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Why are doctors so hands off and unhelpful in the USA?

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

105 comments
  • Not a doctor and just talking out my ass, but I'm assuming part of it has to do with patient workloads and dealing with insurance companies, they're just not incentivized to really take any time with patients, just get 'em through the visit, check whatever boxes they need to, and move on.

    But yeah, I very much have had the same experience for the past 10 years or so with my same doctor, it just feels absolutely useless going to them for anything. It takes alot for me to go to the doctor for anything or to bring anything up even with the doctor if it's not life-threatening. I'm not a hypochondriac by any stretch, I just try to keep an eye out on my health and if I notice my body doing something out of the ordinary, I just ask about it to see if it means anything.

    Before my regular check-up though I'll kind of bank up whatever questions or oddities that I've noticed, things that I figure I can bring up and see if maybe it's a sign of one thing or another. Most of the time when I mention anything though, it just feels like the doctor is blowing me off, or he'll just give a guess, maybe google it and show some pictures. At best he might tell me something like, "Hmmm, well it's probably not cancer." and then just sort of shrug and move on. I'm a guy, so I'm used to no one caring about my health or well-being at all, but I think I had a different image in my head when I was a kid about what it was doctors actually did.

    The one regular benefit I see from going to the doctor is getting my blood drawn and being able to track health numbers from that, my job does the same thing too, so I get two sets of numbers from my blood work every year and I track it to see overall condition of my health, which I kind of wish was something my doctor did. He'll mostly just comment the most obvious thing possible when the test results come in, but there's never a look at health numbers over time, which is why I started just tracking it on my own.

  • 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.

    Source

    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 not 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, wrong in a moral viewpoint, and 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.

  • This is just over generalization of your experience.

    A primary care doctor should ask questions like if you are stressed out as it affects your life but they are not going to have a long non-medical related conversation because you are no longer a kid and also they won’t remember you until you go back the next time so why waste time when they can see other patients, unless it’s a psychiatrist. The questionnaire they have has all the required medical questions.

    Doctors aren’t out to get your money. You don’t even pay them directly. Blame the health insurance companies for that. If they did want to take your money wouldn’t they make you do more tests and take more of your money? There are a lot of ways to get your money apart from anesthesia.

    Maybe there is a different medical reason but it is certainly not to just to make your pay for anesthesia. I’m not in a medical field so I can’t into those details. However, I had some oral surgery and I refused anesthesia as I could handle the pain and didn’t want to pay more money. The surgeon didn’t force it on me. I’m not sure where you live but I hadn’t heard that we are forced to take anesthesia when it might not be required as it has its own risk. Why would the hospital risk that? Just to make more money when they can just order other non-risky expensive tests?

  • 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.

  • Australia checking in ... I feel similarly about the attitude of doctors and the type of care I receive. I don't have any amazing advice that you're not already following, but I'll regale you with my thoughts regardless...

    About 18 months ago I developed a chronic health condition that I will need to manage for the rest of my life (hopefully several decades). In that time I've seen a myriad of medical professionals.

    My first tip would simply be that if you're not satisfied with a doctor or specialist, your only recourse it to arrange to see another instead. Sometimes the advice / treatment prescribed will vary significantly, sometimes they just have a less punchable face.

    As regards GPs, I've come to categorise them thusly: those that just prescribe meds without any conversation, those that try to manipulate you into wanting the meds they want to prescribe, and those that will have a conversation with you about what meds you ought to take. Obviously this last category is the one you want.

    Finally, I've gotten a lot of mileage out of simply staying on top of all the data about me. I have all my test results available on my phone, as well as medications, dates of treatments, contact details for specialists, et cetera. Also just understanding the available treatments.

  • Ask the doctors who moved out of their home states instead of risking being jailed for "performing an abortion" when they were doling out life-saving medicine.

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