I remember when I was a kid, doctors were so interactive and really took time to get to know you and talk to you, learn about what you’re going through and explain things. Now as an adult, it’s been nearly impossible to find a doctor who is willing to take any amount of time to sit down, explain things, show any sort of compassion or empathy at all.
I suffer from acid reflux, and in order to diagnose that, they basically put a tube down your throat, it’s called an endoscopy. You have to be fully sedated with anesthesia and take nearly an entire day off of work because the way the anesthesia affects you, you can’t drive and someone has to drive you. Well for many years now we’ve had this other procedure which is a tube, but they put it through your nose instead. There’s been lots of research papers about the use of it, it’s used in other countries as a procedure regularly. So I asked several gastroenterologists if they offer the procedure and every single one of them said no, and would not provide any additional information or insight as to why you have to be completely sedated and pay thousands upon thousands of dollars for expensive anesthesia. I am simply blown away. It makes no sense. A research tested method that has been written about for about a decade now in actual research studies by board certified medical physicians, and no one offers it. Literally no one, and they won’t even consider it.
I’ve also been through at least several primary care physicians because the ones I have seen are so short and don’t really take time to get to know you at all. They just pop in, ask you a handful of questions and leave, if your test results come back with anything abnormal, they say it’s nothing to worry about, they don’t want to take any extra time to help look into anything or diagnose you… like wtf?
It just seems like doctors these days are out to get you to spend as much money as possible and do the absolute bare minimum for you in return. And now we have direct primary care options where you can circumvent insurance entirely, pay your doctor thousands upon thousands of dollars a year for the same level of care that we had in the '90s. But now you have to pay out of pocket for that in addition to your insurance. Wtfffff
Our Healthcare system is fucked. You really need to be your own advocate and do your own double-checking. Think about how many people are bad at their jobs, and realize that plenty of those people are doctors.
I’m lucky to have “inherited” my parents’ doctor. She is extremely compassionate and gets deeply involved in you and your concerns on every visit. So much so that she is infamous for being behind schedule, to the point where we fully expect to wait for an hour to see her after the scheduled appointment time. She makes up for it by talking with you for as long as you want.
She also hasn’t accepted new patients for like 4 years… so yeah, I guess all the good ones are taken.
To start off, I’m sorry to hear that you’re not receiving the healthcare you need. I recognize that these words on a screen aren’t going to solve any concrete problems, but in the interest of a fuller comprehension of the USA healthcare system, I will try to offer an answer/opinion to your question that goes into further depth than simply “capitalism” or “money and profit” or “greed”.
What are my qualifications? Absolutely none, whatsoever. Although I did previously write a well-received answer in this community about the USA health insurance system, which may provide some background for what follows.
In short, the USA healthcare system is a hodge-podge of disparate insurers and government entities (collectively “payers”), and doctors, hospitals, clinics, ambulances, and more government entities (collectively “providers”), overseen by separate authorities in each of the 50 US States, territories, tribes, and certain federal departments (collectively “regulators”). There is virtually no national-scale vertical integration in any sense, meaning that no single or large entity has the viewpoint necessary to thoroughly review the systemic issues in this “system”, nor is there the visionary leadership from within the system to even begin addressing its problems.
It is my opinion that by bolting-on short-term solutions without a solid long-term basis, the nation was slowly led to the present dysfunction, akin to boiling a frog. And this need not be through malice or incompetence, since it can be shown that even the most well-intentioned entities in this sordid and intricate pantomime cannot overcome the pressures which this system creates. Even when there are apparent winners like filthy-rich plastic surgeons or research hospitals brimming with talented expert doctors of their specialty, know that the toll they paid was heavy and worse than it had to be.
That’s not to say you should have pity on all such players in this machine. Rather, I wish to point to what I’ll call “procedural ossification”, as my field of computer science has a term known as “protocol ossification” that originally borrowed the term from orthopedia, or the study of bone deformities. How very fitting for this discussion.
I define procedural ossification as the loss of flexibility in some existing process, such that rather than performing the process in pursuit of a larger goal, the process itself becomes the goal, a mindless, rote machine where the crank is turned and the results come out, even though this wasn’t what was idealized. To some, this will harken to bureaucracy in government, where pushing papers and forms may seem more important that actually solving real, pressing issues.
I posit to you that the USA healthcare system suffers from procedural ossification, as many/most of the players have no choice but to participate as cogs in the machine, and that we’ve now entirely missed the intended goal of providing for the health of people. To be an altruistic player is to be penalized by the crushing weight of practicalities.
What do I base this on? If we look at a simple doctor’s office, maybe somewhere in middle America, we might find the staff composed of a lead doctor – it’s her private practice, after all – some Registered Nurses, administrative staff, a technician, and an office manager. Each of these people have particular tasks to make just this single doctor’s office work. Whether it’s supervising the medical operations (the doctor) or operating/maintaining the X-ray machine (technician) or cutting the checks to pay the building rent (office manager), you do need all these roles to make a functioning, small doctor’s office.
How is this organization funded? In my prior comment about USA health insurance, there was a slide which showed the convoluted money flows from payers to providers, which I’ve included below. What’s missing from this picture is how even with huge injections of money, bad process will lead to bad outcomes.
In an ideal doctor’s office, every patient that walks in would be treated so that their health issues are managed properly, whether that’s fully curing the condition or controlling it to not get any worse. Payment would be conditioned upon the treatment being successful and within standard variances for the cost of such treatment, such as covering all tests to rule out contributing factors, repeat visits to reassess the patient’s condition, and outside collaboration with other doctors to devise a thorough plan.
That’s the ideal, and what we have in the USA is an ossified version of that, horribly contorted and in need of help. Everything done in a doctor’s office is tracked with a “CPT/HCPCS code”, which identifies the type of service rendered. That, in and of itself, could be compatible with the ideal doctor’s office, but the reality is that the codes control payment as hard rules, not considering “reasonable variances” that may have arisen. When you have whole professions dedicated to properly “coding” procedures so an insurer or Medicare will pay reimbursement, that’s when we’ve entirely lost the point and grossly departed from the ideal. The payment tail wags the doctor dog.
To be clear, the coding system is well intentioned. It’s just that its use has been institutionalized into only ever paying out if and only if a specific service was rendered, with zero consideration for whether this actually advanced the patient’s treatment. The coding system provides a wealth of directly-comparable statistical data, if we wanted to use that data to help reform the system. But that hasn’t substantially happened, and when you have fee-for-service (FFS) as the base assumption, of course patient care drops down the priority list. Truly, the acronym is very fitting.
Even if the lead doctor at this hypothetical office wanted to place patient health at the absolute forefront of her practice, she will be without the necessary tools to properly diagnose and treat the patient, if she cannot immediately or later obtain reimbursement for the necessary services rendered. She and her practice would have to absorb costs that a “conforming” doctor’s office would have, and that puts her at a further disadvantage. She may even run out of money and have to close.
The only major profession that I’m immediately aware of which undertakes unknown costs with regularity, in the hopes of a later full-and-worthwhile reimbursement, is the legal profession. There, it is the norm for personal injury lawyers to take cases on contingency, meaning that the lawyer will eat all the costs if the lawsuit does not ultimately prevail. But if the lawyer succeeds, then they earn a fixed percentage of the settlement or court judgement, typically 15-22%, to compensate for the risk of taking the case on contingency.
What’s particularly notable is that lawyers must have a good eye to only accept cases they can reasonably win, and to decline cases which are marginal or unlikely to cover costs. This heuristic takes time to hone, but a lawyer could start by being conservative with cases accepted. The reason I mention this is because a doctor-patient relationship is not at all as transactional as a lawyer-client relationship. A doctor should not drop a patient because their health issues won’t allow the doctor to recoup costs.
The notion that an altruistic doctor’s office can exist sustainably under the FFS model would require said doctor to discard the final shred of decency that we still have in this dysfunctional system. This is wrong in a laissez-faire viewpoint, is wrong in a moral viewpoint, and is wrong in a healthcare viewpoint. Everything about this is wrong.
But the most insidious problems are those that perpetuate themselves. And because of all those aforementioned payers, providers, and regulators are merely existing and cannot themselves take the initiative to unwind this mess, it’s going to take more than a nudge from outside to make actual changes.
As I concluded my prior answer on USA health insurance, I noted that Congressional or state-level legislation would be necessary to deal with spiraling costs for healthcare. I believe the same would be required to refocus the nation’s healthcare procedures to put patient care back as the primary objective. This could come in the form of a single-payer model. Or by eschewing insurance pools outright by extending a government obligation to the health of the citizenry, commonly in the form of a universal healthcare system. Costs of the system would become a budgetary line-item so that the health department can focus its energy on care.
To be clear, the costs still have to be borne, but rather than fighting for reimbursement, it could be made into a form of mandatory spending, meaning that they are already authorized to be paid from the Treasury on an ongoing basis. For reference, the federal Medicare health insurance system (for people over 65) is already a mandatory spending obligation. So upgrading Medicare to universal old-people healthcare is not that far of a stretch,
I’m not qualified to say if this is accurate but thanks for putting in the effort to write it!
Judging from my own doctors experience, they are way overbooked. Can’t get a personal experience when they gotta see a couple dozen more people the same day.
The US healthcare system is built around money and profit. A cheaper procedure which does not require general anaesthetic costs less, and reduces profit. That can be beneficial to the providers but bloat is incentivised in the US healthcare system as providers battle with insurance companies for money. Crudely healthcare providers don’t care about saving you money; they want to take as much money as they can get.
Meanwhile, countries with tax funded health care opt for the most cost effective procedures, investigations and treatments. The incentive is to reduce costs and offer the most effective things to the most people possible. That can also sometimes have negative side effects if not carefully regulated but in such systems generally Doctors advocate for the best procedure and best medical practice, as they themselves do not directly benefit financially from which procedure is pushed. The downside is you do get the opposite side of things where patients are dissuaded from things as they’re not deemed cost effective by those who control the spending.
I’ve only tangentially heard about this, but another issue is that doctors in the US don’t have to, and aren’t encouraged to keep up with recent research.
Combine that with a medical education system that hasn’t changed drastically in 70 years to keep up with that new research and most US doctors are just out of date.
Our ICD -10 is about a decade behind WHO, iirc.
There is some variation by state but in the US almost all licensed medical professionals are required to participate in continuing education to keep their license.
Which is hit or miss. I’ve been in those CE courses and seminars, and they range from informative and exciting to literal time-wasting. An example: What doctor needs to care about log-rolling patients and backboarding them? That’s something a firefighter or EMT does.
Well yes, the onus is on the healthcare provider to pick CME that’s relevant to them.
- Too many patients, not enough doctors.
- Private insurance and intrusive controlling software: the doctor is limited in what they are allowed to prescribe, they have to check all sorts of boxes, and they have complex computer forms to fill out. They are too busy with the laptop to have much attention left for patients.
- Non-compliant patients who “do their own research” on the internet.
Most doctors I know don’t even want to go to a doctor. They know all the providers are shit talking their patients and just doing the best they can in a very broken system.
Late stage capitalism and medical misinformation have made the doctor-patient relationship almost adversarial.
Non-compliance is often because it’s unaffordable, even diet.
Yes, I would not dispute that. Medication and PT is too expensive for many. And many people live in “food deserts”. Whatever the causes, it’s highly frustrating for doctors.
You know enough doctors well enough to know that most of them don’t want to go to a doctor?
Read what I said. Most doctors I know. I know several. I worked for a hospital system, and I currently have a healthcare adjacent job. We talk about these things, yes. I don’t claim to speak for all doctors.
Non-compliant patients who “do their own research” on the internet.
In the US they advertise drugs directly to us, we’re expected to do our own marketing-guided research to speed along the transaction.
You’re right, it’s a complex issue that my bullet point just kind of touched on (and lacks nuance). In many ways, patients are required to navigate their own health care and be their own champion and advocate It gets messy when we encounter misinformation that tells us what we want to hear, but isn’t based on solid science.
They are too busy with the laptop to have much attention left for patients.
I’m a nurse practitioner, and can confirm this: I spend at least half of my time tapping away at the computer, checking boxes, and completing often-redundant forms for insurance and regulatory compliance and whatnot. It’s really frustrating, and there’s a lot of room for improvement.
It’s astonishing (and insane) how private health insurance has taken over the entirety of health care at every operational level.
This is a type of insurance that started out decades ago as an unusual perk for executives. They called “major medical”. Nobody thought that much about it. In those days most working people simply could go see a doctor and just pay with cash or check.
Now, their tendrils have wrapped around everything from the lowest-paid pharmacy tech to most expensive surgeon…and everything and everyone in-between.
The board rooms of private health insurance companies have a gigantic dragon by the tail, and they have no damned clue what to do with it.
I’ll also add that I very much appreciate nurse practitioners. I have to go in every 6 months for routine “old man maintenance” checkups, and there’s really no need for me to see a doctor for these types of visits. You’re filling a much-needed role. (And I’m sure you do a lot more than just “old man maintenance” consults, LOL).
Also a very litigious society. Even if they mean well, going off the page and trying to figure out a “Haus” solution is just putting themselves at risk.
They have to check all the boxes for your insurance. They have to check all the boxes for their own malpractice insurance. Even if they followed procedure, they might get dragged through the legal system to defend themselves if a client feels wronged.
That turns you, the client, into a number in a dispassionated machine.
And I don’t have a solution to it.
Edit - that was a bit too bleak. There are a lot of doctors trying their best to retain humanity in a system aimed at destroying it. The whole med school journey is aimed at weeding the people out who are just in it for the money. It’s designed to gatekeep the industry to require a massive amount of passion to get your foot in the door. But the realities of the industry do their best to squash that.
Thank you, you bring up some important points. Malpractice lawsuits and insurance are significant problems, too.
In my limited anecdotal experience as a patient of (and support staff for) doctors I have met some very compassionate and capable doctors and nurses. I don’t see health care providers as being the problem with our system. It’s primarily the private health insurance companies and PBMs. They are the main reasons why we can’t have nice things.
I’m not in the USA but this trend is also happening in other countries. I guess USA feels it more because of the already punitive health system.
I’ve been thinking in recent times about pharmacies. 20 odd years ago, pharmacies used to deal with things too severe to put off, maybe not severe enough to see a doctor for. Now pharmacies are about “wellness” which is marketing crap to make more money. Middle aged woman feeling unwell? Cut your hair short and dye it 3 different colours. You’ll look young and feel young! But they’re still unwell and still have sore joints etc. Pretty depressing to think about.
U. S. medicine is corporatized. You are visiting a corporate store front, not a doctor’s office.
If you want personalized medicine from doctors who give a shit, you’ll either need to find a small clinic that gives a shit or you’ll need to get your procedures done for cash while on vacation in Europe.
Medical tourism can sometimes be the same price (including travel) as staying in the U.S and dealing with insurance.
I find a young doctor in a suburb almost 10 years ago. He’s been great and he listens to me, has no problem taking my suggestions into consideration, and he often admits when he doesn’t know something and will literally Google it right there in the room. It took as while to find someone I like, but it was worth looking.
Afaik it has to do with licensing regulations and litigations…
A doctor is licensed to practice by the state, and must carry insurance on a state-by-state basis to acquire a license to practice.
The problem is that if you get sued 3 times you get blackballed by the insurance industry in your state and the insurance companies won’t insure you.
You see a lot of doctors moving states often, its often because they became un-licensable in their former areas.
I have limited industry experience and have talked to quite a few doctors who were indeed a bit distant and hands-off in their practice for this reason alone.
Just fyi, the sedation is usually not medically necessary. I have had it (as well as a colonoscopy) done without, just got a spray to numb the throat for a short while. It’s not pleasant, but I found it bearable and it’s much nicer to just walk out and drive home on your own. If necessary I could still have told/signaled that I want sedation after all during the procedure. Propofol works within less than a minute. In that case they would have called someone to pick me up.
That said, I do live in Germany, so money does not play as big a role as in the US when it comes to healthcare. And the doctors and their staff were exceedingly nice and caring.
Maybe, if you believe you can bear it, and if acid reflux does not make it painful, ask to do it without sedation next time.
I know the sedation is not medically necessary, lots of places outside the USA don’t do it at all. Japan, Europe, etc. There’s research studies that even show non sedated procedures are being used and have been favorably received. Every single doctor I’ve asked about them, they outright refuse to do it without sedation or anesthesia. Guess how much that costs? Thousands of dollars, with insurance. So I have to pay about $5,000 at least out of pocket a year for insurance, then I have to pay $3,500 for this procedure, and the last two that I’ve gotten, they haven’t shown anything. So naturally I’m like okay, can we do a less invasive one without sedation, like they do in other countries? Absolutely not. We won’t do that, and we don’t know anyone else who will ever do it. Like what the hell is this?
This is not medical advice, just some general comments regarding your post.
An upper endoscopy is rarely needed for evaluation for uncomplicated acid reflux. It alone is not even an appropriate indication for an upper endoscopy, except for a specific patient population and that’s to screen for a disorder related to acid reflux.
Unsedated endoscopies are uncomfortable for the patient and the physician. They suck. Many gastroenterologists will do it, but there’s at least some reason for why others won’t. Doctors in countries that do a lot of unsedated upper endoscopies do so because these patients have them much more often (screening for a much higher risk of gastric cancer in, say, Japan). But the way, whether you get anesthesia from an anesthesiologist or no anesthesia doesn’t affect how much insurance pays the endoscopist.
The tube you’re referring to sounds like pH monitoring with an impedance catheter. It stays in your nose for 24 hours, and generally isn’t more convenient than an upper endoscopy. It’s not required for diagnosis of simple acid reflux, and serves a completely different purpose than an endoscopy. It’s used mainly when the diagnosis is in question. Most gastroenterologists aren’t sufficiently trained to read these studies anyway. These patients are usually referred to high volume centers.
Sedation for upper endoscopy isn’t even necessarily the norm throughout different countries. It is in the US, but I had my first upper endoscopy in Japan, and they just numbed my throat.
They’re paid by the job, not by the hour.
IOW they get paid a fee for the visit, a fee for any tests, etc.
Thank modern insurance for that.
They do not get paid any extra to have a conversation with you or to spend actual time with you to discuss whatever issues you are facing. I think the caveat is more that the GP/PCP is more likely to speed by you as they’ve got 20 more patients to see that day and a specialist will probably spend more time with you because they’re only trying to work on one issue rather than deal with weird pains, blood tests, talk to you about your weight, etc…
Doesn’t help that the insurance is the real employer and superior physician as they ultimately decides the treatment too
Because medical care in the US places profit over people
In the US, unlike most other countries, medical doctors are most at risk for suicide.
Source?
I’m not the person you asked but I just did a quick search. I don’t know if it’s more prevalent in the US or not, but here is a scientific journal on the subject:
“The medical profession faces a critical challenge with the mental health of its practitioners, leading to an alarming increase in suicide rates among healthcare workers (HCW).”
The CDC reports rates pretty well below the general average, at least for 2021.
why you have to be completely sedated and pay thousands upon thousands of dollars for expensive anesthesia
I’ve got this one, my dude. It’s because American healthcare is mercenary and broken. When I had, um, a similar ‘retroscopic’ test from the other end, I was under a general, needed a buddy at the end, out for a few hours, etc; seems to be about the same.
Cost: $0
Premiums/subscription: $0
Material costs: $0 also
Like, I pay my income tax and the healthcare is just what’s there – we run it on income tax only, and before covid it was apparently funded adequately. Yeah, we’re short on doctors right now as many of them left the field because of aggressive ‘mah raghts’ hillbillies whipped into a frenzy by the conservatives, but they run the triage and they keep their appointments. It’s so different from when I lived in 07974.
