
Why Some Doctors Purposely Misdiagnose Patients - rrauenza
https://www.theatlantic.com/health/archive/2019/08/when-doctors-purposely-misdiagnose-patients/596068/
======
tmamic
This problem is the biggest in dentistry.

Most dentists are perfectly capable of providing the correct diagnosis.
Unfortunately, even if and when they are, there are obstacles:

\- Weak incentives to provide an accurate diagnosis

\- Strong incentives to provide a particular inaccurate diagnosis

Giving a correct diagnosis often means investing more resources, as well as
continuously investing in education and tooling. If the patient doesn’t see
the difference between a correct diagnosis and “probably correct diagnosis”
then they will react the same in both cases.

This situation where every diagnosis is perceived as the same, an examination
is one of the least profitable services provided by dentists and, naturally,
falls into the problem of “adverse selection.”

Some dentists recognise the opportunity of giving the wrong diagnosis to get a
higher benefit. Be it by keeping or winning over the patient or by leaving
room for the ability to recommend costly treatments.

The results of this are:

\- Patients on average get a less correct diagnosis

\- Dentists earn little to nothing for their diagnostic work

~~~
yboris
Specific example I came across (may have even been a scientific study). Memory
is a bit hazy, but roughly:

Dentists routinely recommended the more-expensive ceramic teeth replacements
for teeth in the back, even though ceramic is less durable than the metal
counterparts. Even though you basically can never see the hind teeth, so
cosmetic reasons shouldn't have applied as they do for front teeth.

~~~
loco5niner
> Even though you basically can never see the hind teeth

I notice metal in peoples hind teeth all the time. This is still a cosmetic
need.

Food for thought. If teeth are constantly grinding against each other, is it
good for the opposing teeth to constantly be grinding against a hard material
like metal?

~~~
realityking
I agree with your point about regularly noticing metal crowns but note that
dental ceramics are way harder than metal. Dental ceramic is a 7 on the Mohs
scale while gold and silver are in the 2.5 to 3 range.

~~~
loco5niner
Interesting. And tooth enamel apparently ranks a 5.

~~~
iends
It’s not just about hardness. It’s about biocompatibility.

------
raxxorrax
In Germany there is a strange policy for hospitals. If you do not do a minimal
amount of operations of a certain kind (e.g. hip replacements), you loose the
admittance to do any further surgeries of the same kind.

The incentive was probably to focus competency to certain hospitals, but you
can imagine how this plays out in reality.

Especially people not familiar about medical necessities should always get a
second opinion. Otherwise you might end up with an extra hip or something like
that.

At least it begins to be common knowledge that hospitals do operate too often.

Still, with all its problems, and there are many, I certainly would prefer to
be operated in any country of the EU compared to the US. Not because of
capabilities of doctors, but to me it seems US health care as a example how
private business can be worse than governmental services. Common market
mechanisms don't work if your life depends on it. It is just about extracting
the most amount of money from suffering and this article describes a problem
to which there is no solution in my opinion.

~~~
merpnderp
The US’s healthcare is hardly an example of private businesses going awry. The
US’s healthcare is by far the most heavily regulated in the country with a
near majority of spending by the various governments. We have the worst of
both worlds, some kind of Frankenstein’s monster of regulatory capture,
government incompetence, and age old corruption. 20% of Medicare billing has
been fraudulent for decades and now the government can’t fix it because so
many parts of the industry rely on straight up theft.

So yes the US health care system needs a push to be more socialized or less
regulated, but it’s not some prime example of a free market gone awry.

~~~
Ididntdothis
“so many parts of the industry rely on straight up theft.”

This will be a big issue in any kind of health care reform in the US. if they
want to get costs even remotely in line with other countries a lot of people
will either lose their job or make much less money. That won’t happen without
a lot of resistance.

~~~
maximente
yep, health care reform to single payer will basically guarantee a recession -
a huge percentage of GDP/jobs will evaporate over the course of the
transition.

there is no such thing as having this cake and eating it too: there will be
immense pain for a sizable part of the economy whenever this gets tackled.

~~~
abfan1127
While those who are negatively affected by the reform would suffer, that money
doesn't evaporate. It goes elsewhere, so it wouldn't cause a recession on a
macro scale. Look into the Broken Window Fallacy in Economics in One Lesson.
its a great book.

~~~
JamesBarney
The money doesn't evaporate, but it very likely would result in less total
money spent. And people spending less money is the textbook cause of
recessions.

~~~
abfan1127
if its not spent, its saved somewhere. Very few people put substantial amounts
of cash in their mattress. Most goes in the bank, which helps set the rate if
interest rates for loans. So, even unspent money goes somewhere and gets
spent. Still not a recession.

~~~
JamesBarney
The problem is near term interest rates are near 0, so the casual pathway of
money saved -> lower interest rates -> more investment isn't as effective.
This is why quantitative easing has so little impact.

And a saved dollar is spent less than a spent dollar.

~~~
abfan1127
low interest rates are supposed to provide information regarding the value of
money spent vs. money saved. However that function isn't allowed to work.
Further quantitative easing add(s|ed) further noise to the flow of money from
investment to spending.

------
outime
I had much more success researching my own health problems than by visiting
any doctor (and have seen a lot, unfortunately). As a bonus, I learned a lot
about the body and the mind.

I see misdiagnosis happening at a very high rate but I also understand they
don’t have the time and/or energy to dig very deep into each patient and they
do fine (money and respect-wise) by doing the bare minimum so many don’t try
to fight it by e.g. setting up their own consultation and trying to do better
(not necessarily making less money).

Of course, a bunch of exceptions can be found and they do shine a lot, but the
average doctor isn’t going to be helpful after the very typical and simple
checks don’t yield anything and they’ll happily prescribe things that won’t
actually help you. That’s been my experience in at least couple european
countries.

Edit: typo

~~~
ssully
I think it's very important for people to be proactive about their out health
and care, but I think listening and working with your primary care doctor is
just as important. If you don't think your doctor is helpful or listening then
you probably need to find a new doctor.

~~~
drdeadringer
> be proactive about their out health and care

My mother did this on my behalf when I was an infant, just a few weeks old.

"Nothing is staying down. Always throwing up. Not gaining wait."

"Oh yea yea sure new mother. You'll get the hang of it. Come back next month
see you then. Naturally under weight since birth it's normal for the kid.
Thanks bye."

Rinse and repeat until some doctor got bloody tired of the repeat visits.
"Fine, come on in and I'll take a look." A few minutes later it was "oh fuck"
and I was on a gurney being wheeled into surgery.

So now that it's decades after I didn't starve to death thanks to a procedure
that didn't exist before 1912 [official diagnostic criteria at 1888] ... yea.
Maybe sometimes you should bother your doctor(s). Sure, humour them and leave
a lot of the time but when you know it's Not Good ... make them stop humouring
you.

And yes, "I have the scar to prove it".

~~~
lonelappde
Nowadays is the baby isn't gaining weight after the first week the standard is
to hospitalize.

------
tsukurimashou
I think some "industries" shouldn't work as a normal business, health,
education, law / police. They just don't work as a business and will end up
corrupt because money.

~~~
frockington1
Education hasn't gone well publicly so far in America. I'm not sure completely
private is the answer but something needs to change. Government funding has
led to massive amounts of money being spent for negligible results. Agree on
health, law / police though

~~~
Thlom
But isn't the problem with public schools in the US that the funding comes
from taxes in the school district itself, so ppor districts will get a
underfunded school while rich districts get a well funded school?

Anyway, the school system should be changed dramatically everywhere. The
current paradigm is hurting children and should be abolished.

~~~
coryrc
In Michigan, where I grew up, Detroit public schools got about 50% more
funding than the public school I attended. Want to guess which schools had
better outcomes?

~~~
IggleSniggle
I would expect schools in impoverished, troubled neighborhoods would cost
QUITE a bit more than schools in wealthy neighborhoods in order to get the
same results.

The students are more likely to be facing food insecurity and odd parental
schedules at home. The school may need to spend more keeping their student
body safe. And one kid with a violent parent who reacts by being violent in
turn can wreck havoc on the rest of the classroom. That kind of person might
need an education that is more therapy than academic.

------
ubermonkey
It's orthogonal to the linked story, but I attended a dinner the other night
where the presentation was on advances in MS research.

The speaker, an MS researcher and clinician, noted among other things that
we've been really really wrong about how many folks in the US have multiple
sclerosis - like, by a factor of 2. There are lots of reasons for this, but
it's not JUST the lack of easy diagnostic tests.

Until relatively recently, there were NO real therapies for MS, so doctors
were hesitant to make the pronouncement. Add to this that a diagnosis of MS
would qualify as a pre-existing condition, and would prevent the patient from
getting health insurance (pre-Obamacare, anyway), and would absolutely put the
kibosh on life insurance.

So there were real world consequences, and they were therefore hesitant.

~~~
joshgel
I think part of it, but also not the entire story.

Take cancer, for example. The treatment is so toxic (potentially deadly) that
we want to make sure that our diagnosis is as close to 100% as possible. To
the point where if you want to transfer where you get your chemotherapy, the
new place will insist that you bring not just the biopsy report that shows
that you have cancer, but the actual 'slides', the actual biopsy tissue for
them to independently evaluate.

Contrast this with MS where there is virtually no therapy (until recently),
the tests themselves are very expensive (multiple MRIs over time) and the
tests aren't even that much better than just talking to the patient and
examining them. But, both the MRIs and the clinical exams/interviews require
multiple visits, sometimes with years of monitoring in between to _truly_ make
the diagnosis.

The system just doesn't incent this type of care and certainly doesn't
reimburse it very well. Patients want answers and answers now. Doctors are
hurried. Insurances change so you have to change networks, etc, etc, etc.

~~~
fao_
> The treatment is so toxic (potentially deadly) that we want to make sure
> that our diagnosis is as close to 100% as possible.

I think you're ignoring how obscure some symptoms of cancer are, though. My
cousin went back and forth with the doctor about a recurring cough, for 3 or 4
years. It turned out to be bowel cancer, and while they did treat it, it was
too late by the time anyone in the medical system thought of that. The only
indication that would point them towards bowel cancer, was the medical history
of her family, her grandmother had it too. She was rather young as well, late
20s/early 30s, so they just didn't consider it.

------
socialdemocrat
Many focus on the doctor, and surely his moral compass was off. But from a
birds eye perspective the primary problem here is companies paying doctors to
recommend certain pills and procedures.

This can make a doctor which was semi-decent and quickly turn him into a
greedy immoral person.

I don't think it should be legal for companies to pay doctors to promote their
products. Do anyone disagree?

~~~
programmertote
My wife is a resident. She used to intern at PCP clinics and was invited by
her supervisor (a physician) to one of the dinners hosted by pharma companies
(Sanofi, if I remember correctly). The dinner was a feast. The doc invited
everyone in her clinic and their immediate family members. We had Shirmps,
Lobster, Wagyu beef (I know it's a redundant word, but that's how it's known
in the US), lamb to our fill. Sanofi rep footed the bill (and asked us to sign
our names on a sheet when we arrived).

Experiencing that dinner and seeing my host family mom (a practicing
psychiatrist in the US for a private psychiatry hospital) getting food every
week from pharma reps, makes me feel disgusted about the connection between
doctors and pharma companies in the US.

~~~
pnw_hazor
I have MDs in the family too, their continuing education classes are sponsored
(free) and with feasts provided as well.

Lawyers have to pay for our required continuing education classes. Sponsored
courses and retreats are clearly a conflict of interest for MDs.

Also, as lawyer, I remain shocked and saddened to see how US medical providers
have abandoned patient privacy in the wake of the US opioid crisis. Patients
prescribed any controlled substance are now put on registers that almost any
state actor (or local police) can review at will.

US MDs have thrown their patients under the bus because they (or their
colleagues) were (lazily/blindly/greedily) writing too many opioid
prescriptions.

~~~
lotsofpulp
How are doctors responsible for laws passed by state legislators (who tend to
be lawyers) requiring doctors to use PDMPs?

~~~
pnw_hazor
Ask the AMA. Docs should have stood fast or at least forced more patient
privacy protection. As it is, some health providers require patients to sign
broad privacy waivers before issuing prescriptions for controlled substances
(including ADHD meds).

My GP didn't even think it was an issue -- here sign this. I couldn't believe
what I was reading. I refused and didn't get the meds I needed -- resulting in
harm to put it mildly. I am lucky that I am not suicidal because it got pretty
dark for me, after a few weeks I had to crawl back to get the meds I need.

------
vivekd
I was keeping an open mind about this doctor, until I read that two other
doctors were willing to testify they had thought he was misdiagnosing
patients. Its notoriously hard to get doctors to testify against each other at
a malpractice case and the fact that doctors who worked with him were Ing to
come in on their own accord is damming

------
r_singh
The medical industry has the biggest conflict of interest I have seen in any
industry. It's actually bad for doctors if preventive healthcare takes off the
way it should, we all eat healthy, balanced diets and exercise to take care of
our bodies and mind.

That coupled with genetic diversity, ignorance of their customers and relative
ignorance of the practitioners itself (we still don't know more than we know)
could truly be a recipe for disaster.

My celiac was misdiagnosed for pharyngitis for long, and since I've stopped
taking any doctor very seriously. I read A LOT, visit a bunch of doctors
(preferably leading to specialists) and ask a lot of questions before deciding
what course of action I want to take.

Luckily, in India, doctors don't charge as much (~$20-40) per session.

~~~
xiaq
> The medical industry has the biggest conflict of interest I have seen in any
> industry. It's actually bad for doctors if preventive healthcare takes off
> the way it should, we all eat healthy, balanced diets and exercise to take
> care of our bodies and mind.

Not in countries with a national health system, where the government is
incentivized to keep people healthy in order to reduce cost.

~~~
WalterBright
> Not in countries with a national health system, where the government is
> incentivized to keep people healthy in order to reduce cost.

It's hard to see how this can be true, since government operations are
infamous for excessive cost.

~~~
tonyedgecombe
We have a pretty lean system in the UK, possibly too lean. The private system
in the US however seems a poster child for excessive cost.

~~~
ekianjo
And in the UK you also have horror stories with patients with cancer who need
an urgent surgery and have to wait months to get it.

~~~
Gupie
Outliers or tabloid stories, while in the US people do not get treatment
because they cannot afford it.

~~~
refurb
Those US stories are outliers as well.

If a lot of people in the US can’t afford treatment, then why does the US lead
the world in several cancer outcomes? If people were just dying for lack of
treatment, that would make outcomes far worse.

------
coder1001
Your typical case of measuring a doctor's success by the number of EGGs and
the likes that his patients do!

Wrong incentives = unexpected outcomes!

~~~
voiper1
Seems similar (or the same as) the cobra effect

[https://en.wikipedia.org/wiki/Cobra_effect](https://en.wikipedia.org/wiki/Cobra_effect)

------
elevenoh
I for one cannot wait for my ai primary physician.

~~~
mikecsh
Great! Let me hook you up with the latest medical AI technology. Actually, let
me hook you up with __all __of the latest medical AIs, throw your symptoms at
them and let them treat all you ailments. And add to that, all the latest
medical robotics, and we 'll take the surgeons and intensivists, interns, and
nurses away.

Good luck with that, I'm sure you will be much happier and healthier when the
current AI tries to decide whether you are acutely dying of hypercalcaemia or
a cardiac tamponade and Marshalls the robots to save you.

\s

For all the faults and failings of doctors (read: humans), I find many Hacker
Newsers __vastly __oversimplify what doctors do and __vastly __overinflate
what AI is able to do now, or will be able to do in the next ten, twenty, or
even 30 years.

It's great that we not have some AI that can diagnose a stroke better than a
radiologist on a CT scan. But it can't tell you the scan also shows a space
occupying lesion. Or hydroencephaly. Or an extra dural haematoma. Or any other
intracranial pathology. And that's about the state of the art.

I welcome new diagnostic aids as I think most clinicians do, but I would take
the fleshy system we have of human healthcare providers and suspect that will
be the case for a good while yet.

Disclaimer: am doctor and engineer

~~~
elevenoh
>It's great that we not have some AI that can diagnose a stroke better than a
radiologist on a CT scan. But it can't tell you the scan also shows a space
occupying lesion. Or hydroencephaly. Or an extra dural haematoma. Or any other
intracranial pathology. And that's about the state of the art.

Why couldn't a model report all discernable co-morbidities?

I don't see any form of objective data analysis remaining optimally in the
hands of humans for long.

Double checked by humans, in the short term, sure.

There's arguably zero 'creativity' in diagnostics. It'll be automated within a
decade or two IMO.

~~~
omgwtfbyobbq
There's a lot of nuance in diagnostics, and information can be scattered
about, especially with relatively rare disorders.

------
dboreham
A benefit of "socialized medicine", provided the government is not corrupt, is
that medical practice can be evidence driven. E.g. compare rates for wisdom
teeth extraction and tonsillectomy between the US and UK.

------
Fezzik
The other side of the coin is that there are lot of (or at least some) doctors
who will “misdiagnose” a patient to get them appropriate treatments that
insurance would otherwise not pay for.

Personally, I had a number of _very_ large lipomas on my body that no
insurance would normally ever cover the removal of as they were cosmetic and
socially stigmatizing and not dangerous to my health. My doctor filled out all
the necessary forms with the proper magic language and my insurance paid the
bill. These are simple, 10 minute, outpatient medical procedures that require
a knife and $.25 of numbing agent. I could have done it myself if I could buy
something OTC to numb myself.

Not all doctors are just looking to pad their billables.

------
reverend_gonzo
In order to counter these risks, we prefer going to doctors and hospitals that
are so busy (and highly regarded) they don’t have time for bullshit.

Of course it helps being in a large city with many options and excellent
insurance. Without this, I’d probably be getting g second and third opinions
constantly.

~~~
smt88
Don't you worry that very busy hospitals will treat you more anonymously
and/or make more mistakes?

------
azeotropic
This actually sounds like an honest (mis?)diagnosis. Confusing migraine and
temporal lobe epilepsy is not a particularly egregious mistake, and the two
conditions often occur together. A number of anti-seizure medications are
prescribed to prevent migraines.

------
yboris
Q: "Is it Worth Getting an Annual Physical Exam?"

A: "No"

[https://nutritionfacts.org/video/is-it-worth-getting-an-
annu...](https://nutritionfacts.org/video/is-it-worth-getting-an-annual-
physical-exam/)

------
rafaelvasco
Jesus. How corrupted people are becoming. And if there's one type of people
that absolutely can get corrupted are doctors. They're dealing with lives
after all. The implications can result in death or at least a lot of
suffering;

------
mlang23
Our medical system is completely wrong. Doctors should get payed for the time
their patients are healthy. As soon as they fall ill, payment should stop
until they are well again.

~~~
banads
What about people who consciously (or unconsciously) live extremely unhealthy
lifestyles?

~~~
ativzzz
They get to pay an "unhealthy lifestyle tax".

~~~
banads
What about the corporations that push addictive and poisonous food with
massive multi hundred million dollar marketing campaigns targeting children?

~~~
mlang23
Maybe the "free market" isn't such a good idea after all...

------
zouhair
Ah, good old Dr Knock[0]

[0]:
[https://en.wikipedia.org/wiki/Knock_(play)](https://en.wikipedia.org/wiki/Knock_\(play\))

------
a_rahmanshah
This is getting very common in India

------
foobar_
Just like mechanics of vehicles.

------
MichaelMoser123
didn't they give the hippocratic oath? doesn't that count for anything?

------
jonplackett
TLDR; Money

------
Iv
Could we add "in the US" to the medical news that may not be that relevant in
other countries?

~~~
chimeracoder
> Could we add "in the US" to the medical news that may not be that relevant
> in other countries?

The incentives are misaligned in many other countries, including Germany and
the UK. This article focuses on examples in the US, but as noted elsewhere in
these comments, there are plenty of articles that show examples of similar
perverse treatment incentives in other countries.

~~~
socialdemocrat
Except nowhere are the incentives as screwed up as in the US. Sure a doctor
does have a financial incentive to not always do what is best for you anywhere
in the world. But in most places this concern competes strongly with a sense
of moral duty.

In the US you have companies which have no scrupulous because they don't see
or know the patients they screw over, actively push and incentives doctors to
work against the interests of their patients.

The prevalence of companies paying doctors to prescribe certain pills or
suggest certain procedures seem to me more of an American problem. At least in
my home country I highly doubt such an arrangment would even be legal.

I mean this just fits in with the opioid crisis in the US. Where medical
companies would basically send young prostitutes to doctors to try to persuade
them to push their drugs. Yes this is a fact. These companies hired young
pretty women, which frequently slept with the doctors they were supposed to
influence. The companies made billions while patients died left and right from
their drugs.

I cannot think of anywhere in the developed world where anything remotely as
horrible has been going on in the health care sector. While everybody has
challenges in their health care sector, everything pales compared to what is
going on in the US. Greed as completely taken over.

------
eigen
A: $

