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

IamAnonymous , 2 hours ago

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 is 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?

corsicanguppy , 4 hours ago

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.

fine_sandy_bottom , 4 hours ago

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.

RememberTheApollo_ , 4 hours ago

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…

InternetCitizen2 , 3 hours ago

Doesn’t help that the insurance is the real employer and superior physician as they ultimately decides the treatment too

circledsquare , 5 hours ago

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.

GaMEChld , 5 hours ago

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.

Drusas , 6 hours ago

I'm sorry you've gone through this, but I am also an American suffering from the same issues as you, and I have found no shortage of ENTs willing to shove the camera down my nose. That seems to be what they always recommend straight from the get-go.

Buttflapper OP , 5 hours ago

Seems to be especially bad in Georgia where there’s very poor access to healthcare. More progressive places like NY may have different results I’m not sure. It’s just shocking, no one will even consider helping me

Drusas , 5 hours ago

That is difficult. I assume you've tried Atlanta? I would think you would be able to find decent care there. If not, it might be worth traveling a few hours to wherever you can just to get a diagnosis at least.

And make sure the doctor or clinic knows in advance what you are seeking.

FridgeReborn , 6 hours ago

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.

Bob_Robertson_IX , 6 hours ago

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.

magiccupcake , 6 hours ago

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.

Lemmeenym , 5 hours ago

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.

curbstickle , 7 hours ago (edited 7 hours ago)

My doctors have been incredible, at least those I’ve had for the past 4 years or so. Including my gastro.

They take the time to talk to me, they remember who I am, and my gastro is even a direct recommendation from my primary doctor (my gastro is his gastro).

I’ve been going to gastroenterologists for literally decades, the one I got a couple years ago is the first to finally find the issue, and I’ve been reflux free. I doubt he’d do a transnasal either - its more limited in scope (hah!), you’re only getting part of what an endoscopy can do. That’s why its not transnasal endoscopy, its transnasal esophagoscopy.

And that’s probably why. Why they wouldn’t just say that, I don’t know. There are lots of places that will do transnasal esophagoscopy throughout the US, so it isn’t a procedure that is just “not done here” or anything, its not as popular in general because its just not as thorough of a procedure.

I hope you find a doctor in the future that takes the time to explain things though.

Edit: Forgot to mention, the hospital system by me is a non profit. Only differentiator I am aware of, and its a great hospital system.

kungen , 7 hours ago

you’re only getting part of what an endoscopy can do.

But it’s much less intrusive, no? So should it not be considered to see if a good diagnosis can be made via it?

curbstickle , 7 hours ago

If it doesn’t cover the expected area of concern? No

If you dont know the cause of the issue? No

If you know the issue, and just need to check the state of the esophagus or something? Sure.

Its done for specific reasons, just like an endoscopy is done for specific reasons. When it comes down to it though, it only does a small part of what an endoscopy can do, and with a generic “acid reflux”, its not going to give enough information to diagnose. Its a way to assess symptoms, not a way to diagnose a gastrointestinal problem.

Buttflapper OP , 6 hours ago

And that’s probably why. Why they wouldn’t just say that, I don’t know. There are lots of places that will do transnasal esophagoscopy throughout the US, so it isn’t a procedure that is just “not done here” or anything, its not as popular in general because its just not as thorough of a procedure.

Here’s the exact wording I got from my Gastro in the USA in a major metro serving millions of people.

I have reached out to our gastroenterology department and have learned that we do not do this procedure. Additionally, we are not aware of anyone in the state of Georgia that offers it.

No one in the ENTIRE state of Georgia… does a Nasal Endoscopy or esophagoscopy, a common procedure all across the world. Truly asinine.

curbstickle , 6 hours ago

I can tell you its done in the tristate area.

Maybe its a Georgia thing.

Rolder , 8 hours ago

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.

Boozilla , 9 hours ago

• 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.

Nougat , 9 hours ago

You know enough doctors well enough to know that most of them don't want to go to a doctor?

Boozilla , 8 hours ago

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.

litchralee , 9 hours ago (edited 8 hours ago)

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 , 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.

financial flow in the US healthcare systemSource

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,

lemmylommy , 9 hours ago

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.

Buttflapper OP , 9 hours ago

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?

crusty_baboon , 8 hours ago (edited 8 hours ago)

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.

Drusas , 6 hours ago

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.