Exactly this. You have to run into an individual on the long tail of mechanics that is uniquely curious about finding the root cause, or throw enough money at them that they are incentivized to track down the problem.
Doctors are no different than other humans. Your problem isn't necessarily their problem.
Sure, but coming at it from a programming/engineering background, that is a tough pill to swallow. If I'm going to a "professional" and paying them $1k/hour, why the fuck aren't they applying their full intellect to analyze my problem ? If we're supposed to expect front line doctors to be mere rule-applying automatons that just take a few pieces of input and produce outputs like "run common test X" and "apply common drug Y", that's technician-level work that should cost closer to mechanics' shop rates - where it can't just be entirely replaced by automation and self-service.
Doctors cost so much because there are artificial caps on supply in the US. So much for the hippocratic oath of "do no harm". Fewer doctors decreases access to the medical system which undoubtedly causes harm.
The main cap on the supply of doctors is imposed by limited Medicare funding for residency programs. Members of Congress who control that funding aren't subject to the Hippocratic Oath.
Not all residency programs are funded by Medicare. And even among those that are funded by Medicare, many have additional slots that are unfunded but exist anyway because a resident provides cheap labor. If a physician decides to change specialties and do a second residency, these unfunded programs and slots are their only options because Medicare won't pay for second residencies.
It's not clear whether graduate medical education programs operate at a profit or loss. The accounting is complex, and the results depend on how revenues and expenses are allocated internally.
When you are a naturally curious problem solver, it can be maddening working with service providers like doctors and mechanics and plumbers who just want to apply some known formula, spend the minimum amount of time, and cram more cu$tomer$ through the funnel. When your problem doesn’t fit into an easy, known pattern, it’s “whellp, you’re on your own. I can’t charge you enough to make this worth doing, and I’ve got 50 customers in line behind you with easy issues!”
I don't think that they aren't applying their brain. It simply can take a lot of time the work from possible cause A to Z. It doesn't matter how brilliant or applied they are.
I agree with your second point. A lot of doctors time and expertise is squandered covering A and B which could probably be handled by a bot. I think there are a lot of regulatory and liability barriers to doing this.
I do understand that even the most brilliantly engaged person isn't going to be able to do much first principles analysis in fifteen minutes, or even an hour. Rather my critique is based on the output most doctors produce, which seems quite one-way mechanical. Trying to have some mutual discussion or supplying your own input (whether from your own investigation or a different doctor) is often met with dialtone or even overt rejection.
In America at least, there's a bit of a trope among doctors who see patients self diagnosing wildly incorrectly after doing a quick scan of WebMD and various quackery websites.
Then there's the old phrase "think horses, not zebras".
Whether their funding is as a business or paid by universal care, all doctors answer to someone about how they charge for care. A doctor letting a patient dictate the course of assessment and determination of illness outside the "standards of care" is at best a potential waste of time and money, and at worst a malpractice claim waiting to happen ("you should have known I didn't know what I was talking about!") if it turns out there patient was wrong.
Edit: FWIW I have a batch of undiagnosed symptoms. I was temporarily on a new medication that cost an obscene amount of money, but it helped... Until COVID showed up, and I stopped it because it could potentially weaken my immune system. Now, my symptoms haven't fully returned, and I can't get a prescription for it again because the symptoms cross specialist boundaries, and no one specialist says that my symptoms for the area they treat are bad enough yet. (Psoriasis, joints inflammation, connective tissue pain, nervous system excitement).
Guess I'll have to wait and see if any one area gets bad enough to go to the right specialist.
> A doctor letting a patient dictate the course of assessment and determination of illness outside the "standards of care" is at best a potential waste of time and money, and at worst a malpractice claim waiting to happen ("you should have known I didn't know what I was talking about!") if it turns out there patient was wrong.
I'm flabbergasted. "At best" it leads to the patient's quality of life improving, the entire idea behind medicine. This kind of assumption that it can't possibly lead to any positive outcome is simply invalid. This thread itself is about cases where the doctor's assessments have failed to lead to any such improvement. At that point, they should either put their own time into considering other options, or at least be willing to engage with the patient doing so. Just saying "Well Ive tried the basic stuff and it hasnt helped, too bad, nothing else we can do" which is the most common outcome here clearly isn't the better option.
You missed the end of the sentence, where the best and worst outcomes were "if it turns out the patient was wrong"
Obviously, the best case scenario for any patient-doctor interaction is to have a cure in hand for whatever ails you; it wasn't even worth mentioning. That doesn't change the fact that patients are usually terrible at diagnosing themselves.
> At that point, they should either put their own time into considering other options, or at least be willing to engage with the patient doing so.
Not all symptoms land squarely within a single area of expertise. If a doctor is out of ideas, the best thing they can do is to refer you to another doctor, not to treat you like an experiment or encourage you to experiment on yourself.
If you want to be an experiment, as others here have pointed out, the best place to go is a research facility at a university.
You do realize there is a huge gulf between being an "experiment" and the narrow rubrics of assorted "specialists", right? Like seemingly your own situation!
I do understand how you have to internalize the system's reasoning if you want to get any medical care out of it. But you also have to step back and look at its constructive result - in yours it's seemingly straight up denying you the medical care you need. My own experience tells me that you should have never told the system you stopped taking the drug, which would have been less suboptimal than the situation you now find yourself in.
Also that someone is seemingly supposed to just know to seek out a research facility, rather than being referred to one in the normal course of care, is a blatant failing of the medical industry no matter how you want to spin it.
If I don't have any unique condition that I know of, besides wanting to bidirectionally converse with a doctor as two intelligent people, is there yet another type of place I should seek out?
Or a specific situation - if I'd like to consider a drug I've heard about that I think could benefit my own medical situation (lets say metformin or provigil), where and how can I have this conversation with a doctor, getting their informed opinion rather than being summarily shot down because I dared to think about my own healthcare in specific terms?
It seems like the only way to go about that under the current system would be to make the initial decision to start taking something fully on my own, obtain it from the grey market, and then just tell the doctor what I am doing and force them to work in that context rather than allow them to gatekeep the hypothetical.
I'd love to exchange thoughts with you on this. You've pretty much written down what I've been thinking for a while now and intend to do. If you're up for it I'll give you my email.
> If I don't have any unique condition that I know of, besides wanting to bidirectionally converse with a doctor as two intelligent people, is there yet another type of place I should seek out?
I'm thinking of looking for a good doctor who will be willing to do just that for an upfront $1k a day or so, possibly in India. Working as a team, spending the full 8 hours together, thinking, researching, looking stuff up - someone who seems it as a challenge.
> It seems like the only way to go about that under the current system would be to make the initial decision to start taking something fully on my own, obtain it from the grey market, and then just tell the doctor what I am doing and force them to work in that context rather than allow them to gatekeep the hypothetical.
I feel like this is a tragedy of the commons kind of thing. 95% of the people that supply their own diagnosis have no idea what they’re talking about. The doc meanwhile has only limited time to talk to that patient during their visit, so they want to get it over with so they can get to asking pertinent questions.
Yeah, I agree those are barriers and leave your information lost. From the doctor's perspective, the challenge is that they don't trust the information from a patient or even another doctor. It comes with so much uncertainty and possible caveats that makes it almost impossible to parse unless it is incredibly binary. The prevailing heuristic is simply to disregard it and start fresh. Obviously this is is a big issue when the progress a single doctor can make during a visit is limited.
Without these two things there is very little to prevent someone from setting up a low cost Clinic out of their garage.
Malpractice insurance is another Factor, but without the legal barriers I'm sure the the insurance Market would be willing to cover someone for extremely low risk basic care.
You can get many medications over the counter from a pharmacist and other countries that require a licensed doctor with 10 years of training and the US.
Meanwhile, hey Barbara can't even cut someone's hair without a year of training and expensive license to operate from the state.
Doctors are no different than other humans. Your problem isn't necessarily their problem.