happen to you, but will statistically happen to a subset of doctors who go through the system.
WRT to that link on what happened in my home town May 23rd, 2011, the local medical response hundreds of lives that night, keeping the death toll down to ~ 160.
It is sub-optimal (to the extent that people die) to train doctors how to make decisions when they're tired by forcing a bunch of doctors to be tired most of the time.
It's kind of surprising that clinician errors kill so few people - about 10,000 (ten thousand) per year in the US.
It'll happen sooner or later, if not done during residency. But residencies have the advantage of a degree of supervision, and in a location where ... I hate to call it a support system, but, still, the people working with them know they're residents and expect them to green et. al.
The alternative is this happening when they're "on their own", even if part of a multi-doctor practice, clinic, ER or whatever. After residency they will statistically be making decisions when they're tired or otherwise not at their best. Didn't sleep well the night before, got woken up because one of their patients is in a crisis and their input is needed (although I gather that's less common nowadays), and there are the unexpected emergencies when their skills are needed without prior warning.
My take on the current system, butressed by all the doctors I've talked to about this, is that it's "optimal" when you consider all the factors. Just focusing on the residency period is insufficient to make a judgement.
It seems to me that it is mostly based on tradition and gut feeling.
Most of the issues with non-resident doctors working when tired could be fixed by increasing the number of doctors and physicians assistants. Of course physicians organizations fight against that as it would lead to lowering their income.
I don't an practical means to obtain "actual evidence", it would require incredibly intrusive tracking of the careers of a bunch of doctors, and deciding the why of adverse outcomes is frequently going to be subjective.
I.e. was it the doctor or the patient? Which patients were more likely to have a bad outcome because of genetics or past history? The subject of "compliance" is sobering, sure you can prescribe a wonder drug, but you can't make the patient take it (aside from some TB regimens where compliance in taking a nasty multi-drug cocktail for 18 month or thereabouts is enforced).
And how does this makes sense? Aircraft pilots have rigid (well, in theory) schedule limits. Of course, this doesn't work all the time, but it's better to try to ensure they're rested than just make them "suck it up" no?
He pointed out the caregiver handoff is also a source of errors--the departing doctor can't fully describe the history and their thought processes about every aspect of every patient they are treating. And people sometimes make mistakes on charts. He said the schedule at his hospital, at least, tries to strike a balance between continuity of care and fully rested doctors.
The demands are also different: pilots don't get called out of their normal schedule to be asked about a problem they observed with plane X the last time they flew it (rather, they're supposed to report it at the end of the flight and mechanics will look at it).
Emergencies also have a different nature, I gather its much more likely you'll be short flyable planes than air crews. A look at the Berlin airlift might be instructive. A book I recently read on the WWII air war in the South Pacific said that was true for both sides. Although of course the rules in wartime are different.
I've had two experiences when I was told to go to the ER even though it was completely unnecessary. Once I had a very painful hemorrhoid. I called the nurse's line for my insurance company and they told me to go to the ER immediately. This freaked me out, since I figured it was a minor (albeit painful) issue, so I called a doctor who was a friend of the family. He told me to just go to a walk-in clinic the next day (I didn't have a regular PCP) and that they might give me a referral to a surgeon, but most likely they would let it heal on its own.
A second time, I was out of state for the summer and needed a refill for a prescription. My doctor's office told me to go to a local ER.
I would imagine that having to handle both emergencies and also routine nonsense that should be handled elsewhere has got to be really grinding on an emergency department.
Having said that the Australian health system is so radically different to that of the US (for the better) that very little in the above article applies to my working conditions
[1] http://www.washingtonmonthly.com/features/2010/1007.blake.ht...
I was physically assaulted by a doctor around six years ago, I would use a much harsher term than asshole.
The experience most interns have on day 1 is a massive increase in responsibility and work load as compared to medical school. Whereas most medical students in their 4th year "manage" (under the very close supervision of residents) 2, 3, or maybe 4 patients, on day 1 of intern year they are suddenly expected to be responsible for upwards of 10-12 patients (under supervision, but considerably less supervision than med students). Interns go from spending most of their time studying and learning medicine, to being suddenly, constantly busy with often mind-numbing tasks. We interns joke that we are nothing more than secretaries, doing tasks for our boses all day without time to sit down and think for ourselves, despite the M.D. we just spent years earning. Eventually, we get better at prioritizing, we learn the system, and we learn by doing.
But, early in intern year, we can't prioritize, we don't know the system, frankly we can't even keep which patient is which straight in our heads. But, regardless, we still have n number of tasks to do by the end of the day.
Spending extra time talking to patients isn't part of n. Empathy isn't an item in n. Figuring out a patient's priorities for their health aren't an item. Those are extras.
And to get home on time, after my 12-14 hour shift, all I have to do is my list of n tasks, which is substantial. So, we quickly learned that long conversations with patients are the enemy of getting home on time. And pretty quickly, we start to eliminate those conversations. Then, we figure out that other things patients need, like empathy, a careful history taking and detailed physical exam, family discussions, etc also stand in our way of getting our work done on time.
Eventually, we learn the ability to keep our patient's complex medical problems straight and become much more efficient at getting our work done quickly. So, realizing we have more time, some of us go back and start to do the things that really matter to patients, like those things listed above and in the article. But, we've already learned, or forced by the system to learn, that we can get away with not doing those things, so as soon as we get a little extra busy or are a little extra tired, those are the first things we skip.
Then, suddenly, we start second year and can now be asked to work 24-28 hours straight, and now we have 18-24 patients instead of 10-12 that we are responsible for and the system again drains us of the very thing we enrolled in medical school to be.
To be frank, this is why I've decided to leave medicine proper altogether and to go down the startup route. Not only do I find startups more interesting, but I genuinely believe that a much bigger impact to patients' health could be achieved while maintaining my empathy, sanity, and life. I don't mean to denigrate you in anyway. If anything, you're far brave than I am.
Is this just one of those cases where, if you made it through medical school for an obscene number of years, you "don't care about the money", and thus just take whatever you can get in industry?
From what I hear around here (again, not in the medical industry at all and never really interact with it besides as occasional chauffeur for relatives) it is just an over-regulated mess that makes market forces impossible to act on it. Is it any better in some of the single payer nations without as much bureaucracy? Or is there even more on that side of the circus?
I think it's more like "holy shit I have $300k in medical school loans, I better put up with whatever I have to in order to become an attending."
> makes market forces impossible to act on it
I believe (though I could certainly be wrong) that market forces are actually mostly responsible. Because a medical intern's negotiating position is pretty weak (they're saddled with medical school debt, they still require a great deal of on-the-job training), hospitals are well aware that they can torture interns because the alternative is pretty grim - even if you went off and became a software developer at Google, $300K in student loan debts will eat up pretty much all of your salary.
Is that happening? Last I heard enrollment in medical programs was still at capacity. Which just goes back to my "don't care about the money" stance, because that seems to have to be the motive if students see whats on the other side yet willfully put themselves through it.
Not necessarily, for the same reason that people join fraternities/sororities even knowing that 'hazing' happens: they think the rewards are worth the temporary punishment.
> Which just goes back to my "don't care about the money" stance
I don't think that's a conclusion you can draw from the circumstances, because there's a big payoff for sticking it out through 4-5 years of abuse. Especially in fields like dermatology, the payoff for 4-5 years of abuse could easily be a 7 figure salary.
I would wager a large sum that medical students and interns are well-versed in delayed gratification (I mean, that's sort of how they get to become interns to begin with), so putting up with a few years of hell for a big payoff is something they're quite used to already.
In many ways it's similar to other high-pressure fields with insane initiation periods like investment banking, though deciding to quit in your 2nd year of investment banking involves a lot less risk than deciding to quit in your 2nd year of residency (because of both debt and alternatives).
I was just worried the problem was that students were not aware of what awaited them after 6+ years of bank breaking schooling, and were stuck between a rock and hard place after graduating.
> apparently the medical system even under such physiologically unhealthy conditions still has all the MD's it needs
Interns will agree to work 100 hour weeks because they have no alternatives, but I don't think that it's necessarily efficient from an economic standpoint. They have all the MDs they need, sure, but it's highly arguable about whether it's efficient from an economic standpoint. We'd have to compare the cost of medical errors (which is non-negligible) from interns due to fatigue vs. the cost of hiring another intern.
> I was just worried the problem was that students were not aware of what awaited them after 6+ years of bank breaking schooling...
We're talking about basically a decade between when you make the decision to become a doctor and when you receive a MD. Even if you start out on the path to be a MD with perfect intentions, people change heavily over the course of a decade (and especially so at that age).
The grim reality is that even after undergrad (halfway in), if you chose a typical "med school" major you're still in a bit of a bad spot unless you decide to go into research in the life sciences. After graduating med school, your MD qualifies you for 1 thing and comes with the heavy cost of crippling debt. Deciding you don't really like medicine in your 3rd year of med school is incredibly costly and practically unfeasible for most people going through school.
Between 1-5 times in a shift of this nature I will be required to do something cognitively demanding, most of the rest is patient interaction, reassurance, and basic basic medical stuff that you master in your first month in the job
Its a truly immense set of call center scripts and procedures to memorize and be tested on, but after your 10000th concussion or 10000th wound needing stitches or woman in labor or whatever, its all fairly routine?
My buddy said it to someone outside the field knowing I'm outside the field, to us as customers every interaction is new and mysterious, much like calling into a call center.
My software job is very cognitively interesting, lots of thinking about new things and new ways to do "stuff" and my doc buddy was a bit jealous of my working conditions and working hours.
I'd have to say that with my current experience I would disagree. My job has a huge range of variability. That may be helped by the fact that I rotate I to totally different areas of medicine every few months and will for another year before I start specialising. Even so, yes it's true (or at least I feel it is) that we are a customer service industry (or at least should be). Sometimes this is the greatest part of my day. I know, for example, that for a certain percentage of my patients I will be able to make a huge difference to the perception they have of the healthcare system just by sitting and taking 5 minutes to explain in laymans terms what we are doing.
In my hospital's patient population (mostly white Anglo Saxon Australians, usually slightly older than the national average) this comes across very well because I am a 6 foot 2 100kg white man, so I fit the mould of what they want as a doctor. (Sometimes this results in the patient confiding in me how happy he is that he is talking to a 'real Aussie' - the racism is astounding and very irritating sometimes) Women have a harder time and many of my female colleagues are regularly assumed to be nurses even after introducing themselves as doctors.
But I digress. Yes, a lot of my job becomes routine. I have studied for 10 years to be where I am and know huge areas of disease and the pathological basis back and forwards. But that doesn't stop many situations from being fascinating.
When I started med school I was all about the science - I loved it. Now I have found that a side benefit is (some) of the people and making a difference. Sometimes I'm too busy, and I can see the ability to get jaded; my (medical) friends and I will often (confidentially) describe some of the horrible situations we have seen; and you need to be able to laugh at times as a coping mechanism.
But I love my job; for the variability; for the characters; for the 1 in 50 patients that totally changes your world view and makes your life richer for having treated them; for the care that is entrusted to me; and for the really top notch people I am surrounded by, who will accept nothing less than excellence from themselves and give their time freely to improve your education and ability
Why the hell should you need to pull 24-28 hour shifts?
It takes a lot of money, resources, and existing doctors' time to train a new doctor. One thing that's likely to help a bit is the move to nurse practitioners and physician assistants for much of primary care.
Don't personally know if this is true, but if it is it's shameful, especially given the "physician shortage" crisis. Or maybe crisis should be in quotes.
Other limits:
- You are not allowed more than 80hrs per week, that is a hard limit and programs will get in trouble if they ask more of you.
- You are required to take 4 days off every 4 week rolling average ( so 1 day off per week, or 2 days off every 2 weeks, etc )
I wish this surprised me, and I wish more would-be doctors understood what they are getting into; that inspired me to write this essay: http://jseliger.wordpress.com/2012/10/20/why-you-should-beco... .
the system again drains us of the very thing we enrolled in medical school to be.
And most people who make it through the system seem to want to then reproduce it. Grad schools have some similar problems, but they're less pernicious in terms of hours demanded and debt taken.
There is a difference between 'spend a day' and 'work long-term'. Medical staff are normal people; there's no training that makes you immune to compassion fatigue. When you go into an ER and it's all new to you and chaotic, it seems crazy that these people are in pain and those people just don't care. But do it every working day of your life, and you have to buttress your emotion against it. Not to mention that it's a fine line to walk, showing enough compassion. If you let emotion get the better of you, you'll be less effective in your actual job of helping people. Throw in the occasional patient that is trying to pull the wool over your eyes, and you become to what looks to outsiders as a callous, uncaring individual. It's not to say that all ER staff are saints, but whenever considering the ER environment, don't forget to view it from the shoes of the people who work behind the counter long-term.
My own realisation of this buttressing: I used to work as a medical tech in what was essentially an outpatient clinic that did some patients on the ward. I remember one day, several years in, casually wandering up to the ward with my equipment, when I turned the corner and was met by a wailing wall of family coming the other way. "Oh yeah - hospital is not a nice place to be. Normal people only come here when something is really bad...".
This week, I logged in to their patient portal because I wanted to look at some previous blood test results. I was absolutely startled when I saw that my AST and ALT counts were pretty high, about twice the upper limit for what is considered normal.
But then I realized that I had that blood work done around the time I had started strength training and increased the amount of protein in my diet. A quick online search revealed that a single strength training session increases AST and ALT levels for up to seven days. Considering I had been exercising multiple times a week, it was completely normal for my levels to be elevated.
Now, why didn't the doctor simply ask me if I had been strength training? Such a simple question would have explained the abnormal test results and saved me some distress.
Last month I was trying to get a copy of my MRI from UCSF, but their cd burner on the PACS was down. They are participants in RSNA image share so patients can opt to import scans into a portal but it took me 3 people in the radiology library before finding someone who knew anything about it.
I found the same info after the initial test, then refrained from lifting for a week before the follow up lab work. Tests were normal the second time but had they not been, I'd have been given a (presumably more expensive) ultrasound.
My only guess is that the lifting-bad-liver-panel effect isn't something that happens often, since so many people strength train these days.
Is this "Patient Portal" software some kind of off-the-shelf crapware? It is terrible.
Not to be impolite but only to make a point: if you read enough to be distressed, you could have read enough to de-distress yourself.
Because of the patient portal with its ability for patients to access info they don't understand the significance of, you were "absolutely startled" and "distressed". If you didnt have access to those results then you wouldn't have been concerned.
Regardless of all that, you should still have repeat LFT's because you don't know for sure that "strngth training" was the cause of the problem.
Honestly, Doctors find navigating the minefield of clinical decision making difficult enough, trying to make judgements on sensitivity/specificity of tests and investigations, positive predictive values, remove confounding, drug company propaganda, publication bias etc etc without patients trying to get into it all as well. Should I spend 1 hour explaining to every fucker with a headache why a CT head is more likely to cause brain cancer than it is to diagnose it?
The solution to the US healthcare woes is NOT more patient autonomy and decision making. The solution is moving towards a less money orientated system and trying to encourage altruism and alignment of patient's goals with doctor's actions.
Yes, absolutely. Medicine needs to descend from its status as a high priesthood and be a little more accessible.
A stereotypical micro vs macro problem where the best possible micro solution is likely not the best possible macro solution.
To some extent its a systemic problem with levels of support. Every customer that calls into a call center claiming space aliens are controlling their minds should not be transferred to argue with the VP of software development for an hour.
Absolutely you should. Because the beauty and the curse of the American health system is that patients can and do find other doctors willing to perform meaningless tests (as the article points out: because these tests are lucrative). If CT scans are more likely to cause a brain cancer, shouldn't the patient be informed?
> The solution to the US healthcare woes is NOT more patient autonomy and decision making.
No, more patient autonomy and decision making is happening regardless of whether it is a solution or a problem for the health care system. Medical professionals need to accept that patients are more informed than ever, and work with that fact instead of against it.
Imagine if the software industry had the same attitude (saying this with tongue firmly implanted in cheek).
I have a fairly qualified job in IT, and I regularly spend hours explaining trivialities to my clients. That's part of the reason why they hire me.
(Also, that particular question should not take one hour to explain unless the problem lies elsewhere -- it should be an order of magnitude less if your time is expensive.)
That this question would even seem to make sense, let alone phrased in a condescending tone, tells me there is a self selecting culture with some room for improvement there.
> The solution is moving towards a less money orientated system and trying to encourage altruism and alignment of patient's goals with doctor's actions.
Altruism essentially never saves any ships. That's just not how the world operates. It's always about money. The only alignment that will work is more money going towards doctors.
In the (non-US) hospital I work we have a really exceptional bunch of general surgeons. 4/6 of them are work-a-holics, 3 work only in the public system (basically halving their salaries c/f if they did a day a week in private practice). They routinely work from 7am til 7pm, love operating, will come in on weekends when they are not on call to see and operate on their patients. The others do small amounts of private work but are still really focused on their public work.
These guys have some degree of martyr complex, some degree of being workaholics, enjoy the status in the community they get from being seen as hardworking altruistic surgeons. They get a truckload of work done and really provide a great service for their patients.
This is not universal but other departments in the hospital have similar personalities.
These kinds of people are the ones that keep a socialised health system going. I think they would really struggle in a for-profit health system because it is really difficult to remain altruistic and go beyond the call of duty consistently when you feel like others are not. When your colleagues are being lazy, when your hospital/insurers are trying to rip you off or tighten the screws, or forcing you to spend large amounts of time doing paperwork and claims. When you feel like you are having to bankrupt your patients by operating on them. All these things make you bitter and stop you caring and performing for your patients.
After dealing with poor health for 30 years; I finally took my health into my own hands. After a series of self-experiments and a lot of journal reading, I now feel like I'm finally reaching health, but every time I see a doctor, it's the same battle ("OMG, your cholesterol is 239; you are a dead man walking!" Yeah, I don't think so).
There is a lot of good information out there, but there is also a lot of complete crap, and doctors have to deal with truly informed people as well as people who only think they are informed. Worse, much of their continuing education is not much more than paid infomercials, making it hard to trust they are getting truly balanced information.
Add to all of this the fact that you have seven minutes with your doctor to work it all out, and it is failing.
There are a few things that can be done, IMO, to help:
1. The AHA, ADA, AMA, AND and other medical organizations need to stop taking so much money from corporate sponsors.
2. Education about and treatment of chronic conditions need to be treated very differently than acute conditions. The treatment for Type 2 diabetes should not default to Metformin.
3. We need more time with doctors to work on treatment plans that can be carried out.
4. Medical school and continuing education needs far more, unbiased education about the value/dangers of nutrition, environmental contaminants, etc, in chronic disease. Alzheimer's prevention starts in a person's 30's[1].
Unfortunately, we see the same kind of care given for stiches as for metabolic syndrome. And it's not working.
1. Based on a current hypothesis that it is the effect of "Type 3" diabetes.
(Found a long time ago via LessWrong: http://lesswrong.com/lw/gvi/metamed_evidencebased_healthcare...)
https://news.ycombinator.com/item?id=5296694
One of their first medical advisors was a disbarred doc who lost his license for writing online pharmacy prescriptions. I'd do some serious research into credentials before throwing in the $5-50k they charge.
They also had a "health researcher" whose primary credentials were "eagle scout": https://news.ycombinator.com/item?id=5296594 https://news.ycombinator.com/item?id=5296724
https://www.metamed.com/ScientistsDoctorsResearchers
They have a Chief Medical Officer, and all but one of the researchers is an M.D. -- the guy who was ordered to suspend his medical license is gone, and so is the eagle scout.
The workings of the immune system are rather like the workings of metabolism: the present vast knowledge, the stuff that takes years to learn and which encompasses many disciplines as no one person can know enough of all of it to make a career of that, is actually basically just a sketch of how things work. It is a map at the high level. When it comes to the all-important details there are decades of work left at even at the present pace and with the damn impressive biotechnology the research community has now in order to get to even a moderately complete picture.
So there's a reason why many forms of autoimmunity are really hard to diagnose, and why you'll find that a great many diagnoses of exclusion are mild autoimmune conditions: here's what's wrong with you, it's the bucket we put people in when you have some symptoms and all the tests we have come back negative or with ambiguous results. Those tend to be the ones where nothing can be done at present. The author of the article should at least be happy that she is one step up from that situation.
The immune system has so many ways of running awry due to malprogramming that there really should be more work done on more gentle ways to reboot it - strip out all immune cells and start over with the patient's stem cells to repopulate it. Aggressive reboot methods involving chemotherapy have been pretty effective when trialed, but that's not something you'd want to do unless there was no alternative.
The advent of biologics for immune suppression have turned the research community away from the possibilities of the wipe clean and start over approach, however, which I think might be a mistake in the long run.
[1] http://www.uchospitals.edu/news/2012/20120203-billing.html
* Doctors are human. Some will do extraordinary things. Some will make mistakes. Some will be assholes. Many will do all three at some point in their lives.
* Medicine is a business. There are financial incentives pushing and pulling on the doctor's behavior. Not saying it dictates everything they do, but denying its existence is folly. Just remember, there is a financial transaction involved every time you interact whether you see it or not.
* No one cares about your well being more than you and those that love you. Yes, doctors are well educated and, yes, they definitely want to heal you. But they aren't going to stay up all night researching your symptoms, the treatment options, the drug interactions. Your loved ones may start from a far less informed place, but they will give every thing they have to heal you. To them you are a best friend, a sibling, a child, a spouse. To doctors you are one patient out of dozens or hundreds. This backseat google-doctoring infuriates medical professionals, but it is unavoidable. This isn't a condemnation, it is just reality.
Agreed, I'm just glad I'm in a position where I can simply walk out on a doctor being an asshole to me. And then proceed to the next practice over.
If enough people do that, things would be much better. Unfortunately, that's not always possible.
There is no particular reason both have to be implemented at the same time. Maybe its culturally popular but there's certainly no technical reason.
I live in a former 1st world non-socialized medicine country and I have no option in where I go for medical care other than on a very meta level of which employer I work at and where I live ... in an emergency (heart attack, car accident) the ambulance drives me to the closest ER, there is no free market deciding which is "better". In a non-emergency, my cheap health insurance contracts with precisely one large medical chain in my area, so if I'm willing to do something like medical tourism and fly to another state I could select a new doc, but again no free market ...
This is a painfully accurate description of the USA
I can change my GP at any time, and I do not have to give a reason.
When I go to my GP for a problem and she thinks I need a referral I then get a choice of 4 different doctors and I can book it online.
You can always ask for second opinions. It's simply untrue to suggest that people don't have choice of doctors in England.
It's not about lack of choice. The choice represents the doctors' competition with one-another. Obviously, as I've pointed out, the choice also has to have meaningful repercussions for the doctor involved, otherwise it's not really the kind of choice that can make a difference.
They get paid for patients on their list; they attract funding for the surgery performed; etc.
Many people/doctors may be bastards; many people/doctors may be knackered; many people/doctors may only be in it for the money. But they're still the minority.
I can think of 1 dentist experience and no doctor experiences where I've felt that the person had no interest in their job.
Ironically, often in the US I've had less choice in providers due to network constraints on insurance.
1) How far along are we in terms of those computers that were predicted in the 80s to one day replace doctors? Not trying to antagonize but I can't see any harm in having a row of booths with terminals that patients can log into and start answering questions about symptoms, being led through the "troubleshooting" steps, etc. There's a lot of time spent just waiting around in hospitals, waiting rooms, etc. Maybe you could have a swipe card that saves your progress on the terminal, combines it with the lab results. The system wouldn't replace a GP just yet but it would instead work alongside the GP.
2) Are there any crowd-sourced solutions available yet for these cases where doctors clearly have no idea? Someone enters all their symptoms and people discuss online and try to come up with some possible options.
3) How much are insurance companies responsible for the sorry state of health care in the US? I was speaking to my friend who says that he pays $850 bucks a month (up from $800 a month last year) on top of what his company pays. I've heard other stories about people basically being a slave to their company because they can't leave due to the generous benefits. I've also heard that insurance companies pay back only 60 cents in the dollar, so to make up the same $100 a doctor was previously earning he now has to charge about $170 (the other option is to be cut from the network of doctors used by the insurance company). And is this the logical conclusion for health care? Will Canada/Australia head the same direction? Seriously, there is a massive opportunity for the US to fix some of these problems now, yet it just seems that you guys are heading in entirely the opposite direction.
I have found out that I, along with my wife and my cat most likely had cancer whenever I looked some symptoms up.
For lyme specifically, the blood tests are generally inconclusive, symptoms vary from person to person and are inconsistent, and even doctors who specialize in lyme seem to disagree on core details of the diseases' effects.
If consensus can't be reached even at that level, and if that level of complexity is present in many other ailments (which I assume it is), how would be able to build a beneficial piece of software around that information?
Also, I imagine there are massive benefits if people all around the world were pumping data into a system. Correlations that a group of specialists may not think to look for may start to appear.
One problem with this style of tech is that your program is only as smart as the rules you give it, and you need seasoned doctors to help put together this knowledge. Even if they had the time, what doctor wants to facilitate the commoditization and automation of his or her profession, the undermining of their voice of authority?
I also question whether regular people have enough common sense and medical vocabulary necessary to safely operate such a system on their own behalf. Seems like it would be a fertile ground for lawsuits.
http://en.wikipedia.org/wiki/Mycin http://en.wikipedia.org/wiki/Expert_system
> what doctor wants to facilitate the commoditization and automation of his or her profession
Agree in principle but it just takes one incumbent to go rogue and become rich selling his knowledge, and the entire market is disrupted. It happened in the securities industry - the knowledge of old-school pit traders has been almost completely transferred to algorithms. We're seeing the start of it in drug stores now too. angersock mentions the same concerns below with doctors' egos, but the thing to remember is that initially these systems are brought in to be operated by a trader/pharmacist; complete replacement is several steps down the line.
On 1:
So, the big thing is that you never actually want to replace the doctors. Their egos won't allow that, they'll see it as an existential threat (which it is), and most importantly: you don't want to give that kind of power to a device which doesn't function as a moral agent.
On 2:
Sometimes, you'll be getting advice from somebody like tptacek...sometimes, you'll be getting advice from losethos. I wouldn't trust my healthcare to random bozos on the internet.
On 3:
Almost all of it is their problem, I'd say.
The increased focus on billing and everything else means that the doctors have to deal with madness they wouldn't have to otherwise. The fighting and billing cycle can take literally a year, so no honest doctor is at an advantage not billing everything they possibly can, and any institution (read: hospital) is going to force that sort of hand-wavy arithmetic (because of the opposition of insurance providers, in turn because of previous bad actors).
The amount of money thrown into these maws anyways (from both insurance and Medicare, a weird issue unto itself) serves to raise the price floors so that you can't even pay for yourself if you want to, because you're literally on a different marketplace.
The companies also go and force you to use doctors that aren't necessarily convenient to you, maybe many miles away. If you try to use a local physician, well, tough shit, you might have to pay for them anyways.
I could go on and on and on and on...
It's a fractal of sadness.
A while back I was looking for info on some medical "issue" that I had trouble defining the correct search terms for. Anywho, I eventually came to some sort of medical site where users could ask questions. And then doctors would comment/answer/respond on it. Now, I presume that these doctors were paid and/or verified, but I never looked too far into it. They sure sounded like they knew what they were talking about, and it wasn't as if they copy-pasted something from the net / a book, the responses were tailored to the questions.
But they aren't commonly used. It's probably because of medical conservatism coupled with business and status reasons.
And in some cases it does help to have the medical interview with a person. But wouldn't a cheaper nurse armed with a great software tool, offering a 20/30 minutes appointment is better than 7/10 minutes of a doctor's time? In some places in the british system that's what happens and research says the results are comparable to a doctor , with patients being happier.
2. There are crowd sourced solutions like you specify. The one i know is a ycombinator company called crowdmed.com . At least according to the media they do bring something very good to the table, but they're very new so it'll probably some mote time to see how they function and scale.
As an aside, there's an an expert system by a company called isabel healthcare, that in the hands of a regular family physician ,can enable regular physicians to diagnose rare and complex diseases at the level of top diagnosticians.It's available via cloud.I'm sure almost no physician of anybody in this thread will have it.
3. Not sure who is to blame, but i think many of those problems are common globally to some extent. Maybe the british system is somewhat better with the policy of employing lower level providers across many roles.
Sounds like the tell-tale signs of socialist dysfunction, from which all the other problems stem. The solution is simple, but, unfortunately, poorly understood and highly resisted: restore a free market for health goods and services.
One thing that would be good about a more free-market-y approach would be an increase in transparency about costs; but that's something that would be an improvement under a socalist or any other model as well.
Many medical services are repeated even if good service is provided. For example, 2 years ago I injured both my L5/S1 and L4/L5 disks. 2 years ago L5/S1 was treated, but the L4/L5 was left alone since it did not cause any problems. This year my L4/L5 started causing serious pain - the first guy did a great job so I went back. Another part of the feedback loop is reputation - if one of my friends needs similar treatment they'll probably go to the same guy unless they are very sensitive to cost (I didn't go for cheap).
I have no idea where this meme that free market health care looks like the US comes from. Maybe Canadians don't realize there are more possibilities than simply Canadian and US health care?
(I don't automatically disagree with your free-market assertion, mind you...we have quite a captive one here. You just need to use a bit better justification.)
.. opaque pools of collateral (subscriber) tranches, zero cost visibility, monopoly pricing power.. sounds like they're trading mortgage-backed securities. That didn't end well either.
E.g. You claim that the problem stems from HMO's spreading risk/cost using premiums, and doctors using that to over-charge fraudulently. But, have you considered why the doctors are able to do so (and get away with )? Perhaps because there is a shortage of them. Or something else, the point I'm trying to make is that we need to go a little bit further.
India shouldn't be in a Canadian's comparison set with respect to health care systems. The resource differences are too great to learn anything useful about the impact of other dimensions. Can you name a developed country with a health care system as or more free market than the American one?
As for your experience in India... Consider how much wealthier you are than the average Indian. If you were that much wealthier than the average American, do you really think you'd have any complaints about the American health care system? Conversely, what do you think your experience would have been if your wealth relative to the average American has instead been your wealth relative to the average Indian?
In contrast, there was a recent NYT article about a person in the US who underwent a similar surgery. A single billing discrepancy (to say nothing about the entire bill) is comparable to a software engineer's yearly salary.
http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surp...
Furthermore, the experience was easy, with none of the nonsense I deal with in the US. When I got to India, my initial medical exam cost roughly the same as a dinner at a decent restaurant. An MRI cost me the same as an expensive night out. I was given a price quote for the treatment and the total cost (including incidentals) was within 2-3% of the quote. The only person who even tried to rip me off during the process was the auto rickshaw driver who took me home.
Certainly the bill would have hurt me more if I were a typical Indian. But the experience I'm describing is not the wealth gap. I know people who are "that much wealthier" than the average American and they do have lots of complaints about the US system.
1.Improving patient outcomes, improving patient satisfaction, reducing medical errors and curtailing costs etc are very hard problems. There are no easy answers. Doctors know about this( because this affects us also) , routinely discuss it, try to solve/amend whatever is in their power but the overall nature of these problems is such that without nation wide measures and policy changes no concrete improvement can be achieved.
2. Becoming somewhat emotionally detached/blunt etc is a requirement for the job. There is no survival without it. It happens to all doctors. It happens to family and friends of people who end up in hospitals for months. Even with the detachment adverse patient outcomes do affect the treating doctors and this emotional trauma piles up over the years.
3.Same for abrasive personalities. There is so much push and pull going on between doctors of different specialties, between doctors and nurses, between doctors and administration, between doctors and insurance companies, between doctors and patients and their relatives that anybody not strong/abrasive/assertive enough looses his ground which affects both the doctor and the patients under his care adversely.
4.Generally a lay person reading up things on his own doesn't bring anything useful to a discussion with the doctor. Sometimes there are real options in which even the doctor is not sure of benefit/risk ratio. The patients should take decisions in these cases. Same for major operations and interventions. But for majority of cases average lay person is better off following the advice of his doctor than relying something he read on internet.
5. A job of doctor will probably be one of the last jobs to be replaced fully by machines. Just like parenting.
6. Doctors are not against technology or threatened by it. For example a lot of lab tests that are automated now were performed by hand by pathologists.They are very happy to use these new technologies. Their role hasn't diminished. The lack of enthusiasm for health IT software is because most of it sucks.It adds to workload, doesn't provide any value, and adds another layer of responsibility/anxiety. Most doctors will run to anything that only marginally improves their ability to handle workload.
And the list can go on.
Some interventions that might work are:
Checklists. simple, easy to use and practical checklists .
Mandatory leave/ time away from patients. The more acute/emergency oriented/high stress specialty , the more the need. For example I think specialists in Anesthesia/critical care/emergency medicine/gynecology/neonatology etc should have 3 months of leave away from patient care every year to stay sane.
>fulfilled doctors make for more-satisfied patients. Tackling the problems of Kaiser Permanente’s Colorado medical group, he took the counter intuitive step of demoting “patient-centered care” as a goal, and elevated “preservation and enhancement of career” for doctors to first place. He restored to them the sense that their work is, as Barron Lerner’s old-fashioned father put it, a “rare privilege” to be pursued with a sense of responsibility, rather than harried accountability.
ABSOLUTELY TRUE!!
There is promise in healthcare analytics, predictive analytics and things like auto flagging of unusual events. Doctors are used to analytics and algorithms and will embrace any good solution to these.
Similarly, machine learning/AI can play important role in things like reducing medical errors and postmortem of adverse events. These should be combined with training for human factors.
Continued medical education in its present form is very ineffective. Continuing medical education and remedial training/retraining etc need to be customized and focused to meet specific objectives.