MD here. I'm of two minds about this. On the one hand, obviously there's a bit of defensiveness since I went through 12 years of school and training to be an independent physician (4 years college, 4 years medical school, 4 years residency) and I've definitely seen subpar care from other "providers" (not a fan of the term) with less training. The wide variety of different "providers" is also confusing to patients who have little idea the differences in training and scope. The training for non-MD "providers" seems very variable, unlike the quite standardized MD training. I definitely think residency training is a much more robust and you need to have that critical feedback from supervising physicians to improve, which I think can be lacking in non-residency based training. Overall, nothing against PAs/NPs, I know some great ones.
On the other hand, a lot of what I do doesn't require 12 years of training, so I am sympathetic to making health care more accessible. I am also a bit jealous that my non-MD colleagues can easily switch from e.g. being a primary care PA to being dermatology PA, whereas as an MD I'm pretty much stuck in my specialty unless I go through another 4+ year residency. Instead of MD-training getting shorter to compete, it's actually getting longer in many cases. Residency trainings are getting longer not shorter for a number of specialties (e.g. neurosurgery, interventional cardiology, pediatric hospitalist).
> On the other hand, a lot of what I do doesn't require 12 years of training
What, besides surgery, really requires 12 years of training? I've found I have a greater success rate with self diagnosis and treatment than I have with seeing my physician, and I've found a very good internist. An hour spent with ChatGPT and Google and I always find a couple options that fit what I'm experiencing as well as detailed descriptions on how to narrow it down. And since I'm the one experiencing the symptoms, there's no chance of a communications breakdown between me and the doctor who is trying to diagnose me.
A recent occurrence I will share related to this was having to convince my doctor that I had Lyme disease. I Googled the symptoms, saw the trademark bullseye, and of course concluded that I had Lyme disease. It was right where I got the tick bite, 8 weeks later.
My doctor refused to believe me. He told me to see a dermatologist about it, thinking it was some skin rash, even though it was exactly where the tick had bit me and it was a bullseye. I shortly thereafter went to an urgent care center where fortunately an RN happened to be from Maryland (I live in the South, where Lyme disease is not really a thing) and she immediately saw my rash and prescribed me the appropriate antibiotics.
The reason my doctor did not believe me? It took 8 weeks for the bullseye to develop. I had gotten the tick bite in Europe (which of course I informed the doctor of very first thing). Typically American Lyme disease displays symptoms much faster (days instead of weeks). The doctor did not bother to do any research to discover what I had found in a few minutes of Googling: that European Lyme disease takes much longer to display symptoms (and I had told him as such as well). He was happy to simply assume that all Lyme disease takes only days to display symptoms instead of weeks, because that's what he knew of, and since mine had taken weeks, well, I just must simply be wrong.
My doctor did have a small redemption: once he was confronted with evidence and did the research himself on what I was saying (after the RN had already treated me), he did call me and apologize. But still. This is a daily occurrence, especially for people that are of underserved genders and races.
I realize this turned into a bit of a rant, but in essence I just want to affirm what you're saying. A lot of doctors, especially PCP, are often not much more than glorified technicians. Combine that with the ego problems that typically accompany being an MD and you get a recipe for people getting subpar care, especially women and minorities.
In the end, unfortunately, only you are responsible for your own medical care and getting the best outcome. It is not sufficient to just trust someone else because they have the words MD after their name.
It’s intuitive that a patient who can spend an order of magnitude more time on his self care, and can self-articulate their symptoms, can occasionally self-diagnose better than a doctor. It’s not intuitive that a clinician with 4 years training and the same 30 minute window to diagnose you would do better than a physician with 12 years training.
The point is that it's easier for a service provider to spend 1-2 hours (or across multiple people) when they don't have to spend 12 years of training with high attrition rates. Both because it's more affordable, and because there's less scarcity.
On the other hand I got a rash and tried to google diagnose and got in completely wrong whereas the doctor figured it in seconds (shingles). Probably best to try both approaches.
You have a point but need to drop the identity politics bullshit. Since when are women "underserved"? Men are far more likely to "tough it out" i.e. refuse to see a doctor when they have symptoms of illness, so by your logic they are the "underserved minority" in terms of gender. Claiming women are disadvantaged in literally everything ever is a groundless cliché. The racial angle may be less false (though not for the reasons you imply) but is still irrelevant to this story.
The article uses a survey about personal opinions as the source for its judgement. Right in the first paragraph (emphasis mine):
> A *survey* conducted in early 2019 by TODAY found that more than one-half of women, compared with one-third of men, *believe* gender discrimination in patient care is a serious problem. One in five women *say they have felt* that a health care provider has ignored or dismissed their symptoms, and 17% say they feel they have been treated differently because of their gender—compared with 14% and 6% of men, respectively.
This does not address GP's complaint regarding men being more likely to refuse to see a doctor in the first place. Does patient gender discrimination occur in the medical space? Probably. But nothing in this article addresses GP's claim of "Men are far more likely to 'tough it out' i.e. refuse to see a doctor when they have symptoms of illness".
This journal article discusses gender disparities regarding coronary heart disease (CHD) diagnoses, with doctors believing that their male diagnoses are more confident than their female diagnoses.
Disregarding the fact that the article still doesn't address GP's aforementioned complaint, the sample size used (n=128) is too small to make a firm judgement, with the ideal being at least n > 1000 to reduce potential statistical noise. The study also doesn't disprove the possibility of men being overdiagnosed with CHD.
This article addresses lower quality of healthcare received by minorities as opposed to white people. No links or direct references to cited studies/articles are given anywhere within the article, and the one time they do reference a source is to a book ("Just Medicine: A Cure for Racial Inequality in American Healthcare (2015)"), with no page citations to the aforementioned book made in the article. This article also doesn't address the GP's complaint at all.
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Personal opinion:
This type of shotgun-style link posting is a variant of the Gish Gallop, wherein the link poster forces participants to "do the research" via the cited links, only to waste their time by not directly addressing the concerns and complaints of the parent comment.
AaronM, at least spend a few minutes to find articles supporting:
"Underserved" here means that when they see a provider, they are less likely to be taken seriously; not that they are less likely to see a provider.
For example, while men may be more likely to "tough it out" of their own accord, a black woman describing her symptoms is much less likely to be taken seriously.
Are they being taken less seriously when they have serious health issues, statistically? I'd like to see some data on outcomes, life expectancy is the best datapoint I've got and men are clearly disadvantaged there. If women are more likely to seek health care early then it makes sense that more of them don't actually need it, i.e. are "not taken seriously". Maybe there's "collateral damage" but I've also not been taken seriously as a male so I certainly can't agree that it's unique to women and I'll need more than anecdotes to believe that there's a gender discrepancy.
Dude here. If you talk to women about their experiences with doctors and -- and this is important! -- actually listen you'll find that they're very different than ours.
I've gone to appointments with my wife and have had to repeat what she's told the doctor to have them even pay attention. Then ask, what's the protocol to handle this? because while they listened, they weren't reacting.
She had to ask me to go with her because they weren't helping. And finding another doctor to go to would have taken weeks/months.
I have a hard time taking self reports seriously particularly because identity politics are in vogue and that means a lot of people are eager to portray themselves as oppressed characters. I've spent time in clinics, hospitals, and ICUs, and have experienced condescension, not being taken seriously, being kept in the dark about my own health, etc., likely because I'm not very assertive by nature (as a male of course). "Just believe women!" is another example of bullshit identity politics and I don't think it's proven to be a good attitude since it became a catchphrase with #MeToo. Sorry if this comes off as blunt/rude and of course I sympathize with anyone getting mistreated by physicians but I really don't believe that women are disadvantaged in health care today, however if you have evidence that women have worse health outcomes due to mistreatment then I'd like to see it. Otherwise I'd rather trust my own experience and the data that I'm familiar with (e.g. life expectancy).
What, is that you likely have an IQ ~2 standard deviations above average. Most doctors are similarly intelligent. While he/she possesses more medical domain knowledge, you are able to problem solve with similar accuracy with a little research. Most people do not possess the domain knowledge nor the problem-solving ability.
I think where this breaks down is when you have something rare that requires immediate attention. My impression is that a lot of that medical training is being able to say "oh that's unusual, you need to see a specialist".
In my experience, no one who has not dedicated a great deal of time to the study of their area of expertise is worth seeking out for help. If they haven’t been taking it seriously for long, I don’t take them seriously.
I wouldn’t consult a first year mechanic, a second year doctor, a third year pilot… regardless of how long it takes to be functional in an area, I’m entitled to expertise and the signifier for expertise is time.
I'm a critical care paramedic, have several friends who are (perhaps unsurprisingly) generally emergency medicine physicians and related (surgeons, anesthesiology, nurses, etc.).
I see the spectrum too. Extremely competent PAs who have long and detailed in depth discussions with physicians as "peers", on one side, and then I see horror shows from people who went from zero to ARNP in programs with "accelerated RN" where they are not functioning providers with far less schooling and clinical experience than even a PA (which is then galling to the PAs, as why are NPs independent practitioners, and PAs not?).
I do think a lot of the issue is in the education and certification process. The AMA is only recently making the slightest inroads into well, not admitting they went too far in restricting physician flow, but maybe acknowledging that there is a problem there. Nature abhors a vacuum, and all.
I had a friend, extremely intelligent, in a BSN program. Called me one day to ask about flow rates for various oxygen adjuncts (nothing fancy, just like "what do you typically run your nasal cannulas at? What about NRBs?") and I was blown away. "Oh yeah, somehow that got overlooked. I know how to set them up, add humidifiers, etc., etc. - they just assume, I suppose, that someone at some point will say some magic numbers to us".
And I'll also say that you see the same pre-hospital too. In PNW, while there are valid criticisms that can be leveled against two of the pre-eminent paramedic programs (UW Harborview, and Tacoma Community), there are far, far, too many "strip mall schools" in other states that will take you from "zero to hero" in 4 or 5 months (of 6 days a week, 8 hours a day, of just class time), and dump you out on the world with just enough retained knowledge to pass your NREMT and the barest amount of ride time to meet DOT mandated minimums. It's scary, to be blunt. These people go out with no clinical experience and are now expected not just to work as a team on a 911 call, but to lead it.
It's the medical equivalent of high school > college > MBA > management position without a day of work experience in your life beforehand. Except now there are literally (at least occasionally) lives at stake.
1) Uniterested, slapdash care from an MD with 12+ years of training and no ability to listen or empathize but eager to make the money s/he went into medicine to make
2) The same from an assistant of some kind who uses ever-degrading search engines to look up not-your-problem and give you potentially dangerous suggestions
The future will undoubtedly be worse. As someone mentioned below, we'll pay current premiums (+inflation) for a touchscreen interface to Chat-whatever-it-will-be.
1) isn’t being entirely fair. MDs or any other practitioner are generally restricted by what they can bill insurance since only a minority of patients opt for concierge care. So if insurance allows for “X minutes for Y service”, that’s what they generally do in most “eat what you kill” practices (which is most). Some will go above and beyond, but that’s to their detriment. Insurance billing generally makes care “billability”-centric.
Believe it or not, I tried concierge care. Pretty much the same thing only with a big "cover charge" and a lot of gorilla juice about personalized attention. Left after three months - initial comprehensive exam where the practice owner/doctor was distracted by multiple phone calls and a student he was teaching on my time. I was telling him about my bad Achilles tendon which he proceeded to whack when the reflex test on my knee didn't go the way he expected. The pain was excruciating and when I found my voice, I let him have it.
He was late to the followup, couldn't explain the results his machines had given him, and then rushed me out after the usual 10 minutes.
I think family practice/primary care is on the ropes. The big lie is that some doctor will "get to know you as an individual." Reality is that s/he's given a quota and time limits by some MBA and the Epic system will make damn sure that the doctor does not use any initiative in solving the patient's problem.
I am still at the point where I can prepare and advocate for myself. When that goes, it'll be curtains.
Isn’t this the natural outcome of the American medical associations license cap? A growing country will always need more medical professionals , if MDs cannot be accessed - then an alternative will emerge.
> Isn’t this the natural outcome of the American medical associations license cap?
It is an inevitable outcome of trying to manage healthcare as a for-profit business. That means the primary directive is to maximize profit, which you do by maximizing throughput and minimizing interaction and services.
"In 1997, Congress passed the Balanced Budget Act, a bipartisan effort to cut back on spending. The act put a cap on the number of annual residencies CMS would support, and froze the funding at 1996 levels. . . . Since 2007, a bill to increase the number of residencies has been introduced in every Congress . . . but never passed."
But why aren't more residencies paid for through other channels?
I wasn't under the impression that medical residents were solely a drain on hospital resources—my sense was they did a lot of the smaller tasks to free up licensed physicians to do more. At some point, if there aren't enough CMS-funded residencies and there aren't enough licensed doctors, wouldn't hospitals just start hiring more residents?
The article you linked to has a heading that touches on this ("how did we end up with Medicare basically determining the number of new doctors per year?"), but doesn't actually answer the question it poses. It explains why the government started funding residencies, but not why the industry is now completely dependent on that funding.
You would think hospitals would be because they pay the high cost for doctors.
I think rather it is a collective action problem.
Hospitals don’t want to invest 150k per resident to have that person leave the day they are done. It is common for doctors to do residency where they can and then move.
A better option would be for the fed to cut residency funding entirely and have hospitals pool resources themselves.
Why do you include your undergraduate degree as part of your medical training? I've asked dozens of doctors (and lawyers) about the relevance of their college/undergraduate education to their day-to-day work and none have said it was critical, most have said it was not relevant, and some have had completely non-medical majors (music and physics). Of course, maybe it's different for you, which is why I ask.
+1. In Mexico there's a "Medicine" major, which is longer than other majors, but not as long as doing a 4 year undergrad degree followed by a 4 years of med-school. I've always found interesting and a little pointless that even if you know you want to be a doctor you have to go through the extra steps of two degrees/schools.
I think the standard pre-reqs in the US are two semesters of biology, math, and physics, four of chemistry (general and organic).
I doubt that any of this is directly relevant to patient care and honestly, I’m skeptical that it’s either necessary or sufficient background for the stuff that is.
> Why do you include your undergraduate degree as part of your medical training?
Was the comment edited after you posted this? Because I don't see them saying this was part of their training at all. They wrote "12 years of school and training", and this is the school part.
You caught something I didn't. The first paragraph states "12 years of school and training". The second paragraph has the same phrase, but without "school". I was focused on the second paragraph without realizing it was likely referencing the first one.
Funny, I missed that phrase in the second paragraph instead. Yeah I think in that paragraph they just used the word training to encompass everything the job requires you to have done (after K-12).
I argued with a PA because they were convinced that the most likely reason for a high white blood cell count in my sample was that it was contaminated post collection. It was a very frustrating discussion that seemed to have gone around in circles many times. I eventually just had to agree to retest. I feel like this would not be an issue talking to an MD.
I have experienced the flip of this: a less experienced MD specialist not recognizing a lab error, and wanting to act on it, which was recognized (correctly) as an error by PA primary care and confirmed in retesting. In this case the MD was significantly younger/less total years of experience and maybe that had to do with it?
PA experience isn't the equivalent of training as a resident (and I think we should be training more MDs) but the MD isn't always right either.
The system is completely broken with you taking 12 years to train.
It means that:
- you are expected to learn way too much and only have a surface understanding of a lot of things (see tick example from sibling comment)
- your time is very valuable so you can’t put any time effort into patients at all to try to deeply understand anything that doesn’t pass your “known expertise” classifier.
My son has back pain that most closely matches descriptions of sciatica.
The 3 MDs he has been given a cumulative exposure time of maybe 15 minutes to have resulted in prescriptions for various muscle relaxers and steroids based on a single xray. No attempt to look at any soft tissues and none of it has helped.
The industry is an absolute dumpster fire of ineffective care unless you land in the top 20 issues for each sub category.
No offense, but the job of diagnosing one of the thousands of possible issues should not be yours. This is what computers are ripe to disrupt. ChatGPT isn’t there yet but something like it that can just crunch data and known results for every obscure thing is going to blow you out of the water. We can both only hope…
I’ve had positive test showing nerve damage. Doctor messages me saying all my tests were fine. I message them in the portal pointing out one of tests showing insufficient sweating means small fiber neuropathy. They confirm I am correct. Then, I have to tell them what meds to prescribe, that the dosage is too small. It was like pulling nails.
I have seen physicians at top facilities in the US. Some are better some are there for prestige and paycheck.
We need to collect symptoms using words and visual representation, not everyone will know what tingling feels like. I welcome AI.
Also, if you search an illness and look for support groups you will quickly find handful of “recommended” physicians in a country.
It wouldn't be so bad, except so many MDs, PAs, and NPs are just bad.
This is coming from someone who has been traveling with a sick family member for a few years. There are great (read: skilled, thoughful, patient, investigative, this.patient data driven) professionals out there, but they are badly outnumbered and booked for months near a year into the future. A huge bunch display the interest, skill, or attention of someone working a a declining fast food franchise. Worst of all, most of the good medical practitioners don't even have their own practices, they can't afford the combo of liquidity and red tape, at least that's what a couple have told me.
I've had two experiences in the last 10 years or so involving two "significant" conditions — not necessarily in the standard sense of threat to life, but in the sense of nonroutine and potentially becoming something more problematic, involving multiple significant testing procedures and several different teams of providers. The two things were totally unrelated issues.
Both of them just reinforced my sense that the degree pretty much doesn't matter anymore. In one case I saw several physicians of different specialties, and none of them had any idea what was going on. My own initial hunch ended up being correct, and I kind of ended up fixing it myself (complicated to explain, nothing illegal or inappropriate; ironically the first physican I saw was also correct, the only one who got it right, but he dismissed it and convinced himself it was wrong). In the other case, the best care we got was from a PA. The physicians were all specialists who were financially motivated to give care that was totally useless but very expensive (we figured this out by looking in the primary scientific literature and realizing that all the procedures they were heavily pushing were no better than waitlist controls). The PA was the only one recommending things that were actually useful.
I've seen useful MDs as well, especially with pediatricians and radiologists. I'm not saying MDs are bad or useless. But I'm increasingly convinced that different educational and training paths do not necessarily mean inferior or superior care; that a lot of services could be provided through different providers or mechanisms; and a lot of what people see providers for could be obtained without any provider as a middleman.
This was my experience going through a half dozen doctors. I found a great one finally, but they didn't even bother taking insurance, and it was very expensive.
Excluding emergency situations, the biggest issue IMO is diagnosis. So many tests, scans, listening, observation, etc. is all about understanding what the problem actually is. Once you accurately identify the problem, treatment can be effectively given (if one exists) via the current system.
For mysterious problems that elude a simple diagnosis you can really be stuck. Most doctors don’t have the time for complex cases. It’s worth becoming your own health researcher if no one else can identify the issue.
> It’s worth becoming your own health researcher if no one else can identify the issue.
This is something I have been a big advocate of. I would never claim to know more than a professional nor would I ever give medical advice to another individual.
However, it has helped me plenty of times. I feel like I have been able to ask more important and impactful questions to doctors, and I have been able to push back on some choices that doctors would have made that I think might have been incorrect.
For example, I was almost prescribed a medication. That particular medication might have treated its indicated condition well, but it is known to exacerbate my immune-mediated disease as a side-effect (to clarify, the medication was not for the immune-mediated disease).
When I mentioned it to the NP I was under the care of, she said, "I have never heard that side-effect." Well, she looked into it, and it turns out I was right. Had I not done my research prior to our visit, then I might have been subjugated to changes to a disease that could have been entirely been avoided.
I still think she is a wonderful NP, and no one can know everything.
I even have another account.
I asked an MD about a newer medication for my immune-mediated disease. He said, "I have never heard of that before." After discussing it with him, he did not seem to be interested in trying it. I swapped doctors, mentioned it to the new doctor, and she prescribed it. It's actually the single most effective treatment I have tried since I acquired the disease 7 years ago.
As Schoolhouse Rock once said, "It's great to learn 'cause knowledge is power!"
The first doctor I had wanted to send me to get my thyroid nuked because it was inflamed after a viral infection.
After 2 years and 6 doctors I found I basically had long covid years before it was recognized. Probably from a low grade garden variety viral infection. My gut developed food sensitivities and I started to develop autoimmune problems from that.
After finding the right doctor who could handle researching chronic conditions, things improved within months and a few years later I completely recovered.
Typical doctors have 5-10 minutes to listen to you and click on drop-down boxes on the computer. They won't care about chronic or complex issues. They are good for low hanging fruit and steering you towards pharmacological intervention but unusable for anything more involved.
In a very meaningful way the line between physician and non-physician had been blurring anyway.
There's a software called Epic which is used by virtually all large healthcare centers, and while most know it as a database system to store patient history and health records (problems and conditions they've been diagnosed for, lab work results, medicine they're currently taking or have taken in the past), it also has a little tab where a healthcare worker can put in some keywords, e.g. the symptoms a patient has, and Epic guidelines gives the health-provider an action plan for that patient, as well as guiding them with differential diagnoses for non-simple issues.
Of course for common ailments a nurse practitioner knows as much as a primary care physician anyway and their treatment plans wouldn't differ, but the thing is a physician basically effectively will also only follow one script that the healthcare/insurance system in-place allows for, that Epic will spit out also.
In the same way some of us see the task of building a CRUD app as something fairly unremarkable (owing to existing frameworks, existing 'best practices' etc), a physician's day-to-day work is really not challenging, and a "people-person" non-physician equipped with Epic software could arguably work to deliver equal or if not better healthcare outcomes.
Having worked in healthcare IT, and as a prehospital provider who has seen and interacted with many EHR systems, including Epic, Meditech, and ESO (moreso for prehospital)... the sooner Epic dies in a fire the better.
Keyword-driven differentials should be, if anything, the baseline, bottom rung, pattern matching to inspire and drive critical thinking, focused assessment, and diagnostic skills. Not to "easy mode" the path of least resistance.
Epic very much is poised to take over and every week it appears a new large healthcare center makes the switch to it.
I think the hard lesson everyone must learn eventually is that they have to take control of/become deeply involved with their healthcare as much as possible, because dragons are everywhere. For the average person acute care is not needed when they're thinking of reaching out to the doctor, and they shouldn't because elevating level of intervention can quickly result in shit: got a headache or a hip injury? The doctors will give you a plethora of CT scans and you end up with cancer. Got pain? They'll give you opioids so you end up with crippling addiction.
Indeed, of paramount importance for us is to learn how to take care of ourselves by going back to the basics (avoid processed diets, increase fibre-intake, etc, exercise (for the strength gains, for the endorphins and cardio/conditioning, for better bone density so that the body can whether through injuries better), cultivate your link to a positive community so it is there for you in your time of need). And download Epic and learn about healthcare/medicines and take charge as much as possible of your own fate. But when faced with a truly acute problem, see a specialist doctor and follow their commands.
Can you really just download epic? Like it’s free? I thought it was super specialized and you had to have some kind of business relationship to get access to it. I tried to find it online but didn’t see anything.
Epic is basically enterprise-grade software. And every hospital, forget health care systems, is an enterprise. Which makes it very difficult to break that moat.
Only planning for the common case is an insane thing to do in healthcare. We don't train doctors for 12 years so that they are faster or more efficient at diagnosing the common cold, we train them so that they have a wide breadth of knowledge, experience, and skills. People already have difficulty getting satisfying diagnoses from MDs with 12 years of training + Epic, imagine how much worse it would be if the person had no clue illnesses other than what Epic spits out even exist.
Exactly. Not everything is a zebra, plenty of horses, but...
When I teach new EMTs, there's a common topic that comes up. For clarity, EMTs undergo about 200 hours of training, for what is called BLS (basic life support) - essentially non-invasive processes. Generally they can only administer about 5 medicines (oxygen, aspirin, epinephrine, glucose, nitroglycerin). Paramedics undergo up to 1600 hours of training, for ALS (advanced life support), and can start IVs, administer ~40 medications, and do a variety of invasive procedures.
So our local EMS protocols say that if you administer a caloric supplement (i.e. glucose) for someone with hypoglycemia, you must "upgrade" that call to ALS and have a paramedic respond.
"But what if the patient is getting better?" As expected, as hoped. And if the hypoglycemia is really just that, then 99% of those patients won't need, or want, further care/transport. And for 99% of that 99% (arbitrary, but very high, percentages), it's probably entirely reasonable. "So if they're getting better, why do we want a higher level of care?"
For the zebras. For the person with endocrine issues, or for whom hypoglycemia isn't a simple diabetes-related thing, but actually symptomatic of early organ failure, or other things, to get a deeper review to make sure we don't say "Sure thing, Mrs Smith, just stay home and have your husband make you a PB&J or two for some complex carbs" to the patient who has something more serious going on.
A few years ago I saw a young doctor and all she did was put stuff into an iPad that told her what to do next. I could not run from her fast enough. Medical care by iPad app is not the way to go
The number of new physicians in the US are restricted because you need to go through residency and the number of residency slots are limited because they have to be funded by Medicare (why ?).
There's a huge lobby (AMA) to keep it that way, to ensure their members salaries remain high.
PAs and NPs don't have the same restriction so hospital systems are pushing to have them handle office visits as much as possible. This also has the advantage of being more profitable because they can charge the same.
In the last 5 years me and my wife have never been able to see a doctor, only a PA, even though we pay the same.
Considering 30 is pretty much the lower bound for becoming a physician, that stat sounds a little bit like "40% of employee absences happen on Mondays and Fridays". Alarmist and of zero value.
I thought about that, but it is indeed getting worse. If a doctor works from 30-70 (not sure what the average retirement age would be), then about 38% should be over 55. Clicking through to the actual statistics:
Percentage of active physicians aged 55 or older: 46.7% for 2021, 44.9% for 2019, 44.1% for 2017, 43.2% for 2015, 42.6% for 2013, 40.3% for 2010, 37.6% in 2007.
So that is a worrying trend, since increasing population should result in at least a steady state, if not decreasing average age.
Also, depends on specialty. 92.4% (!!) of specialists in pulmonary disease are over the age of 55. So I hope the aging population doesn't have any lung problems.
Where I work we have a physician who doesn’t see patients. He reads procedures and supervises 8 mid-levels.
It’s an assembly line. There are inservices that in effect ensure maximum level of encounter complexity to maximize billing.
A month ago my kids had pink eye. One resolved within days, the other got worse. Instead of a doctor’s appointment the next day, we went to the pharmacy where the pharmacist evaluated him and prescribed an antibiotic. Whole thing took 15 minutes. Really made sense for “a parent could diagnose this” kinds of minor ailments.
Also: if it’s the pharmacist determining a med and immediately administering it, is she really “pre-scribing” anything?
The eye is immune privileged and infections can develop into permanent damage within days. It is really not the kind of thing to be diagnosed and monitored at home.
If you go to urgent care, you most likely won't get a physician. 9/10 visits are urgent care you only see a PA or NP and they can't even really do much. Urgent care seems to also provide really poor results--every time I've gone it's a long wait, the workers seem over-stressed, you barely get any time with the doctor, and usually they just do a strep test or give you a Zithromax pack and hope you'll go away.
Anecdote that isn't remotely data: I went to an urgent care facility the first time I had a migraine aura without headache. I described it to the receptionist as a "visual hallucination", since it was a flashing checkerboard pattern that obviously wasn't real.
The receptionist _ran_ to the back to get a doctor. The doctor, in an exam room, very careful, and with significant compassion, explained that they don't have the ability to treat me at that location -- but would I accept an ambulance if they called it?
I took an Uber to the ER, where the admitting nurse gave me a flat stare and said "That's not a hallucination," but still put me at the front of the line to have an attending doctor and a bunch of students stare into my eyeballs before confirming that it was a headacheless migraine.
To this day, I use that experience as an example of a lay person and a professional completely failing to understand each others' word choice.
Possibly similar situation…but probably due to something else other than miscommunications.
I had insurance partnered with my university. I went to the uni clinic due to a headache and fever so I could get some ibuprofen. They had no capacity to perform any tests and told me I needed to goto the hospital. They ordered an ambulance and said I needed to sign a waiver if I refused them. I had no idea what the impact would be to my insurance so I went along with it. At the hospital ER they hooked me up to IV immediately and then said I needed a spinal tap to check for meningitis because they couldn't explain the fever. I asked to leave, but nobody came to unhook me from the IV or bring my belongings back. They then guided me to another room after an hour or so with 5 people in it. I asked to leave immediately, and they said I could have a life threatening case and I needed to sign a waiver if I left. Apparently they were bringing another doctor from another hospital as emergency to do the test. This time I called my family for advice and signed the form but they were very pushy. The headache and fever were gone the next day. This experience has scarred me from going to U.S. healthcare to this day.
You are very lucky. I don't think my urgent care even has an MD in the building anymore. Anything more than a cold or obvious case gets a "nothing we can do" and follow-up with your doctor. Anything mysterious but potentially severe gets you referred to the ER.
Sure, but what about those outlier scenarios? How do I know the NP or PA is actually going to catch those nuances? For example, a few years back I had a sinus infection in the spring and the NP/PA thought it was just allergies and tried to get me to try allergy medication... it was a useless trip. I'd much prefer a physician, but my primary doctor usually is booked out.
canadian anecdote: i havent seen my GP ever. He just oversees resident (student doctors). Ive had chronic health issues for 3 years now without much relief, despite having been to the doctors office 20+ in that time. Most of the time they deflect me from specialist care.
I'm Canadian too, and the only time I didn't see my family doctor (phone appointment) was at the height of the COVID lockdown. Are you located in a remote area?
Honestly, if you have the time, just go abroad to India or Thailand and get a full body check up. Don't leave your medical conditions untreated. Considering the restrictions around getting medications in the US, these hospitals night already have ways for you to prescribe you stuff. Just stick to the reputed ones like Apollo or Narayana Hrudalaya in India or Bumrungrad in Thailand. Or if you can splurge the cash, go for non-resident treatment at an American hospital (which is arguably cheaper than the insurance-covered prices).
there's been an issue with MAID being recommended or encouraged to people who don't want to die, but who have complex chronic illnesses that are expensive to treat. there's been a few really shocking cases of that happening, even sometimes crossing the line into coersion.
> Ive had chronic health issues for 3 years now without much relief, despite having been to the doctors office 20+ in that time.
This is the problem with all of these systems that try to violate the laws of physics (aka: free market economics). They invariably results in substandard care, if you receive care at all. Keeping people alive isn't the same thing as actually solving problems with quality care.
This is my big gripe with the ACA (Obamacare) in the US. It's a shit system that was sold as a quality system. There are so many things wrong with it I am sick of listing them.
My wife is a doctor, so I've been privy to behind the scenes effects. If you think your doctor gives a shit about you when you come to the office with one of the stupid plans, enjoy the fantasy.
Doctors do care. However, they can't see thousands of patients at a loss. They have bills to pay, just like anyone else. More than anyone else, actually. And do, what happens in a lot of practices, is that doctors are forced to become numb to their caring impulse upon realizing that there's a dividing line between quality care and going broke. And so, they churn through patients at a rapid rate because the only way to make it is quantity.
My wife was telling me that the office next to hers has four PA's. They each see 40 to 50 people per day. That's an average of 10 minutes per patient. That's not care. That's medical professionals being forced by a shit system to push on the cash register button as quickly as they are able to just to make it.
It is important to keep context in mind when thinking about some of these things. Imagine an office with a couple of MD's, a few PA's, a few medical assistants and one or two administrators. Collectively, this is a group of people with somewhere around, say, $1.5 million dollars in student loans to repay. They each have homes, cars, kids and other bills to support.
That sets-up a situation where it is impossible for that medical practice to exist below a certain revenue threshold. More accurately, below a certain profit level. If the insurance system they have to work with is shit, they have two options: Close the doors and everyone becomes an Uber driver or keep them open and run as many people as possible through the doors with a $10 to $50 per person gross profit probability per person.
No, do the math. Don't just react to this through emotion. People have to get paid for their work, just like you.
So, let's assume $50 per person average profit (not sure that's a good assumption, it depends on the practice). What I mean by "profit" here is what you get paid (not what you bill, because sometimes you don't get what you bill) vs. what it costs for a medical professional (say, a PA) to provide that service.
Now assume you can churn through 100 people per day. That means $5,000 per day in gross profit. If you are open 20 days per month, the gross profit is $100K per month.
You now have to pay, say $25K per month for rent, utilities, insurance and various other expenses. That means $80K per month. Let's say two MD's own the practice and each gets paid $25K per month salary. You are left with $30K in the bank. You likely have other expenses that will easily consume half of that, cleaning, legal, accounting, software licenses, IT, etc. You are now down to $15K. Which is a formula for going bankrupt.
What do you do? Well, you have to crunch through more people per day and try to maintain the same cost structure per patient. So, you try to see 150 to 200 people per day --if you can, not all practices can do that-- and pump them through as fast as possible. In other words, you cannot prioritize quality care.
Anyone thinking "Just provide better care and bill for it". It doesn't work that way. Say you decide to see only 50 patients per day. Obamacare shit plans are not going to magically pay you double for taking someone's pressure and temperature or going through a basic diagnostic check. The limit function here is that these plans are shit, they don't pay for quality care, they pay for delivering the fantasy of having medical care.
Not to mention the horrible problems of Medicaid/Medicare. That's another half dozen paragraphs.
Yes, everyone should have access to *quality* healthcare at a reasonable cost. No, that isn't possible if imbeciles in government make the decisions. These are the same people who, through incompetence and mismanagement can't seem to give us a world without war and misery. What makes anyone think they can actually deliver solid quality healthcare?
BTW, my wife and her partners finally had enough. They launched a boutique medical care office. They provide high quality care at a reasonable price. Patients are well taken care of, employees make a sustainable salary and nobody has to engage in the soul-crushing practice of treating patients like cattle.
Your per person figures seem low to me, and you're calling it profitability but then taking expenses out of that. Is that an industry term? Where does that number come from?
I would think at least before expenses it would be quite high as medical visits cost hundreds if not thousands of dollars.
This person has an argument but confuses so many basic terms that it gets lost. Revenues are not profits and profits don't include expenses. I'd be happy to read a cleaned up version but right now it's just a confusing mess.
> This person has an argument but confuses so many basic terms that it gets lost. Revenues are not profits and profits don't include expenses.
No. I think you might be confused.
I laid it out clearly. The basic profit has to do with the cost of an MD, PA, medical assistant and front office people interacting with the patient. In other words, the most basic labor cost layer. This is easier to quantify because you can count the minutes each person devotes to that patient.
The other costs are different. These are the business, office, insurance and other general operating costs that apply to the entire practice. In a back of the napkin calculation it is much easier to first subtract basic labor costs from the income per patient and then apply the other stuff in bulk.
I just tried to run through a ridiculously basic calculation to illustrate the point. That was not intended to be a accurate accounting report.
This is a complex multivariate problem. A simple example can't do anything but glace at the problem and, hopefully, inspire people to research and understand. ACA, Medicare, Medicaid and other aspects of our medical system have made things worse over time, not better. Having more people covered isn't equivalent to more people having access to good healthcare.
There are so many issues, for example, the fact that Medicare isn't insurance at all after 55, it's a loan! ACA shoved millions of people into Medicare. In a few years, we might start hearing of states seizing people's estates to pay for the money they owe under Medicare. It's crazy --absolutely insane-- that nobody talks about this and the media did not do their job and educate people as to the realities of this horrid system.
i already understand the economics, these types of systems exist everywhere, usually to the detriment of everyone. However, all they need to do is not deflect me from specialist care, so im not sure it applies 100% here. Check back in a month when i go to the office again and insist on seeing a specialist.
Not sure what you need a specialist for specifically, but for ~$300 you can get an appointment here in South Africa for any specialist you want. If I want to see a specialist, any specialist, I call their office, book, and X amount of time later, they see me. The reason I mention it is that SA has a medical tourist visa you can get, so flying here for your medical needs may well be within the realm of cost-effective for a lot of people in the Western world.
As a general aside. That you have to plead, motivate or beg your government to let you get healthcare from a specialist seems alien to me. I just don't even have the words - your government does not own you!
Mine was more of a general comment on these types of systems rather than an explanation for what you are going through. I have no clue why they are treating you in the way you describe. It might be interesting if you could ask them why they haven't referred you. Even more interesting if they gave you an honest answer.
my best guess is theyre trying not to "over-treat" me, the problem being its a different doctor every single time i go in, so if they all do that i never get anywhere if i have a real issue. also, at my office its tough to get followups with the same doctor. Note that its partly my own fault for backing down when they do deflect me though, but its hard to argue with a doctor when they say "lets just try this for now". Also, Fwiw i didnt downvote you, im not sure why you were downvoted.
> its hard to argue with a doctor when they say "lets just try this for now".
Yeah, I've run into "god complex" with doctors. It's a problem.
When my wife was in medical school she started to get sick and wasn't getting better. She went to probably half a dozen doctors. The outcomes were of the kind you describe "let's try this for now". In the meantime, she was getting sicker and sicker. Ultimately, she did her own research and was able to identify a potential diagnosis. She booked a visit with a specialist. As soon as she entered his office he said: You have a pituitary gland tumor, we have to operate immediately. This affliction presents very specific physical changes. She was in the hospital within a week. Six months later she was back to normal. The doctor said she was pretty much on a path straight to death and, had it not been for her self-diagnosis, that might have been the outcome within a year.
There are many problems in healthcare, cost and insurance are just two of them.
> Also, Fwiw i didnt downvote you, im not sure why you were downvoted.
I appreciate that. Right or wrong, for some reason I have always had this image of a petulant immature child downvoting on HN rather than engaging in conversation. Also right or wrong, I also attribute some of this to the serious failure of our system of education to graduate people who can actually think. They have elevated ignoring reality to a virtue and seem really proud of it. I avoid hiring these kinds of people like the plague, they have shit for brains.
WE NEED TO ELEVATE ACCESS TO HEALTHCARE TO A BASIC HUMAN RIGHT.
That does NOT happen without being critical of what we have.
We need a system where 100% of US citizens are covered and have access to healthcare at a reasonable cost for most of us and at no cost for those who, through whatever circumstance, cannot pay.
What I find interesting about these discussions is that people react badly to comments from someone like me --judging by replies and downvotes-- without ever asking questions to understand perspective. You are one of the few, in my many years on HN, who actually seems interested in actually having a conversation. This doesn't just happen with healthcare, climate change is another topic where people react with uninformed irrational emotion.
Basic concept:
If you want a better world, you have to hold politicians accountable and
you have to push for better results. If you don't, well, here we are,
at the edge of world war three.
Healthcare in the US is a disaster. And this is the case because of a million and one reasons. Nobody can point at a single variable that causes the entire train wreck. Unwinding this on an HN post is impossible. I might be off by a factor of two or more in saying that a full analysis of how we got here might require a 1000 to 2000 page report. So, clearly, for those jumping on my throat for a super-simple example, no HN comment will ever do this mess justice. Chill.
Chill, and understand that we ALL want the same things. The difference is that some of us also want sensible solutions with accountability. In order to improve things, you have to be critical of what you have where that criticism is warranted. You are not going to ever lose weight if you never accept the fact that you are eating too much, eating the wrong things and not exercising enough. The concept is simple, and it applies to lots of things in life, including healthcare.
Obamacare/ACA is a mess on top of our prior mess.
On top of that, we had a President that just lied to the people he was supposed to be working for at almost every level. My family's health insurance cost TRIPLED, from somewhere around $7K per year to over $21K per year. If you include the increases in deductibles and other factors, it's more like $35K per year. When you have a President promising families that they are going to save $2,500 per year and, in reality, they are spending $28K more for less care. Well, this is wrong.
BTW, discussing how much my wife's practice charges their clients is irrelevant. Not going there. My wife and I think it is an absolute travesty that such things have to exist. She would much rather have an open practice. However, she is interested in being able to provide quality care. The effects of Obamacare on medical practices doctors have created a situation where they have to churn through 30, 40, 50 people per day --per doctor-- for things to make financial sense. THAT is the travesty. and that is the consequence of adding Obamacare on top of a system that already was shit to begin with.
How do you get to what I said in the very first sentence in this comment?
We know how. It is conceptually simple. However, it is very hard to execute due to the fact that people don't seem to want to use honest critical thinking:
- You have to abandon ideological cargo-cult mentalities
- You have to be willing to go where the data takes you
- You have to accept that you might reach conclusions that are uncomfortable
- You have to accept that there might be realities that are very difficult to reconcile
- You have to leave politics behind you
- You have to be willing to make honest fact-based assessments
- You have to engage in solid root cause analysis, no matter where it leads
- You have to understand that there's a vast ocean of cost structures that drive this
- You have to understand that there's a vast ocean of regulatory issues that make this difficult
- You have to develop a model that honestly includes thousands of variables driving the problem
- You have to be willing to push reforms out to every problem branch identified
- You have to be interested in the objective, rather than political alignment
- You have to accept lots of things that might not be comfortable
- You have to commit not punishing one group in favor of any other
- You have to understand that the objective will require establishing limits where necessary
- You have to be clinical about the analysis, not emotional or ideological
- Etc.
The list is many times longer than these few points. This is not an easy problem. It is a million times harder when people are not willing to honestly identify what is wrong and go after relevant solutions. It is a million times harder still when people are willing to have politicians lie to us all and fuck things up deeper and wider because they want to protect their ideological alignment.
As examples, I'll give you two problem branches that need to be chased. These are just two of the, likely thousands, we should address with political neutrality and devoid of emotion. Because, frankly, some of these things boil down to just math, accounting.
Every business has a cost structure. Healthcare is not an exception to this simple truth. If you want healthcare cost to come down, you have to attack the cost structure. If you want to sell a burger for $5, the ingredients can't cost you $10.
NO. NO. NO. Insurance companies are NOT THE PROBLEM. They are the effect. The cause is the entire cost structure that drives what they have to do.
Simple example: If you live in a town where everyone is having car accidents at three times the rate of the next town, insurance companies are going to have to charge more. It's simple math. Healthcare is no different.
Where is the cost structure. As I said, two examples. I'll boost that up to three:
1- Cost of education
2- Cost of litigation
3- Regulatory burden
1: The cost of education in this country is ridiculous. At the base of the many branches of the cost structure that drives healthcare costs at every level is the cost of education. Every medical practitioner, scientist and engineer working within the medical industry has, as their baseline, very large student loans to support.
Nobody can work for a salary that does not allow them to cover their own personal cost structure and beyond that, save money and have a life. Everyone needs to retire at some point. You can't work for exactly the money you owe every month. Your "personal enterprise" has to generate a profit.
2: Investigate the amount of money medical practitioners, clinics, hospitals and medical technology companies have to spend on insurance and protecting themselves from the insanity that our litigious society can be. These costs are far from trivial. And, yes, these costs make it into the business equation that drives the cost of healthcare.
3: While regulation and oversight is important, it is obvious that things have gone way too far. As a personal example, a couple of decades ago I became interested in developing a specialized hearing aid for people with a somewhat rare (1 in 100K population) condition called "Acoustic Neuroma". I was ready to invest a significant amount of money to develop this solution. I quickly discovered the FDA approval of this relatively simple in-ear device would cost a minimum of $10MM and as much as $25M (or more). I just dropped it. It made no sense.
Drug and medical product companies have to spend incredible amounts of money to deliver products into the healthcare system. These costs, once again, have to be passed on.
There's so much to unpack. Like I said, thousand of pages and analysis. This is impossible without being brutally honest about root-cause analysis.
By the time an insurance company becomes involved in calculating a premium, all of the above, and much, much, more, have populated the variables they have to use to get to that premium. They are often painted as the culprit. This is so wrong it is probably over three standard deviations away from the mean of the analysis of the healthcare cost structure.
Final example: Our food is shit. Our own food is making people sick. Americans are being poisoned by the very food our FDA (and whoever else) allows onto our shelves. How can healthcare costs possibly be lower when what you start with is a population who's default condition could be labeled as poisoned and unhealthy as fuck due to the food we consume.
No, insurance companies are the least of our problems. That's what Obamacare and every single other proposal from any politician on any side has always missed. They focus on insurance costs and ignore the massive iceberg of root causes underlying the problem.
If we want healthcare to be elevated to the level of a basic human right, we have to be honest about where we are and find real solutions.
Honestly, I don't have any problem with this, and I see it as a great thing. 95% of the time when I go to the doctor it's something routine and basic, e.g. I just need someone to diagnose my cold/flu/infection etc.
My question, though, is where are all the "savings" going if so many visits are now seen by lower paid professionals? I was referred to a sleep study, where a PA or nurse practitioner just proceeded to ask me some basic questions from a form to see if I qualified for the study. She added practically nothing to the process (literally she was just reading questions from a form) and then charged my insurance company $200 for 15 minutes of her time. The whole thing was insane. That visit should have cost $20 max, yet people are lining their pockets at every step.
That my insurer gives me significant financial incentive to see an NP at an urgent care clinic vs. going to the ER suggests the cost savings are translating into lower premiums, all else being equal.
Why go to the doctor to be told it's a flu or a cold? There's nothing to do but treat yourself well and wait, right? I wonder what portion of visits are for common viruses.
Because if it's flu and it's early enough there is treatment (Tamiflu), and it's helpful to differentiate from things like strep, where there is also treatment.
I get annoyed when I send a message to my doctor and it takes 3 back-and-forths to get a message from him, and not the nurse. The nurse's advice tends to be along the lines of what I would find with Google, some semi-relevant copy/pasted advice. I get the sense that they make the messaging system useless so that you have to sign up for appointments/video appointments. They know that for GP appointments, you only pay 30 bucks or so, but they get paid 10x that by your insurance company.
I try to resist this, partly because I generally don't need an appointment to answer a simple question, and partly because this is one of the causes of rising insurance premiums.
They don't want to solve your problem over a messaging system - and prefer you to come in - the MD can't bill anyone for answering you questions over the phone or even via messaging - which is why they push for an appointment.
Not sure what line of work you are in, but are you willing to answer endless emails and or voice mails from customers, all for free? I know I am not - and while you personally may only ask one question a year, a typical MD may have a panel size of 1000 to 3000 patients (at least the ones I know); multiply one question per patient by 2000 patients, and all of a sudden you find out you worked for free for most of the year.
Maybe if insurance companies had a billing model that allowed the MDs for charge for this type of 'support', that made them some money it would be workable - but I can't blame them for not wanting to give out free care this way.
> Not sure what line of work you are in, but are you willing to answer endless emails and or voice mails from customers, all for free?
It's common practice to answer emails and take calls from customers and not charge them for it in many industries. If you have 3000 patients, and you spend 3 minutes/patient/year on these interactions, then you spend ~30 minutes a day answering emails or leaving voice mails which is pretty standard.
No way a typical question takes 3 minutes to answer; just by time you read the message, pull up the chart, read the chart, make the call, talk with the patient and then document the outcome of the call back into the chart, you are in it for 15 minutes at least … not to mention the context-switching time you need as you move from one task to the next.
And I disagree that it is ‘common’ in other industries - ever try to get on the phone with an Amazon or Google or Facebook senior level developer to solve a technical problem -without being on a paid support plan? Sure, you might get some low level clerical person or entry level tech support, but you aren’t getting to those senior folks for free.
The estimation wasn't 3 minutes a call, but that each patient would take an average of 3 minutes of time in this communication channel. I imagine most patients wouldn't want to email their doctor every year, and that those that ask too many questions would be directed to appointments. I can think of a handful of times in my life that emailing a doctor/nurse would have been the most efficient use of time. Mostly the questions would revolve around "I'm having these symptoms, should I come in for a visit or should I stay at home."
I've (acting in the role of senior developer) directly addressed support tickets that were generated by user support emails and have even directly communicated with users in phone calls as standard level support. Not at Amazon, Google, or Facebook but in Fortune 500 companies and in B2C.
If you aren't talking to your users, how do you maintain empathy?
DO you actually have any reason to believe doctors spend more than 2 minutes on each message? I know a few doctors quite well and I've seen them go through the messages. They do not spend much time on each one at all.
This is a problem they're working on solving, I think. The hospital group I've been using in the Portland area recently announced that patient-initiated messages that take more than a few minutes, and require e.g. digging through a chart, are billable to insurance: https://www.legacyhealth.org/messages
MyHealth is just what this hospital system calls their patient-facing Epic portal.
If they don't want to have a way to ask a question, they shouldn't have one. The assistant who answers questions has literally never provided value. She is just wasting her time, and mine. I would actually prefer if they didn't pretend you could get useful info through the "ask a non-emergency medical question" option.
And as tssva said, these questions are often follow-ups on topics discussed at an appointment, so it's not untethered from revenue.
They are willing to answer some questions, I.e. the ones a nurse or medical assistant can answer; it’s the medical questions that only a provider can answer that they need to be able to bill for.
IME they are roughly as useful as Google, but with much greater latency. They are also wrong not-infrequently, either because they misunderstood the question, or because they gave an incorrect response.
When I have sent a message to my provider it has been because I had a follow up question because the direction given during a visit was unclear once it came time to implement it or there was an issue with a prescription (for instance a particular drug ended up not on my formulary and an alternative needed to be prescribed). The last time I sent a message is because the doctor said he was prescribing a medication and it appeared in my post visit summary but the prescription never was submitted. Even in these cases it can be like pulling teeth to get a response.
"Maybe if insurance companies had a billing model that allowed the MDs for charge for this type of 'support', that made them some money it would be workable - but I can't blame them for not wanting to give out free care this way."
Most primary care physicians today work for a base salary plus incentives. The base salary is the compensation for dealing with this kind of support.
I listen to a veterinarian frequently complain about people trying to skip the exam fee via various methods -- and the owner probably doesn't even know that what they're doing is a problem.
A free diagnosis over the phone is a lost exam fee. A health certificate over the phone -- exam fee. A vaccine appointment that turns into a sick pet and the owner just has some question -- exam fee. Trying to skip an exam before boarding: exam fee.
> the MD can't bill anyone for answering you questions over the phone or even via messaging
My patient portal clearly states that the Corporation can bill for questions sent as messages.
The Corporation by the way is a religiously-affiliated non-profit whose CEO earns tens of millions a year. In the past couple of years they have stopped doing vaccinations and blood draws. We go to the drugstore for those now.
So, why stay with them? The alternatives are even worse.
My OD (I have an anti-hippy bias, so I checked and the online sources claim MD and OD are really not different; not sure if my bias is actually correct, maybe MDs are better?) literally googles symptoms. Thanks, I could do that myself without paying $150 for the visit...
What I would really prefer is not a non-physician - it's the ability to get any medicine without prescription + without liability (if you take something that works as intended and harms you, no suing for damages), and the ability to easily get tests, specialist appointments and things like x-rays for cash (e.g. I had a complete change of treatment after having to insist on some test that they didn't think was needed... more than once, usually for injuries).
People should be able to direct their own care as long as they pay for it.
Interestingly, the best physician I had (in terms of being correct and helpful, and no googling) was also the most open to that. When I asked about some drug once he was like, "I think the evidence you refer to is weak, and it won't do anything for you, but if you really want I can prescribe it"
My OD refused to order an online gut test (that for some idiotic reason has to go thru a PCP) cause "I don't know what this test is, you don't need it". I was kinda tempted to say "well maybe you should google it, as usual"
Some states have weaponized this. In Florida for example a huge amount of offices are staffed by NPs but they have passed legislation to lock certain groups of people out from receiving care from them as they are the target of the current political hot button issue. Being told you need to find an MD when most offices won't let you see one and may not even have one in the building at the time is laughable.
Because PA time is cheaper to the provider than MD time. Give it a few years and a trip to the doctor's office will mean using a touch screen a-la-mcdonalds to describe your symptoms and then the first-line medication pops out of a drawer.
I'm pretty jaded with our (US) healthcare system. As long as you stay on the happy path it's fine, but if you stray from that, good luck. Over the last few years I was given antibiotics for a gut infection, a lung infection, and currently a sinus infection. None were improved by antibiotics, but no doctor was willing to do a culture to see what the infection was before prescribing antibiotics because that's the happy path (most infectious are bacterial). I think it might be a systemic fungal infection (I've also had bouts of what I think is thrush), but that possibility is immediately rejected without investigation because 'only immunocompromised people get fungal infections'. Similar for SSRIs. Asked the shrink why SSRIs versus something else - 'got to start somewhere'. Asked them why one SSRI over another, same answer.
Throwing shit at the wall to see what sticks is fine if the cost of being wrong is just the list time of needing to recompile your code. It's 100% not ok when being wrong means fucking up your tendons or making you suicidal.
> Similar for SSRIs. Asked the shrink why SSRIs versus something else - 'got to start somewhere'. Asked them why one SSRI over another, same answer.
At the risk of over-simplifying - and certainly not justifying blasé, ambivalent answers... the brain is a very complex organism. And we have barely scratched the surface of how it actually works. Most of it, we just don't know.
So, from this to psychiatric drugs - SSRIs, MAOIs, SNRIs. Read the drug information sheet in the packet. Not just the "standard" paragraphs on side effects and warnings. All prescription drugs are required to specify "how" the drug works.
For a startlingly high number of these drugs, this paragraph starts with the words:
> It is not understood precisely how [drug] works. It is believed that it does X, Y and Z...
(emphasis mine).
We know that they can work for some people and not others. But while we can perhaps make decent educated guesses, a lot of the time, we can't, because, hell, we don't really know how it even actually works, so we can't know it will work for you.
Disclaimer: while I am medically educated and work as a prehospital provider, I'm not a MHP, despite my use of 'we' in the previous para.
There's nothing actually stopping you from getting a fungal culture yourself. The turnaround time is over a month though. Unless you're at a huge hospital they just farm it out to Labcorp and the like and you can buy direct. Like it makes sense, if it's high-probability bacterial you might as well try the z pack first. It's faster to just treat it and see than to test if it's bacterial.
Also for SSRIs there's nothing to test, you just try them under medical supervision and if they help they help. There is an experimental DNA test that might be able to narrow down the antidepressant options but unless you're struggling to find one that works for you it's usually not worth bothering.
Medicine is crazy advanced in some specific areas but for the long tail we're not that far from leeches.
Honestly I’m surprised the number isn’t already much higher. For at least the last 15 years most healthcare providers I deal with try to get you into a nurse practitioner or physicians assistant, and most have quite a few more of those than MDs and DOs.
Perhaps that’s a West Coast thing, though, and it’s not as common in other parts of the country?
MDs are limited in supply by the AMA. NPs and PAs are not, and for routine cases, sore throats, minor injuries, vaccinations, routine physical exams, etc. there is no reason an MD needs to be involved.
And for the routine stuff I often have a pretty good idea what's ailing me from past experience and I just need someone to write up the prescription again for whatever's worked well before. I have no problems with seeing an NP for that.
In some cases, an NP may have more current experience with figuring out the routine stuff than an MD who's a bit more removed from that kind of practice now.
Perhaps I’m just getting crap doctors but I’ve had so many bad experiences even with specialists that it seems nearly impossible to get help with anything past super basic issues. Over a year ago I had a dive related injury to my ear and I can’t get any help past “everything looks great” from any ENT. For context I can barely stand to be in many social situations without earplugs in one ear because I’m hearing some frequencies extremely loud and distorted and in my head instead of from their source.
What tests did you get? Only thing I can think of when you say “everything looks great” is an otoscope exam.
But if they did audiometry, CT temporal bones, MRI IAC and those are normal? Then those are tough breaks because they can’t fix a problem they can’t see.
Only thing I can think of is maybe a subtle/occult ossicular chain disruption. Is there a little incudomalleal diastases?
I'd like to see every visit for a chronic illness attended by a medical professional, the patient who is paying for the visit, and another patient who is farther along in the progression of that chronic illness.
The input of someone who has been there and seen their disease progress farther is valuable.
It's getting harder to see a doctor, they only let you see a physicians assistant, Who acts like a doctor, but isn't. I understand they meet with a doctor later to discuss the case, but… It's just not the same. A physicians assistant is not a doctor
I hope AI replaces most of them. My experience in the ER, at least in Canada. You're not getting a doctor. You're getting a doctor's 10 minutes attention, while they're running around from patient to patient. Don't expect your diagnosis to be anything more then the most obvious, A -> B diagnosis. When your problems conflate from the drugs they just wrongly gave you, and add in random screw ups, staff and equipment shortages. You will be getting reactive medicine, as your condition worsens. A death spiral, from which you will not escape. Many will be transitioned to the after life in hospital in this way.
Give AI better diagnostic testing data, and AI will make better care decisions then any doctor. The doctors/nurses will still be needed to take care of the patient. But it seems pretty clear that AI will be making the decisions, in the short future.
Personally I’d be happy to see a PA IFF my copay is less.
Why should I pay my standard copay to see a PA for a regular visit, or pay the same much much higher specialist copay if I’m seeing a PA instead of an actual specialist MD.
Related: I was shocked when I tried to get a COVID booster in NY State and they told me they didn’t have a registered nurse on staff that day so they couldn’t do any vaccinations.
In California, all of my vaccinations have come from phlebotomists, and it seems that pharmacists can also do them here.
WA state during COVID basically authorized EMTs to administer the vaccine. I mean it's literally "find this landmark on the lateral arm, steadily insert needle into muscle tissue, depress plunger, withdraw needle, massage site, bandaid". They had to do a 30 minute "training" on it.
Most MDs are just prescription-gates. This is a good thing because we have other reasons why we can't make more people to let you in the gate, so it's best that we just use different non-physician staff.
I can match the performance of many of these people with a modern AI today, for the things I've needed a doctor for.
The things I can't do are effective surgery and emergency care. They're good at that.
On the other hand, a lot of what I do doesn't require 12 years of training, so I am sympathetic to making health care more accessible. I am also a bit jealous that my non-MD colleagues can easily switch from e.g. being a primary care PA to being dermatology PA, whereas as an MD I'm pretty much stuck in my specialty unless I go through another 4+ year residency. Instead of MD-training getting shorter to compete, it's actually getting longer in many cases. Residency trainings are getting longer not shorter for a number of specialties (e.g. neurosurgery, interventional cardiology, pediatric hospitalist).