
Why Did My Patient Leave Me? - dnetesn
http://cancer.nautil.us/article/201/why-did-my-patient-leave-me
======
giardini
In my case,

\- reluctance to diagnose and treat the ailment instead of the symptoms and

\- simply refusing to hear what the patient says.

I had an oozing rash break out behind my knees. The dermatologist said
"That'll go away easily if you put some OTC corticosteroid cream on it."
Wrong! The rash flared up within hours and nearly ate the flesh off the back
of my knees. I happen to know that this indicates a fungal infection so I
stopped the steroids and applied an OTC antifungal regularly. Slowly it began
to heal.

A week later I had a minor bout with detergent dermatitis around my jeans
pockets (happens every winter if I use a strong detergent).

Next time the dermatologist sees the residue of my scarred legs behind the
knees and the "jeans-pocket" rash, I tell her that her steroid recommendation
was absolutely a wrong call, what happened and how I treated the problem.

Rather than take a culture from the back of my legs (and later possibly
prescribing an antifungal), she then prescribes not a tube, but a 1-pound
_tub_ of corticosteroid cream and tells me to put it on all rashes (behind
knees and on "pocket" rashes) for six weeks!

So I figure either she's deaf, has a serious learning disorder or flatter
myself that she is trying to kill me. In any case I won't see that
dermatologist again.

On the upside: I have an unopened pound jar of steroid skin cream in my
refrigerator.

~~~
cmahler7
no disrespect to doctors but you really don't have to be that smart to become
one. It's more about being willing to take out 300k in loans and stay in
school until you are 30+ years old.

~~~
siculars
Mate, you couldn't be more wrong. Doctors, on the whole, are just about the
smartest folks out there. Are there bad, less intelligent doctors? Sure. If
you think it's as simple as "taking out 300k and staying in school until you
are 30+" you're delusional and frankly don't know what you're talking about.
Math, statistics, physics, chemistry, biology and on and on. These are just
some of the areas doctors need to be well versed in.

~~~
orbifold
While I don't think doctors are not smart, the amount of physics, math and
statistics they actually learn is laughable and does not really go beyond what
they already learned in a good high school. Just like in any profession over
time they develop deep expertise in very specific problem areas, but that is
not much different than in any other profession.

------
josephorjoe
The primary reason I have left healthcare providers has been the poor quality
of their administrative staff.

There are too many qualified doctors in the major metro area I live in to put
up with ones where I can't quickly and efficiently make an appointment, can't
get an appointment in a timeframe that is useful to me, and where their staff
can't seem to successfully process routine insurance claims with major
insurance providers.

Also, randomly billing me for stuff weeks or months after an appointment with
cryptic explanations thoroughly pisses me off -- even it if is only $15.00
(going to get a new podiatrist over that one...).

As for actual "doctor specific" reasons for leaving a doctor, not explaining
the reasoning behind his/her recommendations for me to get certain medical
tests or procedures done will get me to look for another doctor. I don't
actually need to fully understand the reasoning (I'm not, afterall, a doctor),
but I need to know there is a reason beyond "hey, you said your elbow hurt and
I think I can get the insurance company to pay for an MRI!".

~~~
csydas
> Also, randomly billing me for stuff weeks or months after an appointment
> with cryptic explanations thoroughly pisses me off -- even it if is only
> $15.00 (going to get a new podiatrist over that one...).

This part gets me a lot as well, and having experienced other pay-for
healthcare systems, it's extremely frustrating remembering just how much I
would pay in the US even when I had fair insurance through my employer.
Getting a simple biopsy done on my leg resulted in a $250 upfront new patient
fee, $2300 for the biopsy, then an additional $400 for lab fees some months
later. Aside from the new patient fee, I had no idea or indication about any
of the other fees until a bill arrived in the mail, despite asking and
persisting about it throughout the visit, and since I had to take time off of
work to get an appointment, I was at a loss as to how to "make a stand" to get
such information.

Compared to where I've been abroad where it's been an upfront fee for walk-in
visits. Appointments were needed, but it was a day or two in advance. And when
I got insurance through my workplace, it was equally simple.

~~~
theoneone
So 3000$ for a biopsy: ticket to Greece and back to USA : let's say 1000€.
Biopsy procedure if it's ultrasound guided around 300€. Lab fee for examining
the biopsy:around 200€ max, maybe less. Hotel room for 2-4 days in
Thessaloniki 120€-150€ in a decent hotel. Total:1500€ or even less. All these
can be done by highly and well educate medical doctors, treatment in private
clinics is very good(since you are paying in cash you always get vip
treatment) and o course you can enjoy a good vacation. I always said that
medical tourism is the future

~~~
samirillian
Obviously, the problem with this strategy is uncertainty. Part of the point of
healthcare is that other people worry about it so you don't have to. Better
the Byzantine, inefficient healthcare system you know than a system you don't
know at all.

That said, I consider myself lucky to have been in Japan when my lung
collapsed. The surgery itself was $80!

~~~
greggman
I love that japanese medical care is mostly inexpensive compared to the USA
but at least 1/2 the doctors and dentists I've visited here over the last 20
years were complete quacks and would not be qualified to practice in he USA.
No training to certification is required to be a nurse here. And, if you need
special treatments like surgery it's common wisdom you should do your research
on your own to find a good doctor a and then pay a several thousand dollar
bribe to see them. (of course thats still cheaper than the USA for the same
treatment)

------
CydeWeys
I abandoned an orthopedist last year because I felt that he was using hard-
sell tactics on me to get me to agree to surgery for my broken ankle.
Basically, he had a surgery slot open in a few days and it seemed like he
wanted to book it, with increasing discounts (including exploding offers!) on
the surgery as I kept demurring. He was a referral from the urgent care clinic
that I went to immediately following the accident, and I think they
recommended him solely because he was in the same doctor/hospital network
(although he did _not_ take my insurance!).

So I spent several hours doing research on orthopedic surgeons and went to
visit one of the best ones at the best hospital in the city (who also happened
to be in-network). He looked at my X-rays and recommended against surgery,
saying that the break wasn't that bad and that it would heal fine with just
the cast I was already in! He was not as personable and a bit more robotic
than the other guy who was giving off the salesman vibes, but I trusted him
because of my research rather than the first doc who was essentially just some
random referral through happenstance.

A year has gone by now and I'm glad that I didn't get the surgery, because my
ankle healed perfectly without it (the second doc was right). I would've been
walking faster with the surgery, it's true, but I also would've had
permanently implanted metal hardware (which can cause lifelong irritation
issues), and which could have necessitated a second surgery for later removal.
In hindsight I regret nothing, and of course not having the surgery was also
much, much cheaper.

So if that first doctor were to ask me why I'd leave him, I'd just say that it
seemed like he was placing profits above the best interests of the patient,
or, more charitably, that since he's a surgeon he thinks of surgery as the
solution to every problem, even when it's not necessary.

~~~
mhneu
Things I have learned about orthopedists: \- they have only one tool and it is
surgery. If you don't need surgery, you need to see a physical therapist. PTs
know far more about soft tissue injuries and rehab than orthopedists.

\- orthopedists make money from each surgery they do. Many orthos are honest,
but some areas of US have orthos who run joint replacement factories to
maximize profit. In the past few months I've gotten two junk mailings from
orthos advertising joint replacement. If doctors are advertising, you know
their financial incentives are wrong.

~~~
arkades
Physiatrists. Physical Medicine & Rehab doctors. They're the non-surgical
equivalent of orthopedists.

PT's... are fine folks. But if you want to avoid surgery and need a proper
injury evaluation, you go to PM&R.

------
jacquesm
I've done this, without feedback. The reason was that doctors seem to come in
several varieties when it comes to bringing their ego to work and my doctor
had a serious case of that. I was dehydrated after an operation and when he
asked if he could do something for me I asked for some water, the doctor then
ordered someone else not in the room to come and get me a glass of water. He
couldn't be bothered to walk to the sink and do it for me because that sort of
thing was beneath him, he was a doctor after all, not some lowly nurse.

That would have been hard to argue as sufficient reason to switch but I
figured that if his primary worry in a situation where a patient has clearly
expressed a need is his perception then he shouldn't have become a doctor in
the first place and likely that would get in the way of him providing care.

I've talked this over with a nurse friend of mine and they totally confirmed
that this is normal, doctors, especially in a hospital setting, are on top of
a hierarchy that tends to self-reinforce their importance. And yes, they are
important. But in the end what is most important is that they realize that the
only reason they have a job is because someone else is in trouble and that
some humility goes a very long way towards establishing real rapport.

The one thing that stood out for me on this subject that I read about a while
ago (not sure if it was in a book or online) was that actually being in the
hospital as a patient immediately made doctors a much better doctor for their
patients.

Dogfooding works, even for doctors.

Another reason why people don't leave feedback: they don't want to get into an
argument, they just want to switch and they already have enough on their
plates and fortunately in many places they have that right.

~~~
peferron
Regarding your first point, that's especially striking in the USA. There seems
to be at least 4-5 assistants (nurses, secretaries...) for each doctor.
Assistants check you in; you're left waiting in a room; after a seemingly
random period of time, the doctor suddenly barges in, diagnoses you faster
than the Flash, and leaves just as suddenly; assistants check you out.

I get that it's very efficient to work this way, but I'm not sure I'll ever
get used to it. My father, now long retired, used to be a family doctor back
in France. He shared his office with 4 other family doctors + 1 secretary that
they paid with their combined income to take care of their appointments. He
used to spend 20 minutes in average with each client. One of his colleagues
routinely spent 30 minutes.

I should ask him about his churn. :)

~~~
jacquesm
France has some of the best healthcare in the world. A family member was
involved in a horrific truck/passenger bus accident in France near Metz and I
spent the better part of a week in and out of their intensive care department
visiting. I've never seen a hospital that I liked better.

Everybody was so unbelievably nice and caring it was a huge improvement over
what I'd seen elsewhere.

[http://krant.telegraaf.nl/krant/archief/20020319/fotos/bin.v...](http://krant.telegraaf.nl/krant/archief/20020319/fotos/bin.venster.metzsectie.jpg)

It was a pretty bad accident (5 dead, 55 wounded of which 3 critical one of
those criticals was my family) with lots of beds suddenly occupied by people
not speaking French and a large multiple of that in foreigners roaming the
corridors and yet they dealt with all that with grace and understanding.

~~~
ThomPete
I do question the sustainability of the french system though and that of many
other european systems.

Its important to remember that in a state economy where healthcare is free or
semi free it's operated as a cost center and thus has budgets that are
politically mandated not determined by market demand at least not directly.

This leads to a number of limitations on what kind of care patients can get
what machines they can buy, what medicine etc.

Not saying the US system is better but all systems have drawbacks.

~~~
jacquesm
Good point. I'm not too worried about France, they seem to have their
priorities straight there, other countries are less stable. Especially in
former Eastern European countries there are disasters happening right now, and
many Western countries will have to come to terms with the cost of health care
and attempting to take commerce out of it.

NL had a very good system which got replaced by something much less efficient,
ostensibly because the 'market' would have been better at making things
efficient where the only real change is that healthcare is now much more
expensive and options are as limited as they were before.

Personally I feel a good society should take care of its sick, poor, elderly
and inmates even if it costs but that's an opinion that seems to be out of
fashion.

~~~
ThomPete
My personal suggestion for a good balanced system is that most people pay most
of the cost for normal healthcare costs like going to the doctor for a
checkup, most of the cost for one of things like a broken leg but that society
pays for more serious and longer term situations like cancer, heart surgeries
where you are supposed to stay at the hospital for a longer time.

I.e. no one should be bankrupted because they get a serious illness.

With regards to France healthcare system here is an article who seems to think
it wont survive though.

[https://www.bloomberg.com/news/articles/2013-01-03/frances-h...](https://www.bloomberg.com/news/articles/2013-01-03/frances-
health-care-system-is-going-broke)

~~~
ido
The problem is that people then tend to forgo preventive care & routine
checkups if they don't have to (especially poor people), and in the long term
end up costing a lot more when they do get treatment once their situation is
far worse.

~~~
ThomPete
No thats actually not true which Denmark has lots of data to show.

It's 100% free to go to the doctor yet a lot of people don't go for checkups
it's not a common thing to do.

Furthermore the situation is even worse for men over 50.

So access to healthcare has very little to do with that.

~~~
mistersquid
Earlier you write:

    
    
      > Its important to remember that in a state economy where
      > healthcare is free or semi free it's operated as a cost
      > center and thus has budgets that are politically mandated
      > not determined by market demand at least not directly.
    

and later write:

    
    
      > My personal suggestion for a good balanced system is that
      > most people pay most of the cost for normal healthcare costs
      > like going to the doctor for a checkup, most of the cost for
      > one of things like a broken leg but that society pays for
      > more serious and longer term situations like cancer, heart
      > surgeries where you are supposed to stay at the hospital for
      > a longer time.
    

But here

    
    
      > It's 100% free to go to the doctor yet a lot of people don't go for checkups it's not a common thing to do.
    

you allude to Danish data that show prospective patients do not take advantage
of healthcare even if that cost is 100% subsidized.

So which is it? Does healthcare that is 100% subsidized distort demand so that
people seek unnecessary care, or is demand so inelastic that people and
populations who would benefit from it decline to use it?

EDIT: add third in situ quotation. Add comma in last sentence/question. Change
pronoun to conjunction in last sentence; pluralize noun.

~~~
ThomPete
Not sure exactly what you are confused about.

I was responding to a post who claimed that if there isn't free checkup for
all then people wouldn't go to get checked.

I simply pointed out that even in a country like Denmark which is 100% free
people thats not the case.

So you would have to show causation between general checkups and cost of
healthcare I don't think you will be able to find that.

~~~
mistersquid
My confusion comes because in my first two citations you suggest requiring
patients to pay for most of their basic/non-life-threatening healthcare. You
say this, if I'm not mistaken, because "free or semi free" healthcare is
"operated as a cost center". That is, by requiring patients to pay for most of
their basic healthcare, that cost center will be reduced because patients will
be discouraged from seeking "unnecessary" healthcare.

On the other hand, in Denmark where basic healthcare is free, the data you
allude to (but do not present) show that even then "a lot of people don't go
for checkups [because] it's not a common thing to do." Additionally, you write
"Furthermore the situation is even worse for men over 50."

So my confusion comes from your contradictory assertions about the effects of
fully subsidized basic healthcare. Either free healthcare generates cost
overruns because people seek out unnecessary treatment, or free healthcare
does not generate cost overruns because people do not seek out even necessary
treatment.

Your assertions about the effect of free healthcare are paradoxical, hence my
confusion.

EDIT: fix typo, recast first sentence of penultimate paragraph. Remove
redundant prepositional phrase from last sentence.

~~~
ThomPete
I am saying that because then they start paying for when they go to get
treated or for checkups which allow for more money being possible to use on
more serious situations.

I am not sure where you get that I want less people to go to the doctor. I
just want to be able to pay for the situations you can't afford by asking for
money in situations where most people can. And yes if you don't have any money
then you should get help, but for people who make enough it should cost
something.

So there is nothing paradoxial going on here. You just assumed I wanted fewer
people to go to the doctor which I never said anything about.

~~~
mistersquid
That makes better sense, but covering costs of extraordinary care isn't an
issue in state-provided health insurance (single payer), nor is it an issue
with private healthcare insurance.

With single payer, taxes cover the cost of care for everyone. With private
insurance, the costs for more expensive care is covered by the premiums of
healthier individuals, which is sort of like what you suggest but does not
financially punish people who get sick.

What you propose may not be workable (or humane, for that matter) because it
distributes the costs of extraordinary care to people who already have more-
than-routine care. Presumably these people already have paid their premiums
and now would shoulder most of the cost for maladies such as broken bones.

EDIT: add missing word "workable".

~~~
ThomPete
It actually is an issue in both systems which is why in state-provided systems
there are limits to what kind of treatments at what stages etc and in privet
insurance systems there are limits to coverage.

The main premise of this discussion is that it's not possible to pay enough
for healthcare. I.e. even if you taxed people 100% there still would be things
they couldn't get because it has to be available to everyone and there are
always new treatments being developed, new machines, new drugs.

Whether you find it humane or not is based on what you consider the end-game
of healthcare.

------
maxxxxx
This is an interesting read. It seems doctors really believe they have a
conversation with their patient whereas most patients feel that the doctor
just rushes in and gives his standard recommendation without deeper thought
and generally doesn't listen to them. Do doctors go to other doctors when they
have a problem? Do they get more respect by other doctors? If they went to a
doctor and got the same treatment as their patients typically they should see
that something is going wrong.

~~~
kbutler
This is definitely more at the specialist, chronic care level. Like anything
else, if you have a weekly contact with them, you are much more significant
than a once or twice a year visit.

~~~
maxxxxx
Probably correct. My girlfriend just had a few surgeries. I was shocked how
little time these specialists gave their patients. I bet most of them spent
less than an hour thinking about the whole case. There are exceptions but we
had several surgeons who stopped by a few minutes before the surgery and
didn't remember anything about the case or confused cases. Then they took 3
minutes to get up to speed. They also often don't look for feedback after the
surgery. Some don't even call and when you tell them that it didn't work they
disappear. Also, they rarely talk to each other. So every procedure starts
from scratch and the patient has to explain the case history.

I can't imagine how bad software development would be if we acted like the
medical system.

~~~
magnetic
I was following you until... > I can't imagine how bad software development
would be if we acted like the medical system.

...which made me laugh. Until I realized you weren't sarcastic (I think).

~~~
bayouborne
..but I understand his broader point - these are not deeply introspective,
gifted individuals. A front line GP (and probably many 'specialists') is an
auto mechanic who replaces an awful lot of ECM modules unnecessarily along to
way to actually fixing the problem. In an aggressively supervised service
field many of these people wouldn't make it. Doctors may get flagged when they
kill enough people over a local threshold, but qualitatively dismal
performance (empathy, followup, even a solid fundamental knowledge of the
subject matter) is tolerated quite nicely in the system.

------
bayouborne
In my field when a customer has an environment with a problem, he or she files
a ticket describing the problem to the best of their ability. Some of these
customers are quite expert in accurately framing the issue, what they've done
thus far, and they frequently provide addt'l information answering what would
have been my next questions. Other customers are inexpert in stating the
problem. Regardless of the customer's level of understanding of the issue,
once we take a case (yes, we call them that) we understand it is _our
responsibility_ to resolve the issue.

Doctors today are literally too busy to care. They never 'Hold the Paper' to
the issue. It isn't enough for a patient to manage to have the proper
insurance and reach out to a primary care physician; it's now incumbent on you
to continually identify the specialist areas which may be germane to your
issue and make the appointments and interpret the resulting data. You, are
_the_ integral component to saving your own life, as no doctor or other
medical professional is there now to provide continuity, or put any of what's
happening to you into context.

I honestly think there is an opportunity for yet another layer to be inserted
into American medicine - that of the patient's advocate, who is smart enough
the carry the day, and who simply gives a shit.

------
tomohawk
Years ago, I had a truly great primary care doctor. She had her own practice,
which was typical at that time. She was caring, but above all, extremely
competent. After she retired, I've yet to come across a situation remotely as
good.

I think she was so good because she was allowed to be directly engaged with
her patients and that resulted in some sort of feedback loop where she was
always striving to stay on top of the state-of-the-art.

These days, those sorts of practices are hard to find. There's the doc-in-a-
box places that dominate, and they seem surprised if you want to see the same
doc rather than whoever can just see you.

There's also someone else in the room these days - the government and
(practically the same thing) insurance company. The doctor / patient
relationship is now more like the doctor stooge snooping on the patient
relationship.

Just look at how many doctors no longer will prescribe medicine for pain due
to the war on drugs. They're scared of losing their license. The collateral
damage is the poor people who need strong pain management but find it
increasingly hard to get it.

~~~
DanBC
> Just look at how many doctors no longer will prescribe medicine for pain due
> to the war on drugs. They're scared of losing their license. The collateral
> damage is the poor people who need strong pain management but find it
> increasingly hard to get it.

Doctors haven't stopped prescribing opioids because of the war on drugs.
They've changed prescribing because opioid meds are not effective to treat
long term pain, and certainly not effective in the way they were being
prescribed.

People with long term pain given opioids will quickly develop tolerance to
those meds, and need to increase the dose. They quickly reach dangerous levels
of opioid use, often with multiple meds, and they're still not getting relief
from their pain. So now they're still in pain, and they have an opioid
addiction.

People with long term pain need rapid access to specialist pain clinics, with
a full range of treatment including physiotherapy and prescribing, and -if
needed- carefully prescribed opioids.

~~~
nullstyle
> Doctors haven't stopped prescribing opioids because of the war on drugs.
> They've changed prescribing because opioid meds are not effective to treat
> long term pain, and certainly not effective in the way they were being
> prescribed.

Watch the documentary "Dr. Feelgood"
([http://www.imdb.com/title/tt5192362/](http://www.imdb.com/title/tt5192362/))
for a couple of very extreme, living and breathing refutations of that claim.
It's not nearly cut and dried one way or the other.

------
dabbledash
I think it's great for doctors to solicit feedback from departing patients to
see if there is anything they could be doing better.

But on a related note: I'm not sure about the value of using patient
satisfaction surveys to evaluate physician performance generally. Patients
will love doctors who tell them what they want to hear, over-prescribe
antibiotics, over-prescribe powerful pain killers, go along with non-
vaccination, prescribe homeopathic remedies or similar nonsense.... I think
most people are not in a good position to evaluate the quality of care they're
getting outside of things like bedside manner, so I wouldn't pay much
attention to reviews for doctors.

~~~
henrikschroder
I saw a study of patient satisfaction across the entire healthcare field which
showed that overall patient satisfaction was the highest for massage
therapists, and the lowest for oncologists.

The former deliver no bad news ever, and treat to make you feel good and
relaxed, the latter deliver nothing but bad news, but they probably save your
life.

So what happens is that people mistake their subjective feelings for the
objective quality of care, and discount the value of being alive immensely.

------
ziikutv
It ain't perfect in Canada either.

I remember losing my hairs and getting patches of super smooth bald spots.
Super embarrassing for a kid in a bad neighbourhood and bad school.

Went to the doctor she looked at my charts and said I was super low on iron so
low that I might even die if it continues to lower. I was given iron pills.

Two months after I went to the doctor again and said my hair patches are not
fixed. She looks at my chart again and said... hey you don't have low iron you
have perfect iron and I never told you to take any pills.

Then upon investigation it was noted that the staff gave her wrong chart; of a
pregnant woman who had a similar "feminized" version of my name.

Edit: Addendum: finally I was sent to a skin specialist who injected me with
steroids for months until my patches were fixed. They said I had alopecia.

I was furious what if the said person had cancer and they started chemo on me?

Same doctor once injected my mom with the wrong fluid. To this day we don't
know. We filed a complaint but she then resorted to personal attacks in her
report and the "college of medicine" or whatever it's called didn't do
anything. Till this day my mom has a red/purple bump on her arms.

Finlly, most other docs don't even check me out they listen to symptoms and
say it's nothing, it will go away, etc while looking miserable (no doctor
should watch House MD lol). Other times they solve the symptoms by tossing
prescriptions at me. Said symptoms always keep coming back and I keep getting
more of the same prescriptions.

Thanks for the free health"care" Canada.

~~~
dleslie
Bureaucratic mishaps and mediocre care providers are bound to occur in any
sufficiently complex system.

~~~
waqf
Have you looked at the work in the 2000s on preventing medical errors, e.g.
[http://www.nytimes.com/2006/10/31/health/31safe.html](http://www.nytimes.com/2006/10/31/health/31safe.html)?

------
stinkytaco
I don't know if my doctor would notice. She sees so many patients it's hard to
get in when I need to, so I end up seeing whoever is available anyway. That
seems increasingly common,large systems with overworked generals and huge
administrative headaches. And it's not like we can switch, we've got
insurance.

------
speeder
I don't bother explaining to doctors why I switched.

Every time I did in the past they got personally offended and refused to
address their flaws, so why bother?

Also I am almost convinced good medics in certain fields (endocrinology for
example) are almost nonexistent.

~~~
zer0tonin
Most endocrinologist only ever see diabetics and people with thyroid disorder.
They are often quite lost when they get to see something else.

~~~
speeder
I have thyroid problem... Endocrinologists even then failed to help for most
part.

I found only one willing to help, and only in an half-assed manner. I still go
most for formality and legality reasons, but I am mostly treating myself as I
want now.

------
danieltillett
I have luckily been very healthy in my life, but I have always believed that
the relationship between a doctor and a patient is a collaboration with the
aim being to help the patient make the most appropriate decision for their
needs.

Too many doctors seem to be of the opinion they know best and the patient
should just do as they say - even if they are correct technically it is not
their life that is on the line. The patient is always right.

~~~
tim333
Not sure the patient is always right but the docs are often wrong.
Collaboration probably works best. The docs have more medical knowledge but
the patient may know more about their particular condition. I recently went to
a dentist with a broken tooth and he wanted to do a root canal not because
their was any evidence it was infected but because he thought it might be and
why not from his point of view. From mine I'd rather wait and see if it was -
it wasn't. That kind of stuff seems quite common.

~~~
maxxxxx
There may also be quotas to fulfill​ for certain procedures. I often get that
impression from dentists when they push for something that doesn't really make
sense.

~~~
ganonm
Quotas for procedures is a very interesting topic. Doctors (in the UK at
least) carrying out appendectomies consider a negative appendectomy rate (NAR)
of around 20% to be optimum. The NAR being the proportion of appendectomies
where it turns out the appendix wasn't the cause of the symptoms.

The reason this is considered optimum is that a doctor hitting 0% NAR (which
you might naively assume is best) is most likely being overly conservative and
missing some genuine cases of appendicitis, which as we all know can be life
threatening if left untreated.

------
bayouborne
The author of this article is living in the some 'It's a Wonderful Life'
twilight zone. Medical professionals now, generally speaking, don't care about
you. Actually they care about you moderately for the time you are positioned
directly in front of them, so if you've got an easily treatable malady there's
hope for you. But if you are frightened and have an abdominal issue you know
is not normal, then you're cast out into the Wilderness of Specialists who put
you through a series of diagnostics and if these tests don't flash positive
for something, you are on your own. Doctors don't care and are not your
friend; a majority are goobs with no troubleshooting skills at all. They know
to prescribe the blue powder for this condition, and the red powder for the
other thing. They do not understand, nor do they care to. The Chinese
physician of 600 years ago may well have served you better. Marcus Welby is
dead; actually he's a fiction, he never was.

------
losteverything
I'd say in a bar to this author dr

1\. Kittens die

2\. You have a unique position to help people.

1\. If you have ever cared for 4-7 week kittens then you know sometimes they
just die. Don't be surprised when they do. They simply do. One moment they
seem healthy and the next-they are gone.

Your patients will not come back. They just won't. Don't be surprised when
they don't come back. It happens. You will not know why. It's part of life
like kittens dying.

2\. You help people. You give them their life back. You are One of the few
people who can make someone better. You improve. You prolong happiness. You
give hope. It's often invisible to you. Yet it is real. It's real when your
patients can travel, cook, walk, earn a living, hug grandchildren, breathe
another breath.

I can't do that. Most people can't do that. But you do. Every day.

So who gives a ### that you don't know why the kitten left your practice. It
never changed all the good you did and all the good you can and will do.

So... Forget the kitten.

~~~
waqf
You are correct to forget _this_ kitten, but that doesn't in any way mean you
shouldn't research ways to stop kittens dying.

------
JimXugle
In my case it was because we weren't making progress towards turning a long
list of symptoms into a diagnosis, compounded with some rather ill-informed
and slightly offensive remarks about LGBT people and HIV/Aids.

------
builtinbuffalo
We've created a patient feedback software
([http://www.repcheckup.com](http://www.repcheckup.com)) that allows doctors
to automate their patient feedback by sending email and text rating/review
solicitations.

On average, less than 5% of all patients seen will leave feedback. When
prompted, we've seen this jump to 10-15% of patients seen, although we do have
a few who have much higher conversion ratios.

(This is likely due to the doctor introducing the feedback concept at the end
of the consult.)

What has been most interesting to see, contrary to the story, is that most
doctors and healthcare professionals are still on the fence about implementing
these sorts of feedback loops.

We find often times that buy-in does not occur until the professionals can see
"comparisons" as to how others are doing.

There are also a ton of hurdles to implementation of these types of feedback
loops, due to HIPAA and other requirements that often makes things near
impossible.

This makes the whole thought of introducing this into a practice daunting for
some and that's why usage of feedback loops like these are not already
widespread.

Hopefully, as legacy practitioners give way to a new generation of medical and
Heath professionals, patient feedback will be more widely solicited and used.

------
ljoshua
This is a growing and very important aspect of value-based care, and really
factors into the discussion of quality that will be more a part of
reimbursement than it ever has been. The article focused mostly on the
provider him or herself, but patients also take into account the entire
experience, including office staff, scheduling and billing procedures, etc.

Shameless self promotion: this is the exact problem my co-founder and I are
working to address:
[https://www.perspexilabs.com/](https://www.perspexilabs.com/) (site currently
looks broadly-focused, but we're targeting medical).

We're finding patients are actually _very_ happy to give feedback, especially
when given a neutral medium to discuss their experiences and when doing so
very quickly after an interaction. The super-tight feedback loop not only
makes everyone more satisfied, but it also has the chance to improve quality
of care too.

~~~
DanBC
People interested in this might also like the "Friends and Family test", which
is used extensively in the English NHS.

[http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-
frie...](http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-friends-and-
family-test.aspx)

[https://www.england.nhs.uk/ourwork/pe/fft/](https://www.england.nhs.uk/ourwork/pe/fft/)

~~~
ljoshua
That's virtually the exact same thing as the question we're asking, which is
virtually exactly the same as NPS (net promoter score). Thank you for the
links, I hadn't seen those ones before.

------
aladoc99
Not that the author of the linked piece will see this thread, but my
experience has been that those patients who leave for personal reasons, as
opposed to logistical reasons, e.g., changed insurance, moved away, etc. are
usually not missed. My office staff will say, "We sent Ms. So-and-so's records
over to Dr. Xyz" I'll say, "Gee, that's too bad." Almost invariably the reply
comes back, "No, he can have her. She's impossible." (Of course, they're nice
to me, but the office staff gets a more realistic picture.) So it tends to be
that people who appreciate my style and personality hang around.

------
Ultramax
As someone who deals with chronic joint pain, getting opiod pain relief right
now is a fiasco.

It is funny: prescribe pain relief, then act like I'm an addict? Give me a
break. Who is selling the opiod epidemic story ad nauseum?

~~~
propman
I have had severe chronic pain for many years as well. I use opioids but for a
very short duration. It is a huge pain to get off them when you take them for
a while. Max dosage of medical marijuana (cbd and indica not sativa) and
synthetic opioids like tramadol not used daily works best for me. Current
political climate is a no no to all opiates which is why it's so hard to get
them now and it is awful for those with lots of pain, but doctors really did
prescribe them too much.

------
z3t4
it can be more rewarding to ask happy customers what they like about you.

------
amelius
> "Why Did My Patient Leave Me?"

I'm seriously wondering how many doctors will ask themselves this question, or
even notice that their patient is gone.

------
lmns
So, in this sense, vaccination should be an individual choice? This is
something which concerns the individual, but has consequences for society as a
whole.

~~~
jacquesm
> So, in this sense, vaccination should be an individual choice?

Emphatically: YES. Bodily integrity is something that is very high on the list
of things that a person should have a say over. Whether they do it because
they are mis-informed, dumb, irrational or religious doesn't matter, they
_still_ should have the final say over whether or not they get a specific
injection or not.

There are many things that concern the individual that have consequences for
society as a whole, in fact, it is very hard to point at a single thing that
concerns an individual that has absolutely no consequence for society. And
many of those things are regulated to benefit society. But your body is yours
and yours alone and that's a good thing even if there are negative
consequences for society.

Fortunately the anti-vaxxers are a small minority instead of a large majority
so the risk is somewhat controllable and fortunately the only people at risk
are those that have not been vaccinated yet (a risk that for many diseases is
extremely small) so the consequences for society as a whole are manageable.

If that should change dramatically then this should be revisited but for now
I'm pretty happy to support this even though I would never apply it to myself
or my children (who, ironically, don't get to chose because the argument isn't
really framed right, it's not an individual choice but in almost all cases a
choice for a parent about their child...). This also ties in with religious
freedom, and as an atheist you might find it surprising that I'm a big
proponent of that, I don't believe in any of this but I will definitely defend
the right of others to believe in whatever they want, including in things that
may make them make sub-optimal choices when it comes to their own health or
the health of their kids.

If you start to take away those rights you will end up with a very unhealthy
society, far more unhealthy (and unhealthy on a different plane) than the
society that has to deal with some actual health issues in a small part of
their population.

~~~
pdkl95
> the only people at risk are those that have not been vaccinated

Remember that this set includes people that _cannot_ receive the vaccine
because of e.g autoimmune disorders, serious allergic reactions, _etc_. These
people need the herd immunity to keep the general risk of infection low. As
long as the number of anti-vaxxers is _very small_ , they similarly benefit
from the herd immunity as "free riders".

Once the number of free riders crosses a threshold[1], non-linear effects can
rapidly amplify the spread of the disease among the population. Preventing any
disease from gaining a "critical mass" in the population is an important part
of how they work.

> Fortunately the anti-vaxxers are a small minority

Unfortunately that isn't really true in some areas.[2]

> so the consequences for society as a whole are manageable.

That management has already started to fail in CA (and other areas), where the
rapid decrease in vaccination rates cause measles and whooping cough
outbreaks[3].

[1]
[https://en.wikipedia.org/wiki/Herd_immunity#Mechanism](https://en.wikipedia.org/wiki/Herd_immunity#Mechanism)

[2]
[https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm?s_cid...](https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm?s_cid=mm6341a1_w)

[3] [https://www.advisory.com/daily-briefing/2014/09/30/in-
wealth...](https://www.advisory.com/daily-briefing/2014/09/30/in-wealthy-la-
schools-up-to-of-parents-exempt-kids-from-vaccines)

~~~
jacquesm
Sure. That's all true. But just like you could have a perfect society without
any unsolved crimes by monitoring everything and everybody even in their homes
there is a balance to be struck between the right to self determination and
the obligation to partake in certain things that society will impose on you by
way of force if necessary.

I believe that that line is drawn pretty accurately at the moment, there is a
strong push towards vaccination, there is education and there are all kinds of
programs to make sure it happens. And yet _we can not force this onto people
that don 't want it_. I'm sure that there are plenty of people that would
rather see this resolved 'for the greater good', I'm just not one of those
people and I feel quite strongly about this even if it is a right I myself
would never make use of because I disagree with the basic premises of those
that want it that way.

But I recognize their rights and will defend them.

------
mhneu
Ok, now this is just being obtuse.

Parent post said single payer encourages checkups.

You said "but there are still people that don't get checkups in Denmark".

Those two points are completely orthogonal. Single payer encourages checkups,
yes. Still some people​ won't get them, yes.

Drop the sophistry.

~~~
dang
This breaks the HN guidelines against being uncivil and calling names in
arguments. Please don't do that, regardless of how wrong someone else is.

We detached this subthread from
[https://news.ycombinator.com/item?id=14120716](https://news.ycombinator.com/item?id=14120716)
and marked it off-topic.

------
known
A good doctor should always tell the patient how his disease could have been
prevented.

