Having baselines is fine, but they don't have to be annual and they certainly don't need to trigger a barrage of tests which are unnecessary at best and potentially harmful at worst.
In somewhere this is where authority fallacy comes into play
People need to push back and ask questions not just accept everything the doctor says at face value..
If I take my car in for routine maintenance and the mechanic comes back with 1000 things they want to do I am not prone to just say "sure do what ever you think is best, you are the expert"
Except physicians don’t practice independently like a mechanic and we answer to several authorities (licensing boards, specialty colleges, hospital M&M and MAC). We follow evidence-based guidelines that have looked at various outcome measures.
It would be malpractice and I would be sanctioned if I were to willfully ignore validated guidelines without strong medical evidence to support me.
It’s a good thing to ask questions but “pushback” suggests an adversarial approach. If you feel like your physician is attempting to fleece you find a different one, in my experience most of us aren’t like that. Physician-patient trust is critical.
If you’re unsure of where to look a good starting point is an academic-affiliated practice which will have more oversight and reimbursement structures that don’t align with over billing.
You point to "several authorities" as meaning the relationship between doctor and consumer should be less adversarial as the doctor then to the mechanic and consumer. as the doctor would have sanctions if they go against that authority, that orthodoxy
to me however that means my personal care is not the only concern, with the mechanic the motives and incentives are clear. With the Doctor they hidden with a split set of masters and at the end of the day the patient is not the primary concern or factor, the Licensing board is, the insurance company is, the government regulators are, but not the patient.
These over lapping authorities you think make the system less adversarial to me makes it more adversarial, as now I have to ensure the motives of your decision making is about me, the patient, and not the government authority that told you what you have to do... not the licensing board, not the insurance company, etc.
See COVID response as a recent example of this, but history is fraught with other examples where patient care suffered under the weight of authority.
this is with out going into the pure corruption that influence many health policies from diet to drugs... Making it less "evidence-based" then I think you are asserting.
I mentioned these as you said “do whatever you think is best” and to contrast with the workflow of a mechanic. I’m not doing whatever I think is best I’m doing what the body of evidence thinks is best, adjusting to specific patient circumstances.
As an aside the “agenda” of these authorities is to ensure we practice safely (i.e. evidence based medicine) in the interest of patient care and not based off our own personal gain or thoughts (as you posited with the mechanic analogy). An example of a sanctionable offense is performing an unnecessary procedure because it pays well, like in your mechanic example.
Where there is no compelling evidence, or when there are unique patient circumstances, I practice with more latitude (e.g. I commonly biopsy lesions that don’t need one when it’s causing patient anxiety and the risks are low, despite not adhering to guidelines, and have no fear of being sanctioned as it is justifiable as reducing anxiety/for the patient’s mental wellness. What I can’t do and will be sanctioned is if I unnecessarily biopsy a benign incidental lesion for the $90).
With respects to insurance and pharmaceuticals I couldn’t care less what their interests are. As part of my job I fight with them routinely and we take industry funded evidence with a grain of salt.
The primary guiding interest in any patient encounter is unequivocally the patient’s health. We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
COVID is a perfect example of why science-based medicine doesn’t work as the response was not evidence based at all, largely because it’s impossible to acquire evidence during a pandemic.
As someone who was critical of the response, you’re right that the authorities limited us (not that I practice primary care) but that period of time was the medical equivalent of martial law. This has been the only period in my lifetime where medical practice was dictated by an authority to such a degree.
Mistakes will happen in exceptional circumstances, most medical encounters are not exceptional. We are also all human.
Pointing out rare exceptions doesn’t disprove the validity of evidence-based medicine or provide evidence of its corruption.
FWIW, I think you're coming from a position of good faith and you do want to see doctors do all they can for the patient's health.
That being said, the structure of medical practice in the US leads to mediocre and expensive outcomes for patients because no one cares to address systemic issues because no one is incentivized to.
> We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
Another anecdote: my uncle was a doctor in South America and he is appalled whenever he sees doctors in the US. Doctors in the US do not care to learn anything about you beyond your symptoms, vital signs, and blood work. They see you like a car engine and follow a cause and effect flow-chart to decide on a treatment. In South America, he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc. to understand if the patient's self-identified symptoms are consistent with other patients with similar backgrounds. Seeing each patient took more time, but he and his patients were much more satisfied with the exchange than in the US. The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
I think there is a very important distinction to be made. An individual doctor-patient relationship may not be concerned with systemic issues, but that doesn’t mean the overall healthcare system ignores systemic issues. If a patient goes in for care, they deserve to have their symptoms and underlying disease treated, irrespective of the physicians ability to make systemic change.
However, I will say some healthcare systems do try to get to the root causes. Once upon a time, I worked for a healthcare system in a “process engineer” role, for a lack of a better term. There was a team of us, and the whole point was to take a systemic look at healthcare outcomes so we could mitigate root causes that led to less than optimal patient outcomes/quality of care.
> because no one cares to address systemic issues because no one is incentivized to.
I'm not sure that's true having practiced both in the US and Canada which are both very similar. Speaking to my own specialty (radiology) there are several academics working to build evidence to reduce unnecessary and expensive follow-ups that seem to have low clinical utility.
I'll give you an example, current follow-up regimens for pancreatic cysts are unnecessarily long and expensive with very high probability although all societal guidelines (US and international, with the US version actually the shortest) have very long and expensive follow-up recommendations based on limited evidence from Japan and expert opinions.
When I report a pancreatic MRI although I don't personally want to I still recommend "follow-up in one year per ACR guidelines" as that is currently the standard of care and in the chance that I'm wrong (no compelling evidence on either side at this point but the status quo is to follow-up) the outcome (pancreatic cancer) is devastating.
Simultaneously, several groups (including myself) are looking at long-term evolution of these cysts so we can one day stop doing these probably unnecessary studies with confidence. This is despite the fact that I can bill $130 for a "stable pancreatic cyst" MRI that takes me 2 minutes to report.
Within my own specialty the same thing has been done for breast masses, liver lesions, ovarian masses and renal masses within recent memory and we have dramatically reduced investigations at financial cost to ourselves in the interest of patient care.
> That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
There's a time and place to fix systems-level issues (which are very hard to objectively evaluate and obtain evidence for fixes), during a specific patient encounter is not one of them.
Inertia in healthcare is real but we also have to remain cognizant that the consequences of mistakes/poor decisions are far more significant than in most other areas of life.
> Another anecdote...
Primary care is broken in the US and Canada (can't speak to elsewhere) due to several issues, the funding model being one of them which greatly limits how much time a GP can spend with a patient while still eating/being able to sustain a practice. Hospital-based specialty care is a lot better on average as we have more resources.
> he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc
For example we do this in oncology where I mostly reside professionally. Treatment decisions are influenced by these factors and every cancer center I've worked in has allied health professionals as part of the team to also help evaluate these factors.
> The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
The issues you describe are most prominent in private practice environments which are very heterogeneous and there are definitely toxic physician groups that optimize billing, but I wouldn't say the system as a whole does not care. I suggested somewhere that patients try to find academic-affiliated practices (ironically my clinical work is private practice) if they are unhappy with their care as these groups have far less financial considerations and are generically speaking a better choice.
Overall I'd say the system is far from perfect and there are many inefficiencies but the majority of physicians I've worked with do in fact care about patients more than financial incentives. There is no easy fix for these very complex issues.
Thanks for the detailed reply, I sense then there are at least 3 kinds of health related interactions we’re talking about: 1) PCP visits which have wide variance in quality 2) non-hospitalized specialist visits where it’s unclear if the cost is justified 3) hospitalized care.
Most people don’t experience 3 until there is a serious enough problem, but when they do their care is far better than anywhere else in the world.
I don't know in which country you practice but here in Switzerland no board will ever give a decision of malpractice short of the doctor sticking a pitchfork in your eye. Theory is all nice but current practice makes this medical responsibility a joke.
