“ Medicine has become a three-way negotiation between you, your doctor, and The Algorithm.”
This characterization makes it sound like a good thing. In reality, the doctor’s responsibility is being pushed to the patient because they are overbooked in the name of economic efficiency.
As a patient with complex, non-specific medical condition, I can tell you how miserable this is.
I can’t count on doctors _at all_ to move the process forward. It’s always me, reading articles on PubMed and coming up with ideas.
I’m not medically trained nor am I scientist. It’s a lot of legwork for me normally, but the ways that being sick limits me make it much harder.
Further, the emotional and intellectual overhead required to negotiate with medical professionals is high.
Back when I could afford to, I saw a neurologist at an office that didn’t accept insurance. She choose to see fewer patients and give them more time, as well as spend time doing research to look for new clues and ideas.
This worked really well and I made progress with her.
The rest of the American medical system? Gatekeepers that block access to potential treatment pathways until you can convince them it’s worth a try.
Can confirm. They paint people who google symptoms as kooks or as annoying, but you have to if you ever want to get an actual diagnosis and treatment, because doctors and hospitals are, quite often, worse than Google at figuring out WTF is wrong.
Do your best not to end up in a hospital without an advocate (friend, relative) watching out for you. They'll fail to treat you at best, then discharge you with a shrug and a huge bill; and they'll kill you with mistakes, at worst.
I was misdiagnosed with Bipolar Disorder for 30 years. Turns out it was Neuropsychiatric Lupus. Despite all my pleading to them to look further they never did. I had to teach myself biology and genetics while I was on disability. They missed all the common signs of Lupus; my skin, bad kidneys, etc.
I am afraid all this technology is taking away all of our wisdom. Too easy to know things, very hard to understand them.
Lupus is really hard to diagnose. There's a reason that ends up being the diagnosis on pretty much every episode of House M.D.
Doctors generally see 6 patients an hour, and have 5-7 minutes of paperwork per patient. The remaining 3 minutes gives enough time to diagnose the obvious, but not much else.
It is not hard to diagnose once you eventually get to a person that can diagnose it. You said it yourself. It is not about difficultly, but time spent with the patient.
But I literally showed my doctor the cutaneous lupus in my ear and she said "Oh, some people just get gunk in their ears" and would not send me to a rheumatologist.
The slow diagnosis is because the specialists are so reluctant to see people. Right now I am on a six month wait to see a rheumatologist. Why? Capitalism.
> The slow diagnosis is because the specialists are so reluctant to see people. Right now I am on a six month wait to see a rheumatologist. Why? Capitalism.
This remark seems somewhat lacking in rigor. I know bagging on capitalism is a common reflex, particularly in medicine, but something more is almost certainly going on.
The default thought process for a retailer is to move units. A lawyer wants to rack up billable hours. A subscription service wants more subscriptions.
So why would a specialist look for fewer cases? There is almost certainly a perverse incentive involved, because a competitive market would usually prompt a service provider to accept business and grow with demand.
Specialists are hard to get a face-to-face with even with socialized medicine (personal anecdote from Sweden). I assume that one thing that transcends national borders is that unless your symptoms suggest anything life-threatening care will be administered in accordance with heuristics. The most probable diagnosis is set, and it is assumed that a patient will return if things does not improve.
However, failing to communicate to a patient that a diagnosis is provisional might serve to undermine their faith in the healthcare system leading to periods of fatigue wherein one doesn't have the self-efficacy to continue seeking care if things haven't improved even if quality of life is severely impacted.
From my limited understanding of the US healthcare system I'd imagine you don't want an excess of cases because each case
1. Is a responsibility, and thus a liability, and
2. every patient your staff needs to accommodate is draining (risk of overwork).
If that would apply to a country with socialized medicine I imagine that Item 1. receives significantly less consideration but that Item 2. is still very much considered. If a unit isn't a first-line care-provider they can in theory be a bit more guarded about who they receive, while first-line just has to bear whatever comes through the doors.
I feel as if I'm shifting to a different point of discussion but I still struggle not to mention the fact that a specialist may not be readily at hand depending on what city you are in.
> I am on a six month wait to see a rheumatologist. Why? Capitalism.
Consider that the AMA is a monopoly enshrined by the government, and their purpose is to limit the supply of doctors, which they do by limiting the seats in medical schools.
It's not capitalism.
See Competition & Monopoly in Medical Care by Frech.
It's regulatory capture, which i'd argue could be part of any economic system, but is deeply embedded in our current "capitalist" system. The AMA has put in place rules to protect itself at the expense of society as a whole.
Specialists are called that for a reason. They are not general practitioners and their time is extremely valuable. Access to them needs to be managed so that they do not waste their time on people who do not need their specialty.
The way it's supposed to work is that the general practitioner rules out a bunch of stuff, and then starts referring to specialists who can diagnose/treat the rare things.
In practice it's not quite perfect, but it's hard for me to think of a better way to deal with it.
> The way it's supposed to work is that the general practitioner rules out a bunch of stuff, and then starts referring to specialists who can diagnose/treat the rare things.
You missed a whole bunch in that progression. You forgot the insurance companies for one thing.
And you are wrong about the diagnosis process for Lupus. My Primary Care gave me the worst test for diagnosis ANA levels for Lupus. It came up negative. Therefore, I could not see a rheumatologist even though I had documented (MRI) spinal arthritis, kidney problems, and all the other symptoms.
When I found out it was a bad test I demanded they did the correct one it came up positive. So you see, when they do not know what is going on, the give up. They do not dig deeper. The process is a failure for people with chronic illnesses.
The better way to deal with it is to have fewer specialist, get rid of insurance companies, and just have more doctors that can spend more time with their patients and learn more in the process. Primary care doctors need to know more and investigate more.
And the only reason specialists time is extremely valuable is because they make sure there are not a lot of them.
For the life of me I do not understand why they just do not throw a bunch of tests at people with chronic conditions. They all say they do not know what is wrong with us bu they never do any testing, and the outcome is the same every time; patients suffer and costs are higher.
Many tests are not 100% accurate, nor do they necessarily pinpoint the problem (often they just rule something out).
There's no magic doctor who would be a flawless diagnostician if he just had more time to spend with the patient and less interference by the insurance companies. And if he did spend hours and hours on your case, and run all the tests, that would be hours he's not spending helping other people and delays in other people's labwork.
Medicine is imperfect, and diagnosis is based in large part on probabilities. Doctors do what their education and experience tells the is most likely to help. Sometimes they are wrong, because people are different, and some doctors aren't as good as others. Sorry your chronic condition was misdiagnosed. It sucks. There's no magic answer.
I had one that was abnormal. They kept telling me to ignore. I had to push really hard for the follow up test. That one was abnormal. I was still told to ignore it. More pushing.
The next obvious test to run was negative. Did a bunch of research and found out there was another related condition. I had every symptom. Pushed really hard. Tons of positive tests for that one. They still told me ignore results.
A hard fight later I started treatment. Dramatic and immediate health improvement. Some of my doctors still refuse to believe I have condition. Process Took 3 years. The average time for diagnosis is 7 years. Had about 30 doctors during this time frame.
There are too many patients and not enough doctors. This isn't caused by capitalism, capitalism doesn't limit the # of doctors. Becoming socialist doesn't magically allow doctors to see patients for twice as long. If we had socialism more people could afford doctors(a good thing!) but it would make this specific problem worse, because there would be more patients. This is caused by the AMA lobbying to limit the supply of doctors in order to drive up salaries.
It's why we have this.
United States – $316,000
Germany – $183,000
United Kingdom – $138,000
France – $98,000
Italy – $70,000
Spain – $57,000
Brazil – $47,000
Mexico – $12,000
The book M.D.: Doctors Talk About Themselves actually interviews someone who discusses this problem, and inadvertently illustrates a problem American policy ran into.
The interviewee says that the Reagan administration tried to drive down the cost of health care by increasing (as opposed to, say, lifting) the quota on production of doctors, with the idea in mind that more supply of doctors would drive down costs. And he goes on to say that the idea backfired by raising medical costs.
In the interviewee's mind, the problem is that doctors can "make their own work" -- with more doctors around, more medical care can be performed than was possible with fewer doctors, and so the cost of health care went up instead of down, making the policy a mistake. That is the beginning and end of his analysis.
No one asks whether the cost of particular treatments went up or down. If total national spending on health care went up, the policy is supposed to have been a failure.
The presumption is that under a "free market" the demand would drive more production - more doctors. But that the rules of the current system artificially restrict the supply of doctors. Some of that we want - credentials clearly serve a purpose - yet are the rules more restrictive than they should be? Should there be more residencies? Should we have more "lower-level" providers like nurse-practitioners, PAs or pharmacists that can prescribe? There is limited ability for the market to innovate in such a regulated environment.
Because it's factually not. At least, unless you define "capitalism" in a specific twisted way that includes "regulatory capture". Which I suppose a lot of socialists do...
Yes, but not in general shortages of doctors. It's a totally different problem, so this isn't really a helpful way to look at it. After all, if there's a shortage of cabbages, it doesn't mean the remaining cabbages benefit and can lobby to keep it that way!
Yes, but when that sort of thing happens in commodities it's an illegal cartel, whereas when it happens with jobs it's responsible self-regulation by a professional association.
I live in a country with (mostly) free health care and we have 6-month wait lists too. Same shit in the UK, who invented the NHS.
Please stop blaming every problem on your ideological pet peeve. Society is too complex for every single issue to be caused by capitalism, financialisation, the patriarchy or systemic racism.
I am on Medicare. Because it is not universal means it is only partly socialized and still operating inside of a non-socialized system. Why does this matter? I cannot get any doctor I want, only the ones taking Medicare, which are fewer and fewer, because they would rather only take people on private insurance.
In France for example you can walk into any doctor and they will see you.
Lupus is a broad category of auto-immune diseases. Some are easier to diagnose than others. It sounds like yours was one of the easier ones. Easier, but not easy! Many Lupus diagnoses rely on differential diagnosis. AKA eliminate every other possible diagnosis and if they all are negative it must be lupus.
> Right now I am on a six month wait to see a rheumatologist. Why? Capitalism.
Typically that's anti-capitalist: there are very strong government and regulatory limits on who can perform the services, and for self-serving reasons, they maintain shortages of supply. The free-market capitalist solution would be for prices to rise to a point where supply and demand are balanced, either by supply increasing (people switching fields), or reduced demand from prices rising.
> for prices to rise to a point where supply and demand are balanced
Is there a limit to the amount of money you would pay to save your life? Is there a predatry loan you wouldn't take to pay for life-saving surgery for your child?
Has this ever been demonstrated to work in healthcare in the real world, outside free-market fantasy land?
The limit is approximately what you would be capable of paying. Putting value on life is a common practice, particularly in single-payer healthcare, mostly relevant to certain drugs.
There are, of course, problems with a system like this. "I would pay literally everything to not die, but can't find treatment" is just not one (assuming certain values of everything), because people will take your money. Problems are things like rich people getting better treatment (happens just about no matter what, but we'd rather pretend otherwise), and evaluating treatment performance as a customer/patient (a reason for most supply restrictions.)
The people who tend to be the most ardent defenders of private medical care are usually the same people who have had the fewest reasons to actually depend on it. They're also the same people that declare the United States the greatest country in the world despite having never lived anywhere else but the lower 48.
> Yes, in the US before the government took over health care.
When did that happen? If you are thinking Obama care, uhm, no.
> BTW, no government is going to spend unlimited sums to save your life.
You are missing the point. Supply and demand curves break when it comes to life and death matters. That is why prices should not be dictated by a free market. Well, I guess that is fine if you are a sociopath.
Not all at once, but decision by decision. One big change was when the AMA was granted a monopoly over the education of doctors. Then there was when companies got around wage controls in WW2 by tying health insurance to employment. Then in the 1960s there was enormous expansion of the FDA, and then Medicare and Medicaid. Then there were laws that required emergency rooms to treat people for free.
All these measures sound great, but they completely mess with the structure of how markets work. And so we have the very expensive, and often dysfunctional, system today.
> That is why prices should not be dictated by a free market.
The free market doesn't dictate prices. Governments dictate prices, which always leads to shortages.
> I guess that is fine if you are a sociopath.
If you have a case, you should be able to make it without insults.
You're blaming Capitalism, it isn't great, but the problem is that in the United States healthcare system you have Capitalism without Free Market, you have "crony"/rent-seeking/regulatory-capture Capitalism.
You can get a rheumatologist TODAY if you're willing to pay (quite a bit) more (at least here in Uruguay). THAT is free-market capitalism.
If you don't have money, you'll have to wait 2-3 months (quite a lot less than what you're saying), and you'll have it for free (here). That's socialism.
In crony capitalism, you have the worst of both worlds...
I live in a country with private Healthcare and I could call and book an appointment with any kind of specialist anywhere from a day to 6 months. The reason it takes longer is usually because they're fully booked due to demand. And when I get an appointment, I can sit in that office for an hour asking anything I want. And my medical aid will pay for it. That is capitalism.
> And my medical aid will pay for it. That is capitalism.
No, that is socialism inside capitalism. Let me explain. I assume by "medical aid" you mean insurance, right? What is insurance? It is a bunch of people pooling their money so they can reduce risk and pay for each others health care.
Sorry. Yeah, my mother suffered her whole life with it and never new it. She was in a wheelchair for the last 10 years of her life with all kinds of issues. It was our kidney issues that tipped me off. That is the reason I went into the genetics, because she, and several other in my family have the same issues.
If anyone is interested, it seems it is partly (mostly?) caused by a Purine nucleoside phosphorylase deficiency. (PNP gene)
This argument keeps being thrown around but it's pretty clear to me that this time it's actually different. Every new attention-grabbing invention is more potent than the last, and the Internet just might have crossed a threshold where it can actually break us on a large scale.
Doctors love to mockingly call this "Doctor Google" and reject anything mildly technical that you read on your own, even if you're just trying to have an open discussion and not push a diagnosis. I think the underlying dynamic is that doctors had one of the early monopolies on "knowledge work" and have never adapted their ways [0]. And so they're not used to having to engage with other's ideas, in stark contrast to the open collaboration we're used to in the engineering/scientific world.
[0] srsly if I'm understanding some recent hospital records correctly, they still mostly work by verbally dictating at subordinates who transcribe for them. And they spend most of that dictation simply reciting the patient's known condition. Compare with programming where the working set is openly displayed on the screen (modulo scrolling), and then our contribution is only that of making changes.
The interesting part about this is that you'll also likely see a NP or physician's assistant, who, at best, "google" (uptodate) your symptoms if the case isn't obvious. Sometimes doctors will do the intake appointment and fail to tell you that any follow-ups are done with their "trained" NP.
And then be billed 400-800$. Such an incredible system!
I also gave up going to physicians with a chronic illness. They're in and out in five minutes, and just ramble off the top two treatments from uptodate. If it's a surgeon, they'll try to sell you on surgery or a diagnostic procedure to "re-validate" the diagnosis (conveniently to generate a trivial 10K for the hospital in a few hours). If you want anything beyond that or to have a discussion, good luck.
i never go under without someone there with me. My father was almost killed twice be incompetent nurses double dosing IVs and other things. My mother, an RN herself, watched him like a hawk every time he was in the hospital to keep the staff from killing him.
Another anecdote, my sister worked at the front desk in some department ( she was an admin and not a nurse) and a patient coded but came back by themselves. Only afterwards did the nurses realize they were marked "do not resucicate" by mistake!
To be fair, the vast majority of patients they see who do bring in their own sources are probably the kooks. Just look at the state of national discourse on any topic related to science. The number of people within the intersect of the venn diagram of "able to interperate the relevant literature", "has time to interperate the relevant literature", and "doesnt trust the doctors ability to interpretate the relevant literature" has to be remarkably small.
A hospital isn't the place to be unless you have a specific, acute need to be there.
They're looking to stabilize you and get you able to survive outside the hospital, not to solve a mystery.
Great place to go if you need it, though. Got internal bleeding? Get that taken care of. The risk of a debilitating or fatal hospital error isn't that high, so absolutely go when the risk of not going is high.
TV, though, has trained us to expect to get everything figured out and root causes solved too. Unfortunately, that's just not realistic even if many of the complaints in this thread were solved. There are a lot of nasty rare diseases and conditions, and strange manifestations of conditions, that will still be missed if they have 60 minutes with you instead of 8.
You should also realize that doctor quality varies as much as any other skill. SHOP AROUND. I've had better luck with second, third opinions than I have trying to pester an original doctor into changing their mind. There are doctors out there who appreciate it if you bring up a written self-history of the condition, the strange aspects or other things that may or may not be related, what has or hasn't worked so far, etc.
In an April's fool story where Eliezer Yudkowsky was pretending to come from a rationalist parallel world (or outer planet), he suggested a medical system with a different way to specialize people.
Most notably, he suggested we separate diagnosticians and prognosticators from practicians. The former do their best to guess what you have, send you to the right kind of practician, and estimate your possible outcomes (with probability distribution and Bayesian goodness and all). Then whatever practician you chose do their best to treat you.
Separating prognosis from practice allows us to have a system where prognosticators are rewarded for their accuracy and calibration, and practicians are rewarded for their outcomes relative to prognosis. Being good doesn't mean having better outcomes, being good means having better outcomes than predicted.
I'm not sure how well this system would work in practice, and there may be a huge problem with eliminating the short feedback loops we can have between diagnosis and practice when they're the same person. What should be a nice separation of concern may turn into a communication nightmare.
Nevertheless, it is possible that specialised diagnosticians may be better than any expert system.
We have the same problem in education; we've stupidly combined certifications (diplomas) with instruction. This is a huge conflict of interest for the schools.
I have some specific domain knowledge on my injury (very sport specific) but obviously have not spent 10+ years in school studying hand surgery.
But I did read and send AND tell/ask in my appoint real specifically relevant med publications saying the only way to see what I wanted was an ultra sound under stress.
My PT also said this. But not a 'real md.'
So I had to pay and sit through an uncomfortable MRI for nothing. And never got the ultrasound. Should have just said no thanks.
> Gatekeepers that block access to potential treatment pathways until you can convince them it’s worth a try.
You assume they actually know what needs to be done. In my experience, you can see they don't have a clue and aren't willing to do research to learn. They just hand out their usual prescriptions, etc and sometimes hope an exam will give them an obvious answer.
On top of that, most doctors only have a very narrow understanding of the human body and don't know when to refer you to some other doctor they will be better equipped to help you.
I‘m really not trying to sound snarky, but - is this the supposedly high quality treatment that U.S. citizens get that is so much more expensive as opposed to the „socialized“ insurance we get in Europe that is cheaper for everybody and supposedly therefore not as good/cutting edge?
From my experience, other countries are even worse.
I'm transgender, and everything the top-level poster said about incompetent doctors, gatekeeping, and having to read literature and teach yourself about your own medical condition absolutely 100% applies to me and nearly every other trans person I've talked to (I remember printing out the Endocrine Society guidelines and taking a highlighter to them in order to convince a doctor that what I'm asking for is standard practice). I also have friends who have other chronic medical conditions, and their experience with doctors is pretty much the same as my experience and the experiences of other trans people.
And everything I've heard from people in Europe is that over there, it's even worse. At least in the US it's possible to doctor-shop and find someone who knows what they're doing—or who at the very least is willing to listen—but in European countries with single-payer healthcare you are entirely at the mercy of whatever doctor gets assigned to your case (yes, this isn't as bad in multi-payer countries such as France as it is in single-payer countries like the Nordics). And in some cases, the barriers aren't even the competencies of your individual doctors but institutional requirements doctors are legally required to follow even if an individual doctor is competent. Mind you, there are some exceptions: in parts of Spain and in much of Southeast Asia, for example, a good amount of medications that are Rx-only in most other countries are available over-the-counter, so at least you can self-med if you've put in the exhausting effort to research your own condition and figure out what you need (and even then, good luck getting blood tests to confirm your dosage is appropriate).
This isn't an endorsement of the US healthcare system, just an acknowledgement that the shit sandwich offered in the US has slightly less fecal content than the shit sandwiches offered in many other countries.
If you go to the Mayo Clinic in Minnesota you'll see people from all over the world for a reason. It feels like the UN, where everyone has some sort of debilitating disease.
They have a system where you get evaluated by a general practitioner (or someone more relevant), and then they schedule you to see however many specialists you might need to see - all within a day or two.
It's not perfect, and I've found it's still hard to get them to drill deep on anything not life threatening or obviously testable. That said, I very much doubt that system exists anywhere with socialized medicine. You don't need a referral or anything else to go. You just call and make an appointment.
I recently had to make an emergency visit to a hospital in a major city, with a really weird presentation.
Within 45 minutes of arrival they had figured out what was immediately wrong and had me hooked up to an IV drip of stuff to fix it. An hour later, a specialist for my issue came and talked to me about the problem and had an idea for a root cause. I was held overnight for observation and had several more tests run; by the time I left the next morning I had a root-cause diagnosis and a prescription to fix it.
"IV drip" - that rang a bell. 25 years ago I was admitted to a hospital with severe abdominal pain. They had a surgeon who was preparing me, mentally, for a temporary colostomy. Fortunately, that IV drip fixed me up within half an hour.
I'll second the Mayo Clinic. I've (unfortunately) spent way too much time there, and it just can't be beat. I wish every hospital/doctor/system worked like this place. I doubt that's even possible, anywhere, but from my experience, it's how medicine should work.
So tired of these "European" comments feigning cluelessness to try to feel above others. There is huge variety in healthcare quality across EU countries (waiting lists are years long in my country) and no one can speak of Europe as a monolith and make much sense. People in my (EU) country who have serious illnesses often seek to go to the US for treatment because they have facilities and doctors that specialise in their illness and don't have a hope of survival otherwise.
I see these comments all the time on Reddit and HN but never see the reverse from US posters. They just come across as insecure and snooty.
I think it depends on the context of the treatment and how specialized it needs to be. For example, I've had relatives from the U.S. who have gotten dental work done in Croatia because its cheap enough to the point where they can buy a transatlantic flight and spend some time visiting family members along with getting the root canal and crown done. A lot of people in southern California also opt to drive to Tijuana for dental work or other procedures. If its not some cutting edge thing or world renown surgeon, there is no point to paying the costs associated with a lot of treatment in the U.S. at least. For some stuff, yeah, the U.S. is best in class; Saudi princes fly out to Cleveland to get their heart work done.
Sometimes that can be a good idea. But many times, you are also getting riskier, out of date treatment for less. For example, root canals and crowns are kind of the cheaper and less effective way to treat a bad tooth. The gold standard is usually extraction and a new implant.
And considering that you can find a dentist to do a root canal for $300 without too much trouble, I'm surprised anyone would be able to fly to Croatia and get treated for that little.
Yes, I have heard of people traveling for implants. But if they travel once and are done, then they are going to cheap route there as well. You can get all in one implants, and they are cheaper, even here in the US. But the kind of implants you really should get are the type that require placing a base first and then wait a few months for them to heal and set before installing the posts and permanents.
I'm reminded of that Simpsons episode (can't find it on YouTube easily) where they temporarily have to take in boarders: backpackers and so forth.
Then the financial problem is fixed, and Homer carries one of them, all the while spouting about the European health system, to the garbage can. He says "Time to take out the Eurotrash."
In my experience the quality varies wildly, but every doctor has a base level of knowledge that is far deeper than a layperson. The quality of that knowledge is usually very high, and seems to be pretty well retained by most doctors I've met.
The quality of the actual doctor varies on whether the doctor is a lifelong learner, a deep thinker, a good listener, is good at extracting information from people who are bad at introspecting how they feel, and communicating with people whose language skills and mental capacity are far below or above their own. They also leave out their personal biases about "what" the person they're treating might be (drug seeker, hypochondriac, malingerer, etc.).
If you visit a doctor and they don't have the ability or time to execute those non-medical training qualities, then you get a bad doctor.
The main issue is that the good doctors usually go to desirable places to live. This is often not in rural or even suburban areas of the country, and that's typically where the bad stories come from (adjusted for population density anyway - lots of stories from cities too but there are more people in cities).
Most have knowledge of what they studied in college and what worked over the years and by worked they mean did not get sued, made the most money on and worked quickly.
They are not paid by outcome they are paid by referrals, tests, drugs sold and consulting
Depends on which doctor you are going to. We have some of the world’s best doctors but they might be in hospitals or doing a concierge service. You get what you pay for.
No, with the American health system, you do get what you pay for (i.e. more money ⇒ access to better medicine); but you don’t necessarily pay (the right amount) for what you get (i.e. !(worse medicine ⇒ costs less)).
Which is to say: standard-of-care treatments can cost far too much relative to other countries; but also, if you’re willing to throw millions of dollars at private clinics, you can opt your own way into experimental treatments that don’t exist anywhere else in the world.
> is this the supposedly high quality treatment that U.S. citizens get that is so much more expensive as opposed to the „socialized“ insurance we get in Europe
I am an American who has lived in several countries and had experience several medical systems.
The US has the best care… if you have access to it. This access can be limited by geography, insurance, money, awareness of the specific doctor, etc.
In a random provincial area with no university medical school nearby, the treatment will often be quite sketchy.
In other countries I’ve lived in, the best medical care was still in the large cities, but the standard in provincial areas was to a much higher standard (imho) than in provincial areas in the US.
The Canadian system (well the one in Québec anyway, each province manages it's own system so I cannot tell about the other province. Hell, I cannot even tell about the one in other administrative regions inside Québec) has a big luck component.
If your lucky enough to have an accessible primary care physician who personally knows specialist and lives where there is a University hospital center, the system is awesome. If you don't, the system appears to be a special kind of administrative hell.
> On top of that, most doctors only have a very narrow understanding of the human body and don't know when to refer you to some other doctor they will be better equipped to help you.
Are we talking about doctors, not nurse practitioners? It's hard to understand how a doctor with 4 years of medical school and 3-7 years of residency would have a "very narrow understanding" of the human body.
Also, my experience has been that I have always been referred to a specialist when there was any uncertainty about diagnosis or treatment. My trouble has come from them not following up when an RX is denied by insurance, and making it difficult to schedule a doctor's appointment due to not being able to transfer my previous information.
I suffer from pretty debilitating fatigue. It started when I was 13 or so, which was also a few months after I suffered a bad concussion. I have low testosterone, and treating that helps some. Autoimmune diseases run in my family; my father has lupus, his siblings all have something, and I have a small patch of psoriasis on my head (to which my doctor said "huh.."). My white blood cell count is always moderately low, even after an infection. I get sick extremely easily and stay sick longer than other people. I frequently get chills in my limbs like a person does when they're sick, though the testosterone helps. The chills are a sure thing when I don't get enough sleep. I get cluster headaches, and recently I started getting really frequent eye twitches leading up to when the cluster of headaches start.
Who should I see to try and figure out the root cause of the fatigue? An endocrinologist? Urologist? Sleep doctor? Neurologist? Immunologist?
Rheumatologist?
It's hard to know what's relevant to the fatigue. When I was first treated they simply put me on antidepressants. After giving up on those, years later I did some research and had to practically beg just to have my testosterone levels checked along with some other things that were fine.
Doctors are T-shaped [0] - a GP knows a little about a lot and most have an area of interest or two that they're really well-versed in. There's just too much complexity, even within a single system, to be an up-to-date expert on everything.
For instance I have an endocrinologist (at Stanford, not to name drop but to signal this person is really good even among doctors) who only deals with thyroid. I naively figured that an endocrinologist would deal with all kinds of hormone issues but no, she's thyroid and thyroid only -- she has a colleague for testosterone, another for diabetes, etc etc.
I don't know that I'd say GPs "don't know" when to refer you; GPs are gatekeepers who will try conventional solutions to conventional problems and generally unless you push won't often suggest going deeper with a specialist. It's not that they don't know to refer you, it's that they're Level 1 Tech Support for the body and often times unless you make a stink they won't connect you to Level 2.
The average PCP is usually also an internist, which is just a fancy term for someone who knows just enough to be able to send you to the right specialists. And since in the US many specialists require a referral, that's all most PCPs are good for.
Even if a doctor spends a bunch of time on you, you should still do research. End of the day you're the person that cares most about your health in the whole world, why should you just leave it to a random expert with good intentions? If you spend time researching and come to them with detailed information about your symptoms, what you already ruled out and things you've tried, as well as a good understanding of your medical history, you'll get better treatment, either from a good or a bad doctor.
I agree we should be able to rely on them more, but the point is to get a better outcome, and to do that, being an active participant in your treatment is a great option.
I care most about my car, house etc in the whole world too.
The risk I guess is that being informed might make me want to overrule the experts. On a population scale the advice might be bad. Depends on how good the experts are.
So your opinion is that if research tells you that you should overrule a doctor's opinion, the right course of action is to not bring it up, not do the research in the first place, because the doctor "knows better"?
In my opinion if you disagree or have doubts about treatment you should definitely bring those up with your doctor, see what they say about your reservations, and either get convinced or find some second opinion to increase trust in the expert opinion vs your own research. One thing I've learned from living with a doctor for several years is that an informed curious person on a very specific subject knows more than a doctor that has to know about a million things and probably isn't up on medical research papers. Your duty should be to bring up that research to your doctor and bring them up to speed. Once they read those they'll understand them better than you, but before... not a given.
Discussion is always better than no discussion. Engineers get thing wrong all the time, but code reviews help. You should help your doctor to minimize mistakes rather than just accepting everything.
Not only that, medical history is often wrong. I've often corrected previous notes to a new doctor - learning only then that the previous one hadn't actually understood what I had shared. There's a million ways in which your active involvement and care improve your outcomes.
Another time I asked about several aberrations in an x-ray after a surgery, and the doctor admitted there had been a slight mistake during the surgery that chipped a bone, but that it wouldn't have negative consequences. He didn't bring it up until I asked.
Everyone's using that word in this thread: research. Watching a bunch of YouTube videos is not research. Browsing medical web sites and choosing "treatments" that are cleverly and subtly marketed to you is not research. Matching your symptoms with a TV ad is not research. We saw what two years of "dO yOuR oWn ReSeArCh!" left us with during a deadly pandemic.
We're all dunking on doctors in this thread, but look at it from their perspective: They're probably sick and tired of patients coming in to their office saying "The TV told me: Ask your doctor about Provalanix!" And patients who googled "How to get your doctor to proscribe SSRI medication". And patients who insist they should go with their aunt's Healing Crystal Therapy. And patients who asked HN for medical advice[1] !! If you want to really do research, go get a medical degree and then do actual research in an actual academic institution.
Yes, have a discussion with your doctor. Yes, ask him or her if you have concerns. Maybe even get a second opinion (from another real doctor). But don't think your keyboard is going to bring you to The Truth That Doctors Dont Want You To Know.
The internet with the latest and most information available to mankind can be ignored?
If someone gets information from video format they should be ignored?
If someone came in and wanted to have a conversation about a medical product they recently heard about they shouldn't go to their doctor with questions?
Sounds like someone is close to retirement or leaving the field with that attitude. Those are all valid concerns the general public may have. That's your job as a gp (to schedule appointments while patients tell you things you suggest your ideas).
PubMed is a great resource. Of course, it takes a lot of effort to really get something useful from those papers, since you need to try to understand the experiment they did, and not just read the conclusion (scientists have biases as well, and will often read what they want into the results).
But depending on how bad your condition is, it could absolutely be worth the time.
> But don't think your keyboard is going to bring you to The Truth That Doctors Dont Want You To Know.
Neither do I. I expect instead it might bring you to The Truth That Doctors Don't Know.
Sure, but if a professional breaks your car or house irreparably then they have insurance to buy you something equivalent or better.
If a doctor breaks your body irreparably, it would seem there's a high probability that you have no recourse other than in rare situations you might get a settlement for some cash. Cash that won't fix your problem.
My main point is that the risks aren't comparable at all.
> The risk I guess is that being informed might make me want to overrule the experts. On a population scale the advice might be bad. Depends on how good the experts are.
My experience with "experts" has been almost universally underwhelming. The only notable exceptions I've had is with a couple of veterinarians.
>I can’t count on doctors _at all_ to move the process forward.
This has been my experience as well dealing with fatigue. I was 25 when I finally got diagnosed with sleep apnea, after over a decade of symptoms. How something so common could go unnoticed by the adults and professional doctors in my life astonishes me still today.
Eventually, thanks to ego, I questioned the narrative that I was just normal and lazy. Without the internet, I might not have ever learned that sleep studies even exist.
I was more than half-asleep for all of my schooling, college, and early professional years. I've spent the last 5+ years trying to catch up.
I think the situation has improved there in the last couple years. I had a friend who I suspected of having sleep apnea. She called her doctor and asked for a sleep study. They gave her a device to wear while sleeping and the diagnosis of sleep apnea came the next day.
Getting insurance to approve the CPAP, though... that is still an open problem. Weeks later, no treatment for diagnosed disease.
>I had a friend who I suspected of having sleep apnea. She called her doctor and asked for a sleep study
It doesnt sound like the situation has improved. Without a friend like you, would she have received treatment?
I think the community has gotten better at addressing the undiagnosed sleep apnea epidemic. When I needed help, there were some discussions about it on forums that I could find with the right search terms. Now, it's become much more common knowledge on the internet that people can spot it in others. which is fantastic.
The Doctors still seem to suck at it. For starters, fatigue is possibly the single most common symptom of disease - and is not something proactively asked about by doctors (in my experience). Every doctor at every check in should be asking "How tired have you been?". The fact that you can notice apnea in your friend before trained professionals even suspect to ask about it is the problem.
And the bigger problem is that even if we address this for apnea, how are we to know how many other issues are going around waiting for the patients to bring it up themselves? I certainly no longer trust that proactive diagnostic due diligence is being done on anything other than blood test result levels.
Doctors rely on patient complaints to govern their behavior. full stop. Check-ins and physicals are way more superficial than most patients understand, imo. Still very helpful, but not nearly enough
Yeah, you're right that doctors kind of missed this. Sometimes I wonder how many questions they ask (depression is what she was being treated for with little success) and how much is volunteered.
I happen to enjoy reading NTSB accident reports in my spare time, and they're always sleep apnea, so it was at the top of mind when I heard things like "headache every morning" and "I randomly fall asleep on my couch". I didn't go to medical school so I'm not sure if those are anxiety/depression symptoms, but a sleep study sounded like it wouldn't hurt. You're absolutely right that doctors should at least be asking these questions ("how tired are you", there is even a scale with more specific questions).
I'm not sure what your friends financial situation is but maybe try to collect some money for her and buy one? I googled that the average cost is just under $1k for a CPAP machine. If it could change her life then maybe should could even pay it back one day.
I second this. Absolutely pay out of pocket if insurance drags their feet. I spent $5k on a mouthpiece for my treatment and would do it again.
It is far from an ideal solution, but in the 3 months it takes insurance to get their shit together - your friend could have the energy to work a side job to pay off whatever it costs and just be generally happier overall
note out of pocket doesnt mean independently - definitely still have a professional approve the purchase decision in case something about the configuration needs to be tailored specifically for your friend
in my case, i needed to see an orthodontist every 2 weeks to have the mouth piece adjusted. I am not sure how CPAP works to say if it is safe to "plug and play out of the box" so-to-speak
ironically my situation was the opposite. My vitamin D was a bit lower than the acceptable range so I kept getting brushed off until I fixed that. It was kind of hard to fix when I was dragging through life by a hazy thread though
I can be a PCP check it out - What is the most easily observable "defect" that's tangentially related to your symptoms? What is the most common treatment for that defect? Next patient.
In my experience as a software developer, I've grouped my peers into a few different categories. This is just a rough estimate based a small sample set, there are probably various gradients in-between.
1. Super coders: These are the coders who write the algorithms that pave the way for coders below them.
2. Natural coders: Competent coders who take to the craft easily. Can easily learn new things, but probably won't be designing the next great video codec. (I fall here)
3. Amateur coders: that somehow got hired. These are the coders that you curse because you're always cleaning up after them.
...
I have a theory that the same medical professionals have similar categories. This theory was first formed when I once saw a doctor who, on my first visit, regaled me with stories of taking Uber into the city for a night of drinking.
I'd put this guy in the lowest category of medical professionals. He's there to make money by providing a service with little regard for the long term outcomes of his patients.
There is more to the ranking than his crass unprofessional behavior. Upon leaving the appointment, I was given a card with a request that I rate him on some rate-my-doctor.com ... It had the same slimy feeling as one of those "give us 5 stars" cards found inside the box of many product sold on Amazon.
I totally agree with you but I'm pretty sure you just described the Normal distribution. People need to stop putting certain occupations on a pedestal. I've had good doctors and bad doctors, largely the latter. Tbh, most doctors don't have the time to be good doctors, due to how most hospitals operate, so it's really tough to judge them fairly. Also to add I'm only discussing US hospitals I haven't had enough experience outside the US for any of this to be applicable outside of it. My small amount of experience with Drs in Tokyo and Prague were great.
I have been struggling with what I have come to understand is a very rare neurological condition, which I've had for over a decade, but which became chronic just over a year ago. I liken my process over this last year to being a general contractor of my health, hiring migrants at the Home Depot parking lot for the day.
I've been through 8 doctors now. I've had 4 specialists in different areas tell me that there was nothing they could do for me, and just leave me hanging, without even giving me an idea of what to look at next. The only reason I've been able to get any help was because my wife just happened to stumble on a couple of doctors (who work together) by researching my symptoms online. Luckily, the last two have identified my problem, confirmed the diagnosis, and one of them just operated on my back a week ago.
During this year, I wasted time, health, and money on a surgery I didn't need, and which the specialist who performed it SHOULD have known wouldn't help. I can't help but think that he saw an opportunity to do a surgery, covered by my full-blown, "Cadillac" insurance plan, that might have helped, and he took it.
Now I've had an experimental surgery (i.e., uncovered by insurance), and two trips to California. I figure I'm running about $30,000 out of pocket on this whole fiasco. The good news is that the surgery seems to have been a success, but I won't know for sure for 3 to 6 months. Maybe even a year.
> I can’t count on doctors _at all_ to move the process forward.
My feelings directly echo this. No one in this process is responsible for my overall HEALTH. I'm old enough to remember that it didn't feel like this. Your PCP would have been the "general contractor" several decades ago. Now, all anyone cares about is selling me a service, and then getting paid. And my PCP is notorious for trying to upsell me (per the FA) and get me to do tests and labs that I don't need.
On the other hand, I just had a lengthy conversation with my dad on why he shouldn't drink chlorine dioxide, and that a Bitchute video from a guy who got a "doctor's of philosophy of medicine" from a diploma mill who had a patent application on drinking it to cure COVID, was selling books and lectures on his crockpotery, and had charges brought against him for two deaths resulting from drinking the thing might not be the best authority on the topic.
For people that are very good at research, self-advocacy and research is absolutely a night and day difference from just going in to the doctor for 15 minutes and being rushed through the system. If not for that in my own chronic health condition, I'd be on immune suppressants right now vs a much lighter treatment regimen in conjunction with generic/supplements supported in limited academic research abroad (the funding bias in research for patented vs generic/non-patentable treatments is its own topic).
But that's not the majority of people, and far too many think that they are capable of "doing their own research" when they aren't equipped to do so at all.
Particularly when it comes to medicine, that's a dangerous misconception, and Dunning-Kreuger is actively killing people who can't discern between snake oil and a meta-analysis.
So many of the people doctors are dealing with that are Googling ARE idiots who endanger themselves with their 'research.' Which sucks for the people who are actually good researchers and dealing with biases towards self-research.
Though in my experience, typically good doctors very quickly realize you're adequate at research and work with you as a treatment partner, and it's the people like my dad who will fight against actual research efforts in a quest for confirmation bias.
Some things to think about.
I personally know of a friend who walked into a Dr. office in the "top hospital" in Chicago, described her symptoms, and the Dr. without making eye contact, or saying anything, pulled out his smartphone, and googled every symptom she described. Then he said something like "lose 15 lbs. and come back if its still an issue". :-P
More importantly though, when deferring to "experts" in medical practice, you should ask yourself, "has the amount of money we've spent and 'expert training' these practitioners have gotten, and the 'breakthroughs in medicine' that they claim have occurred over the last 80 years, resulted in a statistically significant and measurable positive patient outcome?" What I'm seeing is, since the advent of hospitalization and deferral to medical 'experts', we've as a society, become much more fragile, non-resilient, addicted, overweight, and unhealthy.
To add some more anecdata: I've been going to a local clinic by where I live (a very poor area) for a little while. Some time ago I had a full blood workup on intake and it turned out my liver enzymes were out of range by like 5% of the standard deviation. They were in range for what the NHS said was normal for someone in their 40s and I'm in my early 20s.
I took this seriously and made some changes. I went back for a follow up I had scheduled for 6 months later. I met with a different doctor this time and she looked at my charts, asked why I was here, I explained I fasted over night and wanted to take a liver function test and I needed her to order one. She argued that "It's fine, you're not even that over the maximum!" and "Do you feel pain? If not you're fine."
From my research there are both completely false statements when it comes to increase in this enzyme at my age range. Everyone said that if they see an increase in 6 months that's a sign of a larger issue and it's worth getting the test since your insurance would cover it (which mine did) just to be safe. After telling her I wasn't leaving until she ordered the test she opened her laptop to enter it into the EMR. I saw her open Google, copy "Hepatic" from "Hepatic Function Test" on my previous labs and then read the popup Google showed me out loud: "Liver.. ok good" and then order the test in the EMR again.
Some doctors haven't got a clue. It's unpopular to say because it's a convenient fiction to think you will get good care from any qualified doctor but when one doesn't know what "Hepatic" means then I don't know what to think.
I have noticed the same. My wife has some chronic problems. I figured going to a specialist would be able to give some good advice. For a few thousand in fees you'd think the hospital would be able to give you a book or at least a link to some reputable websites, instead we got a photocopied page and told to google it.
A few years ago I noticed my stool was unusually dark (sorry for too much information). I did some googling and discovered this was an indication of blood in stool. I went to the pharmacy to buy a fecal occult blood test - a strip of paper that you add to the toilet bowl and it changes color if it detects blood in the water. When I got a positive result I retrieved my strip with tweezers and put it in a ziploc bag and went to go see a doctor.
The doctor decided this was an ulcer and said the ulcer could be bacterial, viral, or idiopathic (meaning without a cause). His solution was to prescribe an anti-bacterial and a steroid and to take both. I asked if there would be any complications or drawbacks to taking both, and he said there would not. I asked if I should take one first and then the other so I could narrow down whether the ulcer was bacterial or viral. The doctor thought this was a good idea and said I could do it if I wanted. I asked if I should take the medications in any specific order and he said it did not matter.
I went home and read up on the two medications he had prescribed. Sure enough, the steroid would make a bacterial infection worse. Following the doctor's advice, without my own research, could have made things worse. Without doing my own diagnosing and testing I would have had a much longer time to treatment too. (Wound up going away with the anti-biotics)
I don't know that. My research didn't turn up anything about taking both at once. I think, either way, it would have been safer to try anti-biotics first then the steroids. It's not like I was suffering from the ulcer, I had time to experiment, so why not go with the simplest and safest treatment route?
The cost and bureaucracy required to get one working will probably kill this idea. Those machines require consumables to run the tests, as well as for calibration and QA. The vendor might be willing to sell you the supplies and send a technician to get the machine set up to run a valid test, but it won’t be cheap, and they might be unwilling if it’s some guy trying to run the machine in his garage rather than a medical facility. Beyond that, there is a reason that the machine is on eBay and not being sold or donated. It could be obsolete and the supplies unobtainable, or simply beyond economic repair.
From my experience, in most states you can order whatever tests you want from Private MD Labs and just walk into any LabCorp location and get your blood taken and a PDF of your results emailed to you within 24 hours.
Which are just a wrapper for asking one of their in-house doctors to prescribe you the test you requested, without a real review of your need or the actual potential benefit for you in doing so. So it technically meets the letter of the government requirements for medical tests, but not necessarily the intention behind restrictions around tests.
Labcorp is fantastic. I do my own yearly checkups through them. You can pay 100-200$ and get a comprehensive panel done on you even checking your testosterone or estrogen levels. You can pay a few bucks and have a doc review your results too or you can give them to a teledoc to review that most insurance providers have.
I hate going to the doctor's office to have them order a panel so that I can go to a labcorp and have the doc call me and say everything is good. It's all free but my time isn't.
Going directly to labcorp bypasses everything and they give me the results to review myself.
The gatekeeping these incompetent doctors do is infuriating. If I want a random blood test, why do I need to pay a doctor for to order the test from the third party lab. They add nothing to the process except frustration and expense.
I hate to be so negative, but it's likely that by the time you have significant medical conditions to worry about, you will no longer have the time/spirit to engage in such productive playing.
You experience is similar to mine. It goes even further than that, though. I have seen the relief in a specialists eyes when I present them with research and tell them the decision that they should make for me. I am essentially designing my own treatment and care plans. I am not a medical professional, nor have I any training, either.
The United States' healthcare system is fundamentally broken. As it stands, it's probably completely irreparable, as well.
For anyone reading this, I've found good success in printing out actual studies or other relevant literature and bringing it to the doctor. It lets them know that while you've done your own research, it wasn't stupid YouTube research.
Congratulations, you have earned the achievement “chronic condition”.
Your rewards are as follows.
You have max exhaustion at all hours of the day!
Exercise recovery is bumped from next day to 2 weeks!
Your pain level is now on par with dying cancer patients!
Everyone now considers you lazy and incompetent!
Doctors now blame all symptoms on anxiety!
You gain +1 to medical research ability. But -20 to Reputation.
You now get spontaneous and useless medical advise from people that believe in essential oil.
You are now on timer with your job until sympathy runs out!
Disability now can mock you openly as clearly your faking and don’t have a real condition!
You are now a burden to your family!
+10 sneak score; you quickly learn to hide your suffering!
+20 to loneliness!
-20 to persuasion! Asking for help gets little from doctor's.
+10 Planning! Your kids may be orphans soon, make sure they get taken care of. Read fine print on death benefits. ——-
Staying positive when you have a chronic condition is incredibly difficult.
Your not going to get through it without losing your mind now and then.
Not saying that you are wrong, there are bad doctors like any other profession.
But in general, the counterpoint to that view is that medicine is one of the only professions that never industrialised. You have to put a highly trained MD in front of every patient for every problem. It just doesn't scale. And some patients have the expectation that this MD should also cuddle them, provide emotional support and listen to their life. I am glad when I see a doctor for something and I am in and out within 5 minutes, it makes me feel that I resolved my problem without burdening a precious resource.
> I can’t count on doctors _at all_ to move the process forward. It’s always me, reading articles on PubMed and coming up with ideas.
This seems to be the case with most medicine. Doctors in the US don't seem comfortable making suggestions. I recently got appendicitis and at first they only offered an appendectomy as a thing I could do (or not do). I had to specifically ask for a recommendation to get someone actually recommend a path, and this probably is one of the most routine cases in an ER. Can't imagine having something more complex.
When a business personn asks me for a new feature I spend a couple hours discussing their requirements and customer needs. I make sure to ask the right questions and draw out corner cases they haven't thought of. The business person has a bit of training to put forwar their requirements correctly
A doctor might spend 5 minutes listening to your symptoms, you have no training on how to recall them correctly or bring up the right ones. Another 5 minutes might be spent discussing treatment. And you life might depend on this
ugh yes re gatekeeping -- maybe there's an argument for requiring a prescription for some treatments, but at least in the US it's illegal for patients to self-order diagnostic testing. the new york AG sued a lab for doing walk-in blood tests without a prescription
'didn't accept insurance' is interesting -- in the econtalk episode with the surgery center of oklahoma, the guest claims that he's able to offer better medical outcomes by being out of the insurance system, and implies that billing things at a mainstream hospital has become so hard that it consumes more mental cycles than medicine
it seems like the medical system as-is isn't the right service for people who are fighting the system to get a diagnosis; I wonder if there's a different model that would work better
or tbh a specialized concierge doctor that just prescribes things that you ask for
Are there any laws that treat medical providers as fiduciaries? That seems like a minimum bar that insurance companies would want to enforce (at least in the short term when premiums could remain high while treatment cost plummets).
Insurance companies in the U.S. are barred, I think universally and definitely broadly, by state law from being too profitable. The outcome you describe would result in returned premiums or other profit sinks.
A doctor's job is to worry about your health, not not how wealthy you are.
Quite literally. If a more expensive treatment has a better chance of saving your life, or a more expense test has a better chance of detecting a disease, the Doctor could be sued for malpractice for not ordering it if you die.
You can sue them for malpractice, that's something, at least. But I can't imagine how bad a doctor would have to be before they were subject to criminal charges. Simply being awful at their job wouldn't do it.
Litigation/malpractice probably plays a role too. I imagine doctors are under a lot of pressure to do everything by the book. If it works, awesome. If it fails, they can say they followed best practices and it's not their fault. If they deviate for any reason, they do so entirely at their own risk if/when it blows up in their face. It's just not worth it (in the expected value sense) to step out of line.
It seems that they have very little incentive to take risks/deviate from the common path. Why help an outlier patient, when even if their unusual treatment doesn't do any harm, it could be wrongfully associated with some random bad outcome?
With the system set up like this, game theory basically guarantees we end up with the state as OP describes.
If you have something exotic you are basically on your own. Maybe you live outside the city where a doctor knows every patient by name and is really invested in research or you find a clinical study that might align with your conditions, but chances for that latter are extremely low.
> In reality, the doctor’s responsibility is being pushed to the patient
In reality, your choice is your responsibility. Even if one could delegate medical power of attorney to a health care provider, it would be unethical for them to hold a dual role.
Chronic conditions that are not well characterized and addressed by medicine are awful and as you said are a combined burden: the condition in of itself and the effort necessary to address the condition. The science and practice cannot progress fast enough to address the long tail of rare disease.
Informed consent is a principle in medical ethics and medical law that a patient should have sufficient information before making their own free decisions about their medical care. A healthcare provider is often held to have a responsibility to ensure that the consent that a patient gives is informed, and informed consent can apply to a health care intervention on a person, conducting some form of research on a person, or for disclosing a person's information. Informed consent is, in fact, a fundamental principle in the field of health protection, obviously wanting to mark the very close and unavoidable connection between the need for consent and the inviolability of the right to health.
In Norway I've seen documentaries about them sending the same people to multiple dentists, and some of them receive wildly different advice. Some of that can be ascribed to some being in the school of pro-active, so they want to fix your teeth at the first glance of issues. But in the end, most of the things being quoted were unnecessary. They all seemed very intent on removing wisdom teeth, even when they pose no problems.
They re-did the experiment recently, and I think one of the guys they sent got his teeth cleaned and tartar removed from 10 dentists in a week or so. No one stopped to see if it was actually needed, they all just do it by default and charge you for it.
I went to a new dentist for a broken filling and they tried to tell me I had 14 cavities and set me down with a finance person to set up a payment plan for how I was going to pay for them over the next 5 years.
I went to a second dentist, they fixed the broken filling and said my teeth were otherwise fine. I have the paperwork to back this up.
I’d been seeing another dentist for a while and he suddenly wanted to crown 3 of my teeth. Again I got a second opinion, and again they were like “That’s probably not necessary”.
I think a lot of dentistry comes down to how much money they need that month. It certainly doesn’t feel very scientific.
I went to the same dentist for years as a child. Brushed my teeth once a day, never had any issues at all. All of sudden, during a regular checkup, he told my parents (I was ~15 at the time) that I had 9 cavities and needed fillings. In the 20 years since, I have never had a single cavity. And what a shock, he sold his practice between that procedure and my next checkup. I fully believe he was just pumping up his revenue to increase the sale price, and my parents weren't health literate enough to get a second opinion, and I was too young to know that just because he has a white coat on doesn't mean he's a good person.
Dentists are in the sweet spot where they actually are very important and necessary (as opposed to chiropractors, who are universally charlatans and frauds), but they don't get quite the scrutiny and oversight that physicians are used to. And they make as much as some of the top tier physician specialties. PCPs, OBs, ER, etc. all make less than dentists by and large.
That a chiropractor can relieve pain doesn't mean that chiropractics in the "medical" sense isn't a fraud. Imaging that shown the entire concept of "subluxations" in the chiropractic sense are a myth.
I've gone to chiropractors for manipulations. Some even were able to bill my insurance (yet surprisingly the cash price was the same as my insurance copay, imagine that). But I treat it the same as getting a massage. It feels good, and I might feel better after, but it's absolutely not any sort of medical science.
What do you mean by "subluxations" being a myth? Most of my back issues come from subluxation of the T2 vertebra. As shown by x-rays and physically being able to feel that is is out of alignment with the rest of the spine.
Are you referring to those charts that say these are the random other symptoms you might have from alignment issues? Those definitely seem shady, and pseudoscience at best.
Yeah, I'm not sure about this. After two car accidents one year apart my back was killing me. I went to a year for physio and nothing happened. Then a friend recommended this chiropractor and within 3 months I was fine. To be fair this chiropractor said alot of chiropractic was a bit fluffy, and I insisted we discuss the science behind it and stuff which he was totally literate about.
> I take it you've never thrown your back out and had an adjustment that fixed a lot of pain?
A _good_ chiropractor will only perform adjustments, but the foundations of Chiropractic "medicine" is pseudoscience that many still practice to this day. Wikipedia has a good summary on this: https://en.wikipedia.org/wiki/Chiropractic#Pseudoscience_ver...
But, in my opinion, if you're only going to a chiropractor for adjustments you'd be better off finding a Registered Massage Therapist or Physical Therapist (depending on your level of pain).
Equine chiropractors are pretty mainstream nowadays. The one I use is an excellent vet to start with who also does adjustments. There's wackos out there, but there's definitely some properly trained individuals who do a lot of good. I get my mare done every other year or so. Her back gets sore, it's super obvious when you're riding her, the chiro comes out, and she's so much more relaxed and moves more freely when I get on her the next day. A year or two later, she's sore again and we repeat.
Crap, even the old school Kansas cowboy I used to ride with uses them. When his ranch horses start acting sore, he gets a chiro out. The man can do pretty much anything else veterinary himself, and does, but calls in an equine chiro for his working animals.
In the past, I spent a lot of money on chiros basically "cracking" my back. I eventually taught my partner how to do it and she does it so much better than any chiro ever did.
One thing I will say after having seen ~10 chiros is that the ones who actually x-ray you are the only ones I would place any trust in.
Having spent many years dealing with chiropractors... There are two types of issue they handle. The first is sharp pain due to some, likely traumatic, event like whiplash or trying to pick something up that is too heavy or a sports injury. They can often fix those issues with limited treatment and a few exercises.
Then there is chronic pain due to some issue like disk breakdown or another illness. They can do little to nothing with these illnesses but they will not admit that. They will bill your insurance for all they can and eventually when insurance will not cover it anymore they will try to get you to pay out of pocket or tell you to kick rocks.
I wish chiropractors would be upfront about this but I've never talked to one that is willing to. I have spoken to several who I know socially who have said this is more or less true in their clinic. At least the part about being able to help some but being useless with chronic pain.
Are they fully charlatans and frauds? No. But they do take advantage of people who they cant help and promise something they cant give.
Yeah I think people are blinding themselves to the huge differences between chiropractors and just lumping all of what they do into one single bucket and tossing it out. In physical labor heavy areas they help a lot and 90% of their business comes from relieving pinched nerves, fixing dislocations, deep tissue massages, and physical therapy regimes. Nothing quacky about that, especially when it is hard to find a doctor these days who will put their knee into your back and pop your shoulder out and back into the proper place instead of prescribing narcotics and endless rest for weeks on end that is not feasible in those communities.
But on the other end of the scale, you also got ones who don't have that sort of business and are selling new-age crystal moon beam energy healing power and claiming anything and everything they can sell you will cure you of any and all ills which I think most people would consider irresponsible and dangerous.
One side argues for chiropractors because of what they do above on top of being super cheap and affordable for the average labor worker. The other side argues against it because they only see new-age crystal therapy in their areas while also being able to themselves afford better healthcare with a significantly less physically damaging workload.
Technically speaking, if there's any decay in your teeth, that's a cavity. The deeper it is, the faster it'll get worse. When you want to get that filling though, is a judgement call that a lot of dentists make for you sadly. Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned. Can it be delayed though and done later? Almost certainly. Just a bigger filling later. Or maybe a crown if it gets too far gone.
Also, how fast your decay progresses depends on a variety of factors. For some people, it won't be long before those questionable cavities become serious problems. For others, it can be many years if they decay much further at all even. I think it's largely genetic, but also depends on oral care, diet habits, etc.
So, no, I don't think most dentists are just seeing dollar signs and putting fillings onto teeth without cavities. Its not outright fraud or malpractice. But some dentists are sympathetic to your financial situation while others think dental health should be a priority above everything, no matter the cost.
So it's a mix I think, between dentists' values/philosophies about dental care, and the lack of science about how fast tooth decay can vary from person to person (and an inability to measure that).
It's not that cut and dry. Just because you have a small carie doesn't mean it's only going to get worse. That's the reason for fluoride in our water, in our toothpaste and in the wax the dentists applies at the end of your cleaning (that for some reason, insurance never wants to pay for).
Fluoride treatments and good dental hygiene can reverse carries. Carries should only be treated if they're large, or if they're still growing after discovery and alerting the patient.
The reason it's a good idea to clean your teeth is because if you don't they'll stink and become discolored. It's not because it keeps them healthy, because cleaning your teeth strips some protection from bacteria and acids away from them while deepening the pockets around them, creating a nice place for disease to live.
The idea that intensely cleaning your teeth (and keeping them white) is healthy is an intuitive leap that marketers take advantage of, just like the bad intuition that makes people clean their faces intensely to get rid of skin problems. The reality is more complicated. Clean, pure, healthy, white.
Fossils have better teeth than we do, but we have prettier, less fragrant teeth.
If you leave the plaque and tartar on the teeth without fixing the fundamental problem (immune health) then there of course will not be better health outcomes.
Caries are a sign of an immune disorder or imbalance. As long as dentists only scrape peoples teeth and do not integrate their health into their practice you will keep having plaques and tartar to be remove as your body fight this battle.
>Caries are a sign of an immune disorder or imbalance
Or just terrible habits like drinking liters of soda everyday. Besides the diabetes, the mix of sugar and acid is terrible for dental health, and contrary to the myth, brushing your teeth will not save them, at all, if one persists in terrible habits.
In vitro study shows that plaque protects against externally-applied acid. Ok. Now what about the acid produced by the bacteria hiding behind the plaque?
Just because dental caries show up with plaque and tartar in no way means that plaque and tartar are causing the caries. These are the mechanism our body uses to protect our teeth from unbalanced oral bacteria. Just like the microbiome of the gut, we have one in our mouth. Removing plaque and tartar does not stop caries.
Caries are initiated by direct demineralization of the enamel of teeth due to lactic acid and other organic acids which accumulate in dental plaque. What is tartar?
Heavy staining and calculus deposits exhibited on the lingual surface of the mandibular anterior teeth, along the gumline
Tartar is a form of hardened dental plaque. It is caused by precipitation of minerals from saliva and gingival crevicular fluid in plaque on the teeth. This process of precipitation kills the bacterial cells within dental plaque.
> Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned.
Modern science says no, you should apply topical fluoride for most early cavities; and if the teeth use a modern pronamel (cough stuck behind USDA approval) should be able to recover quickly.
> Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned.
This is mostly untrue. Fillings don't last forever, so prematurely filling cavities "starts the clock" on the longevity of the filling. When the dentist is replacing a broken filling, the dentist has to remove more of the tooth. Eventually you will need a root canal and/or crown. So for maximizing your health, the dentist still has to make a judgment call on how early or late to fill.
I say mostly because mercury amalgam fillings do seem like they can last effectively forever (20+ years), but they have fallen out of favor.
In our eastern european backwater and largely primitive country (Slovakia), greed has its prime. New dentist offices sprang up recently all over the place from where I come from. They took relatively big loans, and as greed is bottomless, want to pay them as quickly as possible to move to other investments.
I had similar experience as others - one guy wanted to set series of visits (4 hours each) to remove all older fillings. He was doing a fine work otherwise (replacing urgently one that started breaking apart). The detail being, he didn't do an X-ray to check if older fillings actually needed replacement (the idea is, your teeth can handle only few filling replacements depending on situation, so definitely don't fix things that aren't broken).
After that (and few months), went to another dentist who first did full x-ray, found that one filling needed replacement and the rest were fine and I ended up paying 5% of the price of first one. Good dentists are worth gold (same as many other professions for that matter) - if you find a skilled professional who is not ripping you off, you stay there till you die. This quality mix is unfortunately not easy to find.
Wife is a dentist. There certainly are practices where treatments are recommended as a function of money and cashflow (laser treatment and other "optional" treatments are a great example of this). However, crown / cavity recommendations are largely dependent on how aggressive that particular dentist's philosophy is. E.g. my wife only goes to her father for treatment because he focuses on saving teeth whenever possible.
Unlikely that a dentist would ever recommend filling cavities if they didn't believe it was necessary – they're not very profitable for practices. Crowns are sometimes recommended when a filling will suffice, but that's usually because crowns last ~10 years and fillings only delay the inevitable crown for a few years.
This is why I like going to dental schools faculty or student practices. They are all about saving the teeth if it can be saved and will need to see sufficient evidence in the imaging before moving forward with just about anything. Things seem to take longer and involve more appointments (e.g. i have to schedule a separate appointment with dept of radiology vs the private practice dentist walking me to the next room with the xray), but it seems like every decision involves multiple dental professors looking at my imagery or feeling up my teeth or gums before anything is done, which definitely boosts my confidence. I like having a committee and hearing them discuss the evidence in this war room setting when I'm laying there on the chair mouth open
I've looked into this myself and one negative is that students still have some pressure to overtreat because students have graduation requirements (e.g. must do a certain number of fillings, crowns, etc.). Granted, having to run everything by a supervisor will eliminate the egregious cases.
They can't overtreat due to the nature of it with literally all work needing a professor looking at the mouth or the work in progress and validating. If anything they need too much evidence to go forward and will want to see things like a CT to validate something in a traditional xray. When they want to do a certain amount of required things, they screen the local community for cavities and turn up plenty, including mine when I went and they were sure to point out the cavity to me on the imagery and go over my options and relative risks. Most of the times they are overburdened with demand of patients since this is about the only place where low income people can afford dental care so I expect they see plenty of examples to study. Oddly though my student told me he hoards extracted teeth to study and practice with.
There are a lot of decisions in dentistry that are subjective. There are a ton of borderline cases of cavities where you ask 5 dentists what they think, and 2 say to treat and 3 say to wait and see. This is what I'm talking about where dental schools will probably lean towards treating.
All my previous experiences I had minimal issues, and then suddenly at a different dentist I needed several fillings and needed to drill a good tooth to "fix a cavity" in-between my teeth.
I didn't get any of that done.
My next visit at a different dentist a couple years later and I had a single tooth that needed a filling.
When something feels off, it's always good to get a second opinion.
The thing seems to be more interesting, here I talked to the university dentist, and it seems there a like 4 stages of cavity, and you only start treatment at stage 4. But it seems not 100% clearcut when stage 4 is reached.
> Former employees say Aspen Dental trained them in high-pressure sales. Corporate management scrutinizes the production of dentists and staff daily. And internal documents show that dentists get paid bonuses as key production targets are met.
> "Especially when that fraud involves performing unnecessary procedures on kids —here, unnecessary baby root canals and tooth extractions, among other procedures —we will not hesitate to use every tool at our disposal to punish those who break the law," Bash said.
> The accusations against Kool Smiles included prohibiting parents from being present during root canals "to keep hidden the child's suffering" and retaliation against "unproductive" dentists, according to a federal complaint filed in San Antonio in 2013.
My wife went to Aspen recently (we didn't know better). They told her that she had periodontal disease and needed an expensive procedure. She was shuffled into a "financing" room before even completing her checkup. While waiting, she Googled Aspen and figured out that this happens to oodles of people, declined, and went to another dentist. No problems detected.
In addition to being a scam organization, we got to see the group of people in the waiting rooms at Aspen vs our current dentist. As you can imagine, the folks waiting in the Aspen waiting room are observably less wealthy and are statistically going to be less able to defend themselves against medical scams.
Having an unexpected cost and thereby not making a profit isn't actually a punishment - it makes the risk calculus a tame "I probably won't get caught", while the expected value remains positive. I realize I'm criticizing our entire enforcement philosophy for white collar crime here. But still, unless there are actual routine-disrupting punishments like jail time for violating basic professional responsibilities, we would expect unethical behavior to just continue increasing.
And this goes double for setups to make such violations "nobody's fault" like the creation of perverse incentive structures. In the context of blue collar crime, that's called a "conspiracy".
It is unbelievable how much my faith in the necessity of dental procedures has risen after I started going to see a dentist that was my friend first, and my dentist only later (after I got tired of constantly wondering if the others actually had my best interests at heart).
I never doubted the dentist I had during my youth, and as far as I know he’s actually just really good at his job, so it was kind of a shock to find that so many of them are just winging it.
This was my experience as well. I went to the same dentist office for years with no issues. He sold the practice so we went to the new guy...every single time we went in there was a cavity that needed to be filled.
Went to a new dentist and everything is fine again.
One of my good co-workers is daughter of a dentist from the UK. the practices there are much different. We have had him analyze xrays and scans, he says its fine the people here just want/need your money!
If you are in need of cavities repaired I suggest getting in touch with your local dental school. Once a year there will be a practical where students have to repair caveties on a patient, so they will often offer free cavity screening + repair to the public for these exams. When I went to one, they discovered a few very small ones that looked like they could get bad in the future and opted to just do them right then. Dental schools outside of this are probably the cheapest way to have competent dental work done especially if you are uninsured (payment plans will be very permissive too)
> I think a lot of dentistry comes down to how much money they need that month.
I notice that even with my NHS dentist and just in how long he recommends leaving it until next time.
When I went back after 18 months (on a recommendation of 12-18) I got a cursory checkup, probably the most glowing 'all fine' I've ever had, a routine X-ray (i.e. that wouldn't be due again for a while) and then he asked to see me in six. I double-took and confirmed, so booked in for six months.
(Then we had a pandemic and it was more than two years before I could get a non-emergent appointment. That went fine too.)
My dentist is very busy. That often means that I have to wait a couple of months before I can get an appointment, if I'm not in active pain. That is of course sometimes annoying. The flip side of that is I'm quite confident that she won't suggest anything that isn't necessary since she already have a full schedule.
Reminds me of an experience I describe as "two out of three doctors agree: you're not on fire".
(It was just a bit of body hair hit by an electrocauterizer that was smouldering, but two doctors in the room told me I was imaginging the heat and smell, while the third rushed to grab a cup of water).
I had a dentist appointment before COVID. They found a cavity and scheduled me to have a filling. Then, COVID hit and I cancelled the appointment.
I went back two years later for another checkup/cleaning. They didn't find any cavities.
Maybe it healed itself? Apparently that's possible via re-mineralization. Either way, if that was possible, then perhaps they shouldn't have been so eager to drill and fill?
To add to the confusion of the very real risk of immoral and unnecessary dental work mentioned elsewhere in this thread - xrays can be legitimately difficult to interpret when looking for small cavities.
Ideally you do want to get even small ones filled as a preventative measure. However IME trustworthy dentists will acknowledge the potential for false positives on less obvious xrays upfront and offer a choice of either probing the area with a very fine drill first or simply defer work altogether and monitor it on each check-up.
Point is, in your case it could be an untrustworthy dental practice (suggesting unnecessary procedures), or the original xray was ambiguous and there was never anything there, or the dentist was poor at interpreting it. Either way if it was that minor they should have made it clear - i'd recommend scepticism next time, feel free to interrogate them, they are doctors and usually welcome it... if they are unconvincing and defensive, go elsewhere.
> Ideally you do want to get even small ones filled as a preventative measure.
To add even more confusion, this is mostly untrue. Fillings don't last forever, so prematurely filling "starts the clock" because the filling will eventually fail and every time a filling is made, more healthy tooth must be removed. (I say mostly untrue because mercury amalgam fillings really can last multiple decades, but these have fallen out of favor).
90-degree? Yeah, you should get those wisdom teeth out because general anesthesia at your advanced age would not be good for your longevity. That is, if your wisdom teeth were ever then to surface and rot.
General anesthesia? Here in Europe we don't do that. I had one wisdom tooth that got rotten and the injections did not help with the pain because of the infection, so the nurse held me down while the doctor pulled the tooth, me screaming in agony. Then they gave me a shot for the trauma so I would calm down. This is Northern Europe.
Holy smokes. It sounds like you weren’t given the option, but did you prefer that to the risks of GA?
(Honest question, no agenda. That sounds like something that would make me never go back to the dentist, but maybe that’s just me projecting popular dentist horror.)
Honestly it's just not a possibility in most of the dentist offices I've visited in Estonia as well as not really a thing (I don't know anyone who has ever gone under GA). Whatever horrible stuff that needs to get done gets done with you wide awake, and that's the norm. Good thing is that it's over pretty quickly.
When I lived in Spain I knew they offered GA there, but it usually meant paying 100+ EUR more, which is quite a lot. And europe doesn't really have a thing such as dental insurance. In most countries (Not 100% sure) in Europe you pay out of pocket for all the dentist stuff. Maybe you get a free cleaning once a year.
But other than the availability of GA and the money, I have nothing against it and would have obviously preferred that to my experience of medieval dentistry.
Not only that but from what I understand, a major nerve in your jaw grows closer to your wisdom teeth over time. So if you wait on a procedure like that until later in life, it increases the chance that the nerve will be damaged in the procedure, leading to a potential loss of feeling in part of your face. At least this is what I was told by my oral surgeon, assuming he wasn't lying to me for profit...
I waited until later in life. I have a partial loss of feeling in my face now, along with referred sensation in the same area (I feel things on the inside and outside of my mouth simultaneously, it is bizarre.)
Impacted, unerupted wisdom teeth are not always a problem. If you're over 25 [1] it's highly unlikely they'll ever attempt to erupt, never causing a problem.
Impacted wisdom teeth don't always stay impacted when they start moving too. They can straighten up when they start coming in.
I have 4 impacted wisdom teeth completely sideways, and dentists on the east and west coast of the US have told me not to bother taking them out since I was 25 or older unless they start causing me problems.
Dentists are trying VERY hard to get included under standard medical insurance in the US. If you think they're scammy now, wait until they can start billing your insurance. People with insurance are often divorced from the cost of services rendered so they'll really be able to reap profit then.
The naive part of me wonders if this will improve services. I have good health and dental insurance and while my health insurance becomes really beneficial once I've hit a threshold and met my deductibles, there is a hard upper limit on how will be paid for dental work annually, to the point I've had to spread (non-emergency) care over multiple years to cover the costs.
Ah yes! I had to repair a broken tooth when I was in the US, which was covered by our insurance. The dentist took 19(!) x-ray plates of my teeth, which she then charged the insurance company for.
We recently moved and my wife & I both scheduled checkups at the same new dentist. She recommended a crown replacement and Invisalign to both of us, in my case while wearing an Invisalign-branded face shield. We both got weird vibes from that place and don't intend to go back. Didn't help that the hygienist said something like "oh, the crown replacement is easy, we just got a brand new machine to make them in-house!" which sounds to me like "wow we really need to pay off this machine"
I had a very similar experience with a new dentist this week and the front desk was very pushy with getting me to schedule an appointment for a routine cleaning. I'm still mad at myself for acquiescing but they were determined to steamroll right over all of my attempts to politely demur. I don't intend to return to the practice but I am absolutely dreading the phone call to cancel the appointment because I know I'm in for even more of their aggressive "encouragement" to change my mind.
Dentists don’t remove wisdom teeth, they just refer you to an oral surgeon. The problem with wisdom teeth is that they increase maintenance requirements, it’s hard to clean back there and they can affect adjacent teeth if they do go bad. So I get why many dentists default suggest to remove them (I still have mine but recently started running into problems at 47).
Yes, there is a risk of complications with wisdom tooth removal. I was lucky twice, but when I had the lower ones removed, I got an infection blowing up the side of my face with a racketball-sized lump.
The oral surgeon had to prescribe anti-biotics and follow up with a "debridement", reopening the site, draining and flushing it. No fun at all. Also not something that's normally done at a dentist's office.
No way would I have done lower wisdom tooth removal without total-knockout anesthesia (Propofol). For me it's as much about the sensory input, sounds, and visuals of the hardware tools used. With the Propofol, it was a painless "30-minute time-travel" experience but I still felt exhausted for a couple days after the procedure. It's like my body knew what it went through even though I have no memory of it. Apparently this is a common feeling.
The upper wisdom teeth come out easier and heal faster. I had those out with just local anesthetic injections, nitrous oxide, tightly shut eyes, and headphones blasting music.
I had all of my wisdom teeth removed with just local anesthetic and nitrous oxide. It is certainly an interesting experience as you listen to your teeth being broken up by what amounts to a large ice pick. It didn't really bother me though.
The worst part of the entire procedure was that they wouldn't call my prescriptions into the pharmacy in advance, so I could just go home and not run errands after the procedure. I guess people will schedule fake wisdom teeth removal so they can get a 3 day supply of Tylenol with codeine? I remember being very annoyed waiting around for a half hour in some grocery store with my mouth full of gauze and the pain setting in. Would have preferred to be at home in bed. Sigh! At least I don't have any more wisdom teeth.
Perhaps in the US where they drug you down? Here the dentist just gives you a local anesthetic and pry them out, unless there is something extraordinary. Or perhaps it's a different person? But still the same company getting the money.
I'm in the US. I've had one out and I just got novocaine and elbow grease.
It was honestly an awful experience. Trying to pry that thing out while I couldn't feel a thing, but I felt incredibly drained afterward. Not sure if it was from adrenaline/anxiety or if you still respond to the trauma despite no immediate pain or sensation.
Then I had the pleasure of little shards and chips working their way out as I healed over the next several months. It really did take a good 3-4 months before I felt remotely healed back there.
The US usually has both options - and the dentist will usually recommend the surgeon, especially since some medical insurance will cover that but not the yank and jank.
Oral surgeons in the US are usually found in larger hospitals; most dentists are just dentists.
It would also depend a lot on what's going on with your wisdom teeth. If they haven't erupted at all and are causing trouble, that's oral surgery time. If they're fully erupted, a regular dentist may do it. In between, it depends.
I was referred to a oral surgeon at the university of Washington (but there are oral surgeons affiliated with Swedish hospital also), my dentist is the typical private practice. Financially they are completely unrelated.
"Payment by or to a physician or health care institution solely for referral of a patient is fee splitting and is unethical. Physicians may not accept: Any payment of any kind, from any source for referring a patient other than distributions of a health care organization's revenues as permitted by law."
While I have heard of plenty of scammy dentists myself, I don't see a reason to complain about them cleaning your teeth. If you actually told them you just got your teeth cleaned that is a different issue though.
Dentists aren’t really setup to assume the patient is being weird. It’s like going to a full service car wash right after getting your car washed - they’ll wash it again for you.
You don't just get your teeth cleaned to remove tarter though. It is part of preventive holistic dental plan. If you want a better chance of finding early decay and get to the bottom of any sensitivity you need a hygienist to poke around a lot more than the dentist usually does.
In my case they found a tumor in my jaw during a cleaning that even was overlooked in a full set of X-Rays.
I think you'll see the same thing wherever people have complex problems and they consult people with an individual profit motive. Car repair, for example. Or alternative "medicine" things like chiropractors. Some of the people will be legit. Some will be frauds. And in the middle you have a bunch of people who don't intend to be frauds but that just hill-climb their way to good businesses but aren't skilled and disciplined enough to measure the value of their interventions.
I suspect the same is true of people getting contract development done. Given the number of horror stories I've heard and the number of terrible code bases I've had to clean up, I'd guess the custom-software industry is no better than dentistry or car repair.
my dad is a dentist (oral surgeon by usa definition) and he took out all my wisdom teeth (that didn't bother me at all) one time I visited him at his practice.
from my single data point I can conclude that:
1) dentists will remove wisdom teeth that don't bother you even for no financial gain.
2) never visit your parents practice unless you have a excuse to bail out immediately if they try to get you on the chair.
One explanation I've heard (don't remember which news source) is that dentists just don't have as much demand as in previous decades.
Due to improvements in hygiene, and public health measures such as water fluoridation, children get fewer cavities and adults lose fewer teeth ("having an insufficient number of teeth" was once a major cause of men being rejected from the military draft).
So dentists have had to pivot from providing necessary care, such as fillings and extractions, to more discretionary services such as whitening and other cosmetic procedures (oh how my last dentist used to try to push Invisalign® on me at every visit!)
And some dentists are straight up charlatans wanting to line their pockets. When I moved across the bay I left my dentist of 10+ years and went in search of someone closer. I admit to delaying a couple years, but found a place, got cleaned and x-rayed. The dentist told me I had 13 cavities that needed to be tended to. I was pretty shocked; I don't have great teeth, but to have developed that many cavities in such a short time seemed wrong. I went back to my old dentist for a second opinion and he told me that I had 2 genuine cavities at the edges of old fillings, but the rest of it was pretty much nonsense: amalgam fillings that could be replaced with porcelain for appearance but were still perfectly good, and some slight discolorations that were not actually cavities.
At least in the US its because dental insurance isn't part of normal health insurance. Dental insurance mostly just covers the bare bones (teeth?) treatments like regular cleanings and an xray every couple of years. SO in order for the Dentist to make money they ahve to upsell every other treatment not covered by insurance. With regulars health insurance the doc is payed for pretty much any specific treatment they deem necessary so they know they will be payed.
I think if we had the 'pay out of pocket' kind of thing for other health care we would see the same thing.
I'm not sure I see the contradiction? I'm just saying that if regular health care only covered something like wellness visits and a cast every other year they would probably be more likely to try and sell you additional services to drive their revenue.
And by upsell I just mean convincing you the financial burden is worth the proposed extra treatment. Right now as long as I have health insurance I don't care abut the extra cost of extra treatments beyond a health check because I don't directly bear the cost.
I mean pretty much every other health related thing that's not covered by insurance has the same dynamics; eye care, cosmetic surgery.
I think its because they don't keep up with the field. You have some dentists who learn how things are done when they are in dental school in the 1970s and that's how they continue to operate in their private practice until they retire. They might also be good friends with other specialists and will send their patients there because of that relationship (and they do at least trust their work). There are also different philosophies. Some dentists might prefer you keep original tooth if possible and have you get some advanced imaging done before they decide a treatment plan; others might lean on the side of avoiding additional imaging and just pulling the tooth assuming it is compromised.
To get around that, I prefer to get dental work done at dental schools. The faculty at the schools have their own practices within the schools, and you can be sure that they are doing all the up to date stuff that is currently being taught and following sensible practices in terms of treatment plans. Prices are also fair. If you opt for a student dentist its even cheaper and many low income people use this service (although appointments are much longer since everything they do has to be signed off by a faculty member responsible for a floor of students).
Pediatric dentistry is especially scummy. If you don't do insanely expensive treatment that almost no one did 20 years ago you could maybe potentially sometimes damage your kid's oral hygiene permanently.
If you want a laugh, walk into a chiropractor's office, and learn about the many issues your spine has.
People tend to be unfortunately incentivized to find something wrong with you, as they get paid based on treatments performed.
In the US, this produced the idea of Health maintenance organizations (HMOs), where there is a large member count paying a fixed fee. The hope was they'd want to spend on preventative care, and minimize other costs.
> Laser bacterial reduction (LBR) is just one example of the many high-stakes medical decisions
Whether or not to drop $400 is not a "high-stakes medical decision". Also, expecting Google to give you high-quality medical advice when your actual, licensed, trained dental hygienest is not is asking a lot of a search engine.
Personally I've found sticking "examine.com" on the end of most results to be very useful for anything supplement-related, and "reddit.com" as a suffix pretty good for anything else.
> Whether or not to drop $400 is not a "high-stakes medical decision".
This just feels out-of-touch. $400 on a medical decision is a MASSIVE choice for many people -- it could be the difference between whether not they eat.
Ok it's not life or death so it's not high-stakes to you, but it's about whether to get treatment to prevent your teeth from falling out. Whether or not to ignore your doctor's suggested treatment for that is certainly something I'd consider high stakes.
The point is that by framing it as a medical decision they change the calculation, pushing it ahead of other important things the patient might spend on.
It's still a laser focused at your gums based on limited studies. What if this ends up creating health issues? Looking at some studies on risks for that procedure, there's small issues like itching sensations that last for days but also more serious issues like badly fitted eye protection that could potentially end up causing blindness.
All medical decisions are high stakes, even if they don't end up working. Even without effects and side effects, the confidence from the laser could mean the author stops flossing for example.
Think sugar pills and homeopathy. If you end up trusting that the useless pill prevents cancer, you might stop going to your cancer screening appointments.
It can also become very costly if the procedure is then added to all other appointments. In an economy 64% of the population lives paycheck to paycheck, this can open a can of worms when presented as a mandatory (or strongly encouraged) procedure.
> Also, expecting Google to give you high-quality medical advice when your actual, licensed, trained dental hygienest is not is asking a lot of a search engine.
This is true.
> and "reddit.com" as a suffix pretty good for anything else.
LOL. Our definitions of "high quality" are apparently different.
I don’t have a source off hand but I definitely read an article about how Mods are routinely contacted by advertisers. I’m not saying every subreddit is a bunch of corporate shills but we are basically trusting unpaid volunteers to not take payments to look the other way.
A one-time, or even recurring, payment of $400 may not be a high-stakes financial decision (though for too many people it is), but there is quite a lot at stake medically in choosing dental and periodontal care and treatment.
I appreciate your suggestions for improving search results.
> In the pre-Szaszian era, medicine was something that happened to you. You would put your health in your doctor's hands and they would unilaterally decide your course of treatment. But in today's patient-centered world, doctors are more like consultants
To be honest I've only seen this level of "patient-centered" stuff in the US. Never heard the phrase "Ask your doctor about xy" anywhere but on US TV. Sometimes pretty hard drugs like psychotropic drugs. When I first head it my response was "WTF, shouldn't the doctor tell you what you need and not the other way around?"
I guess it comes down to the batshit crazy US healthcare system and people losing trust in doctors that give them 40k$ bills for simple treatments or short hospital stays
> Never heard the phrase "Ask your doctor about xy" anywhere but on US TV. Sometimes pretty hard drugs like psychotropic drugs. When I first head it my response was "WTF, shouldn't the doctor tell you what you need and not the other way around?"
This was the case for many years where it was illegal to have advertisements for prescription medicines. They lifted this like 15 years ago. This was very favorable for the pharmacutical companies as now patients are going to go to doctors and ask exactly that.
What is worse now IMO is these direct to patient ads on social media from Cerebral. They show a lot of common things that people do (Like slack off, not pay attention to something boring), and then encourage them to talk to them for ADHD treatement. While more awareness of mental disorders and health is great, it is a bit scary when people can get convinced they have a disorder that needs pharmaceutical intervention and shop these firms until they get a script.
Imagine your grandmother who knows nothing about computers or tech asking you about GPUs and which programming language is best because she's curious about buying Bitcoin vs investing in Ethereum.
For someone who can't tell the difference between a screen saver and a computer virus, the discussion is meaningless, and only the illusion of control exists
I had a sugery for a common issue performed, as it happens, by the ex head of some surgeons union type organisation in my country (Ireland). The established technique has an uncommon but not so uncommon tendency to have issues where you just dont heal properly. I was unlucky and I didn't heal. I spent a year being tended by various nurses and reviews etc etc and when I finally started to research it myself I found there was a new far better surgical method available, but the guy who did my surgery was old and hadn't kept up to date. I found a surgeon who specialised in the new method and I was fully healed and done forever in a couple of months.
They might be an expert, but it's your (literal) skin in the game.
This is such a silly metaphor I am going to ignore it and answer the initial question.
Why? Because the things I personally value in my life and health are not always aligned with the things doctors try to optimize for.
I’ve told the story here a number of times but my tonsils swelled up to the size of grapefruit a number of years ago. After 6 months of steroids and having them drained I wanted them removed. My doctor did not think it was necessary, even though I was living in misery. I ended up just going to a doctor about an hour away and had them out within the week.
You're abandoning the context of the thread. The original comment you replied to was about how the US Healthcare system should be fixed so that you always know doctors are optimized for your needs
And to extend your analogy, instead of the grandmother talking to a helpful expert, all the information they are given comes from BitCoin salesmen, and she's expected to "do her own research."
Not everything is “fixable” in health and sometimes this means that there isn’t one “right” choice for treatment. Involving the patient in the decision making process is important because people have preferences for what is right for them and their life and the doctor can act as a well informed partner in care.
I have multiple sclerosis. There’s not a cure but there is highly effective medication. There’s also less effective medications. The highly effective stuff is various degrees of immunosuppressive or has a risk of fatal brain infection that is manageable with proper testing and monitoring. The less effective stuff can seem “safer” because it lacks these particular risks. A regular neurologist might not know very much at all and give outdated advice and treatment plans compared to some specialists and for this reason advocating for oneself is hugely important as long term outcomes can be greatly different based on the treatment choices. The fact is that you can’t just let “medicine happen to you” because the person that cares the most about your medical outcomes is you. Obviously this is an extreme example but it’s one of many.
Well, you know a phone book? And, you know how if you want to phone someone, you tend to look up their number in a phone book?
"Yes"
Well, computers are the same. They only know numbers, they're computers after all, and DNS maps the names you see for websites, to numbers, so computers can find the website.
"Uh, OK"
The adblocker I am going to install, makes it impossible for the computer to see the numbers for advetisers. It can't find them in its phone book any more. So, no ads!
Now grandma understands how DNS works, and what some adblockers do.
Some things are not as technically complex as we think they are.
Maps names of websites? I don't know what that means.
Timmy showed me The Amazon and the egg cooker from there worked wonderfully so I don't want an ad blocker.
I mean, I do see where you're coming from, and I have in the past second guessed some medical advice and asked if they'd considered a particular diagnosis I had a hunch on.
On the other hand, they're a professional and they've usually spent the majority of their life training to be good at what they're advising you about. I don't demand to be involved in the design of planes I fly on or bridges I cross, because frankly I'd do a worse job than even a pretty bad qualified engineer.
I "feel" like I would like that as well. But if I every get really ill with something longterm, I'm also afraid I'd spend too much energy on all the decisions and research. Giving patients options also gives them doubts.
I think individual patients have very different preferences on this. I've taken pets to a few different vets, and some say things like "There are many possible reasons for these symptoms. Let's try XYZ and see how it goes." Others are more like "Your dog has X. We'll do Y and it should clear up."
My preference is for the one who I think is being honest with me about how certain they are about what's going on, and when a medical professional seems like they want to appear 100% certain all the time it makes me worry about their judgement.
I think many people have the opposite preference, which seems to me is asking for dishonesty. Seems like an ethically tricky area.
It goes the other way too. If you have anything but the most common illnesses or conditions that you are likely more knowledgeable about your situation than your PCP since they're the tier 1 help desk of medicine. This kind of thing is totally fine and expected, it's why specialists exist but it's really frustrating because your PCP is often treated as a either a gatekeeper or unnecessary busywork to get to the more qualified person.
That's not true. We have the drug ads in the US because legal precedent since the late-70s/early-80s (roughly) in the US now protects commercial speech.
Companies are legally considered persons, hence their speech is protected. This is consistent with individual sovereignty. If people are wards of the State, then the State would have the responsibility to police "harmful" speech; advocating untrained people to ask their doctor for a specific medication could be considered harmful speech (since apparently only two countries in the world allow it, and not even the US before the 70s-ish, apparently).
I'm not trying to condone terrible drug advertisements but man there has to be something to let people know that their "normal" suffering isn't normal or that there are new developments that your PCP for sure isn't gonna keep up with.
I know the meme de jour is teens diagnosing themselves with ADHD because of TikTok but it's the perfect example of a whole bunch of people being like "holy shit it's not supposed to be this hard all the time? You can actually do something about it?"
Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit.
Many physicians thought that DTC ads made their patients more involved in their health care.
Seventy-eight percent of physicians believe their patients understand the possible benefits of the drug very well or somewhat, compared to 40 percent who believe their patients understand the possible risks, and 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs.
Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
DTC ads help patients have better discussions with their physicians and provide greater awareness of treatments.
The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
there has to be something to let people know that their "normal" suffering isn't normal or that there are new developments that your PCP for sure isn't gonna keep up with.
That should be the doctor's job. Doctors have too much financial pressure to pump patients through, so they have neither the time to get to know individual patients nor time to keep abreast of current trends in their speciality.
Should MedicineX be allowed to have a website with a FAQ? Yes. Should MedecineX be pushing ads on TV/radio that make it seem like it's a cure for everything that ails you? Nope.
Sure, but people need to first know what they're dealing with isn't normal before they can even ask about it.
I have really, really bad fatigue. It took me years to figure out everyone else didn't feel that way. I was in high school and was able to skate by on intelligence alone.
Low-quality SEO content marketing has been taking up more and more of Google Search results in the past decade.
Maybe it has always been this way, but anecdotally it feels like it has gotten so much worse in the last few years.
The exception to the SEO spam rule seems to be a small subset of “highly trusted sources”, that at least for medical information seem to be biased pretty heavily towards “don’t say anything that can get us sued.”
I don’t know the best solution to all of this, but I really think that content marketing is getting to a point where it has drowned out actual content. I wish Google would put a downvote button on their search results page that I can click to indicate that a highly-SEO’d result was not actually useful for my query.
It's about to become uncontrollably bad. With really powerful artificially generated writing available, spammers will develop it to be indistinguishable from real human writers when analyzed by google's own machines. We're going to have billions of websites that are 100% generated, with content that most humans can't distinguish as entirely generated, and a LOT of it is going to be wrong. It will completely drown out human written content to the point that websites using humans will give up, and there will only be spam left.
It's always been bad. But Google has always been less bad then other search engines.
Then also you need to ask the right question. Googling something like "Toyota RAV4" will give wildly different results than "common problems with Toyota RAV4".
In this particular case the better question should've perhaps been something like:
There are times when I just cannot come up with the terms to get past the SEO at all and just give up, not knowing the answer or finding the relevant source. It seems like it happens all the time these days. You end up with something like writers block coming up with new ways to frame the question to shake off the spam. The best I can hope for usually is appending site:usuallyrelevantinfo.com to a term but that requires a priori knowing these good sites for a given topic.
I have found that dental clinics in the US can be some of the shadiest health related businesses you have to deal with.
There are few independent clinics around. Most of them belong to huge corporate conglomerates that push down shady treatments like this, or offer predatory financing for these “treatments”.
I’ve had only two instances of a health professional outright lying to me and telling me I had a health condition that I didn’t have, and both times were dentists. One of those times was also about periodontal disease, so it seems like this is a common thing.
A good heuristic is that if the treatment isn’t covered at all by insurance it very well might be worthless.
One thing I've found is that many doctors are willing to share the rationale for their decisions and recommendations if you question them on the state of the research. Some have even gone as far as to send me papers after we've met. Doctors in many cases are human body-nerds and are willing to talk with interested patients about their subject.
Doctors who won't justify themselves can often be avoided at least in medium-sized and larger urban areas.
The main observation is that in medicine you need to be your own advocate. The doctor is used to people who just want an answer or a cure. They're not going to break out the journals for every patient because most patients don't want that. This also goes for dentistry.
Maybe that's regional? In my area (Minneapolis/St. Paul metro), there are tons of independent dentists and few conglomerates (at least that I know of). In my little-ish suburb (25k people) there are no corporate ones but about 6 independent ones.
I go to an independent office (2 dentists) and I've never felt pressured by them and they've even said things like, "It looks like that may turn into a cavity, but we can wait and see what happens."
Obviously I'm not saying it doesn't happen, but like anything, it's not everywhere.
I’m quite critical about Google declining search quality but in this case I think pointing the finger at them is clickbait. The fact is that the dentists have “flooded the zone with shit” and google hasn’t much to work with.
I would appreciate if google could elevate more “google scholar” results and also have a zone of clearly marked “likely low quality matches” but apart from the howls of outrage from the bullshitters, this would be very hard.
Also note at the end the author pitches their alternative.
==
BTW the laser is a capital investment (or lease) for the provider so the laser manufacturers are always coming up with new ways to use the device and sending them to their customers (mainly dermatologists and dentists — people outside the managed care, and often insurance, infrastructures). These suggestions are typically worded in a way that doesn’t get them in trouble with the FDA.
So even if a dermatologist buys a laser to remove birthmarks, most of the time it will just sit unused in the corner of the room. So they add tattoo removal. Next thing you know it’s a cosmetic liposuction alternative for the area around your mouth.
I had almost the exact same experience. Sitting in the chair prepped for a cleaning and the DH dives into this tale about “bad bacteria” and how if it gets into my stomach during the cleaning I could have all kinds of problems including heart disease and so on. Then the follow up treatment plan had other “beneficial” procedures not covered by insurance - platelet treatment to improve healing. I called the insurance company to ask about the plan and discovered the uncovered items were more than the actual procedure itself. The dentist wouldn’t negotiate or change to a code the insurance company recommended.
Imagine a health care system where the insurance company is, relatively at least, the "good guys." That's how badly off we are.
I personally have a story of a great doctor who went to the effort to try a less-well-known (but still entirely conventional) treatment that resulted in a much better outcome for me. But that just highlighted the fact that great treatment outcomes are a haphazard occurrence in a sea of crud where neither the insurer nor the provider prioritize the patient over maximizing revenue.
What this story illustrates is that paying out of pocket, which presumably put greater market based pressure on health care providers, is even worse.
Not all parts of the economy work bast when least regulated and maximally market driven. Without information from disinterested parties, and without oversight from outside the profit-driven parties, you just get farmed by crooks.
It's really weird. One of the widget boxes rephrases some of your search into explicit questions, and then the result is an out-of-context snippet that is definitely not answering the question.
This is 100% true. While attending an NLP
class in college, a speaker from Google came and spoke about how they evolved their systems etc. He admitted himself that results from those QA excerpts are hilariously wrong.
Reminds me of my old dental hygienist who would "threaten" me with a more invasive (and expensive) cleaning process every time I'd visit. Switched dentists, mentioned my "gums" and the concerns of my old dentist, and they were like "no, your gums are fine".
Also reminds my of my experience with my disease "specialist" and my GP. Specialist is concerned about my cholesterol, puts me on meds, schedules regular (now expensive) blood tests. I mention it to my GP and he's says "your cholesterol is fine, don't worry about it"
I have been dealing with "mysterious" pelvic pain (cpps) for about 8 months or so. No doctor has been able to figure out what is wrong with me. The process of working with doctors has been traumatizing to say the least. I once had trust in our medical system, but my perspective has changed.
I now have little faith in most doctors ability to solve my medical problems. I recall someone on HN saying they are basically "chat bots", and sadly, I find that to be an accurate description. I've turned mostly to the internet for help. The internet has both helped and harmed me, though I would say overall has been less harmful than the experiences I've had with doctors.
Doing my own research on the internet does make me feel like a "kook", but I would not even have a label for my condition if I had not done so. I can live with some discomfort if I can at least put a label on what I am feeling. It's also comforting to know there's people out there with the same condition as you.
I have access to research and studies online, but if the doctor was not aware of it, they are quick to discredit it.
The one thing I am grateful for about seeing doctors is their ability to rule out the common/serious conditions. That has been helpful, although I have found that simply "getting permission" for a procedure, or to see some specialist, is way too difficult. Often times specialists are booked out for months. It's so discouraging.
My wife has a mystery condition that flares up every few months / years. Every time it gets bad enough, the doctor prescribes antibiotics and then runs some tests. When the test results come back 24hr later, the conversation is always the same: "I thought it was [a very common problem], but the test results ruled that out. Since you already started the antibiotics, you should finish the course. Call me again if the problem gets worse."
So we're left without answers and with an unnecessary prescription for antibiotics, every time. It's pretty frustrating, to say the least. The internet has come up with "interstitial cystitis" as a possible culprit, but it's not much of a diagnosis with an unknown cause, no diagnostic test, and no peer reviewed treatments.
I mean in the broadest sense that's a cultural question and most big online platforms have decided that it is their place—Facebook and Twitter in particular—because of pressures from the public.
In a much, much narrower sense, we are talking about Google and not an online platform. Google's explicit mission is, “to organize the world's information and make it universally accessible and useful.” Like, filtering out misinformation is literally the thing that Google says is its purpose.
I once asked the dentist why are there so many different toothbrush head shapes, with the bristles at all kind of angles and patterns, rubber inserts and so one. Surely by now we know what's the optimal shape?
And the answer was that yes, the optimal head shape is known, but since it's not that consequential this is not regulated as other medical stuff and basically everyone does weird shapes just for marketing and differentiation purposes (like colored specks in powder detergent which do nothing)
From my research the most important thing is for it to have soft bristles with round bristle heads (obviously you can't check bristle heads with your eyes, too small). Most you find in supermarkets have medium or hard bristles.
The head shouldn't be too big, so that it can reach even in the back.
Rubber inserts are not recommended, as they tend to irritate the gum.
Typically the better ones look more plain - no multi colored bristles or spaceship looks. However, since this becomes more known, it becomes a marketing signal in itself - like "plain brown paper package" chocolate, etc.
I have two “Cadillac” dental insurance plans. When I sit down in the chair I just inform them that I am not interested in any service that is not fully covered by my insurances, and if its partially covered, I want a pretty detailed breakdown of why I need it before I will agree to the service.
Dental insurance is sort of crappy in that what we think might be important treatments are sometimes classified as cosmetic and not covered (like implants). This is why there is a cottage industry of dentists doing implants for cheap in Tijuana.
My insurances do a good job of covering things that are related to my oral health. If I want a cosmetic improvement over a covered service, I dont have a problem paying for it. I’d rather the occasional outlay than my dental insurance being prohibitively expensive to account for a possible expensive covered cosmetic change.
What I'm saying is when you have a bad tooth, what do you expect to happen? Insurance pays for you to look like the toothless geezer spitting into the spittoon in old western films. That's the minimum standard of oral care they provide. If you want something as simple as a fake tooth, something i think anyone who gets a tooth extracted would opt to get, its not covered. Why can't I get insurance that covers this? Implants can be a lot of money and as a result there is this cottage industry of people going to other countries for lower priced implants vs having that dental care done where they get all their other dental care done. Just in terms of the carbon footprint alone that's a terrible solution.
Actually…you probably can, but it’s going to be more expensive that you…or your group (if it’s employer provided) will be willing to pay. So in those cases it’s not even offered.
My wife sells dental insurance to businesses. These brokers are doing plan designs that specifically exclude certain services to get monthly costs down to the expected competitive floor pricing. Think of it this way, you have 100 people in your group. 5 are willing to pay for implant coverage at $100/mo, but to get that rate, you need 75% participation of the group. 95 people will not participate if it’s more than $20 a month. Your plan design is going to be designed to appeal to the 95 over the 5 and that broker is going to bring in a plan that is as close to $20/mo without going a penny over…and hope like hell that their competition isn’t lower with a similar plan design.
Internet was always full of spam. But somehow Google was able to correctly categorize it. Now it seems like Google is not keeping with it. It seems like that sites which might provide trusted information are not ranked well. It is interesting that these sites do not have Google Adsense (since they are mainly run by schools, public institutions, etc.) The same is happening with YouTube.
I think it is definelly possible to sort results better (pure engineering problem). But there is really no short term insentive for that. Maybe in long term this will help Google to stay on top but that is not 100% clear: it is hard to predict how content discover will look in the future.
My guess is that having to dig through the results increases engagement time and clicks, so they probably have their AI test how long you’re willing to dig for an answer before giving up and calibrate results accordingly
I have a huge gripe with the phenomenon being talked about in the article.
First comes the idea that you can't make health decisions yourself, or treat yourself for health problems. Got a back ache? See (read: pay) a doctor. Got a wart on your toe? Got a sunburn? Go pay a professional for their services, this is the only solution.
Adding to this is the lawsuit addled consumer climate of our society. Best not give anyone any sort of information about anything, lest they sue you for it.
I actually googled a question and an article I read told me to talk to my healthcare team. Team? Each of us has to have an army of highly paid professionals to figure out why our head itches?
You can't google anything health related anymore and actually get information about it. You get a little walkthrough of possible causes of anything followed by a "see your doctor." I just want to know what exercises to do to relieve back pain.
Taking care of yourself shouldn't require you to visit a specialist for anything other than extreme circumstances. The information on how to take care of yourself is available online, hidden behind marketing funnels. Used to be I'd find a bunch of crystal healing blogs and the like, and I'd bitch about it, now I'm wishing for them back because in between the bullshit they're more helpful than being told to pay someone to (maybe) tell me.
I'm interested in an update on the author's startup. Last time I heard he was shutting it down, but at the end of the article I realized this was content marketing for it.
Btw these small brushes regularly applied _as instructed by professionals_ fixed this problem for me. I understand it can get really bad and can actually require more drastic measures.
> My DH clearly pushes this LBR thing on all her patients
Also for all our learnings' sake xrays often fall into this category. Dentists will basically demand xrays as often as the insurance will pay. This is not only a waste of money, but contributes to cumulative damage.
Yes, if you have specific exceptional circumstances then the cost/benefit may be greater, but I understand that in the main and for better exceptional cases you every 3 years is fine.
Whenever I see an article about the US healthcare system, I’m forced to wonder:
How is this system itself not a cruel and unusual punishment? Now obviously it’s because it isn’t applied as a punishment for a crime, which is I think the letter of the law.
Still, it feels like we live in some Kafka-esque nightmare where a huge number of things the US government ought to take care of are outright cruel… and that the cruelty is the point.
I just left my dentist because they kept pushing braces on me (invisalign). I am over 60. The old dentist didn't do these things. The new dentist was hard sell. They also wanted to replace a crown that was fine.
I found a dentist with a less invasive approach (and associated with the local dental school).
I think there is a problem with dental care. You have 1 dentist and it's hard to verify what they say.
There are tons of ethical issues in allowing medical ads to consumers as it creates perverse incentives (and just the for profit system in general, but let's not develve into that fight).
I get tons of Testosterone replacement therapy ads. And also 'adhd' ads.
These are real MDs, but they will give scripts to almost anyone. Many online only.
I'm not judging people who want to use. People will use drugs legal or not and it is far better to get real stuff from real MDs.
But advertising it? The whole point is to create / increase demand. This is not passively allowing safer use.
These ads are misleading; TRT ads of young super fit people or getting people hooked on stims for no reason.
How would people feel if there were FB ads targeting people who listen to EDM with dope or E ads? We are also inundated with alcohol already.
All drugs aren't comparable or similar danger profiles, but just shows how prejudice and assumptions from a prohibition system are imho hypocritical. using a more extreme thought experiment can highlight this.
My eye doctor a few years back tried to get me to get some kind of treatment (a device or some snake oil potion, can't recall) because I was allegedly not blinking enough and had dry eyes that could spiral into (insert mildly scary eye disease) if left untreated. Some googling helped me reach the same conclusion as this blogger.
So it's not just dentists... at least my dermatologist is pretty transparent about all the aesthetic treatments that complement their medical services, though they seem to always find a mole that needs a biopsy and every year it turns out benign. I wonder how many times it was necessary, versus how many times it was just an easy money grab because my insurance covers it and it's very minimal of a procedure. I don't have a problem with for-profit healthcare, but fee-for-service is driving the insane cost inflation in the US
> How often has Google responded to your medical question with putrid, SEO-optimized landfill? Google has found 29,100,000 results for my query, but it's like an all-you-can-eat breakfast buffet that serves nothing but reconstituted eggs and Yoplait. You know there’s a gourmet, peer-reviewed omelet station around here somewhere, but you won't find it by wandering around the main rotunda of Google's sad smorgasbord.
This expresses a lot of my feelings with the modern web experience really well. I feel like I'm constantly in "avoid" mode and it's becoming more and more difficult to get to content of actual substance and you are constantly being bombarded by garbage that is becoming more and more AI generated, making the volume higher and quality/relevancy even worse.
The cynic in me was thinking "ok, I've read the article, what product is the article selling? ok, here we go".
Although to be honest, I was nodding as I was reading. It's not only about medical decision, but with most decisions where you want to buy the best X. Maybe medical decisions are less... selfish? I mean - if I want to buy a toaster, I'll look at Which, and won't splurge on the most expensive one, but will look at what other people are finding useful. With health however, you probably don't want to spare expenses, so the decision making process will be a bit different - we trust people from which we're getting health advice.
I'm not in USA, and don't think this sort of thing is confined to USA
I read this whole thread, it seems to miss one major point. Insurance companies control treatments in the USA to an amazing degree. They push to overschedule doctors, literally down to minutes per visit, try to push as much as possible to lower paid staff (mostly nurses), and shape things for maximum profit. Nurses are handling things today that would have used doctors in the past. Much of the frustration people get is trying to convince doctors to go against insurance companies and order more tests, referrals, or treatments.
This is also why a weekend on pubmed and similar gives you a better result than a doctor ... who spent 2 minutes reviewing your chart and comes into the room for a few more minutes to talk to you.
Years ago I worked with a start-up called MetaMed, funded personally by Theil, to provide a team of private medical researchers.
They didn’t make it, but the premise was sound / that standard of care is about 30 years behind research (at best).
The mindset I learned there helped me overcome a diagnosis of Bipolar / schizoaffective by doing primary research and rejecting the medications of Standford Psychiatry…
8 years later, with a mix of shamanism, spiral dynamics, mens work, underground mdma therapy, 5meoDMT, somatic therapy, biomythic.com and coaching and I’ve finally got some place to stand within itself, no need for medicines, and no longer dealing w suicidal depression or manic psychosis.
Unless you have a specific issue dentists offer mainly preventative care. The thing with preventative care is that you can never really prove what is working and what is not. Also, you can never really know when you've done enough.
I think of it kinda like a car wash. You can pay extra for the fancy spray on waxes or you can just get a basic wash. How much does wax quickly sprayed on by a machine do for your car in the long run? Not much. But it makes you feel like you're taking care of your ride. Sub in teeth (a part of the body) for a car and they can charge almost whatever they like for shining bright lights in your pie hole.
Search google for the phrase "climate change" without quotes.
About 4,010,000,000 results (1.01 seconds)
Why don't the results go past page 5? (Only a few dozen exist)
If the dead internet theory [1] is true a new search engine may eventually emerge which focuses on indexing verifiably human-generated content with high information value. I have no idea what is going on with Google search results.
What the article author doesn't seem to realize is much of dentistry (and medicine in general) is not based on evidence. There is zero clinical evidence that flossing actually does anything beneficial. I wouldn't be surprised if there was a lack of evidence for 6-month cleanings actually being beneficial. Similarly, doctors make decisions based mostly on hunches and gut feelings unless you're actively bleeding from a gunshot wound.
I look forward to the day when AI is sophisticated enough to take medical decisions out of the hands of fallible and emotional human beings. (We're not anywhere close to that day)
The reasoning behind flossing makes a lot of sense:
1. You remove food sources for streptococcus mutans
2. You avoid inflammation from teeth shifting
3. You disrupt biofilm (plaque) formation in the joints of your teeth
I imagine the evidence is limited because genetics, diet and other oral hygiene routines significantly impact the outcome. There is a whole microflora system in your mouth, and the advice is to throw everything (floss, scrape tongue, mouthwash, brush) at it for everyone because personalising it is not worth the effort.
Yeah, but these same arguments apply in favor to the diode laser treatment the original article talks about. There is biological and chemical reasoning behind it. There are favorable vitro studies. And a couple of the systematic reviews linked in the original article conclude there is weak evidence that it is weakly effective (same with flossing).
I appreciate what you’re saying, but it’s worth keeping in mind that the cost of a single diode laser treatment can supply you with enough floss for an entire lifetime.
If the service was being provided for by the dentist for $1 I don’t think the author would have cared so much about the evidence behind it. Floss is just so incredibly cheap that even with weak evidence behind it it’s worth doing —- having just a 0.1% benefit, even if it’s just placebo, still has it being worthwhile.
Something is working, even if it may not be clear specifically what that is. My grandfather had a full set of false teeth by the time he was the age my parents are now. The other big change in that time would be diet, but I don't think more refined sugar improves tooth quality.
I mean, some things that dentists believe in do have strong evidence, like water fluoridation and fluoride in toothpaste. And some things dentists believe in don't, like flossing.
I only use Google to learn more about procedures, not to convince me to get said procedure. When my coworker and I got into a conversation about LASIK vs PRK, I found a Hacker News thread on Google that had discussed SMILE surgery as an alternative to both. I'll defer to my optometrist when I speak to him later this year and see what he suggests and what he knows because I know I can't trust Google to give me the type of answers I am looking for.
I've gotten to the point where if Insurance doesnt cover it then I don't get it. I can count on one hand the amount of non covered things that have been helpful in the past.
This policy is what stopped me from getting a treatment from my dentist that involved grinding down my teeth. Google results were mixed on the benefits. Dentist pushed it very hard. It was like $500 so I said no. Teeth have been fine without it.
It's a nice story about the motivation behind GlacierMD. Which seems like something that should be marketed to health insurance companies, assuming it targets a US audience. That's who stands to benefit enough from people making better decisions about discretionary health spending to actually pay for it... marketing it here seems like spending effort on an incompletely learned lesson from v1.
Google worked great for a long time. The beauty of capitalism is that a competitor that provides more valuable may supplant it. The day Glacier falls into the same short term cash trap, I hope someone else rises up in its place.
If you read through to the bottom, you'll see the article itself is just a call to action for yet another service which the author is starting. It's an ad. Seeing it buried so deep doesn't make me feel that the author has any better intentions than Google itself -- credibility already gone.
That's an extremely jaded outlook. Just because the OP is presenting an alternative solution doesn't necessarily mean it was all borne out of greed/profit-seeking. At least the OP's service was built from the outset to be facts- and evidence-based unlike Google search results.
I'm really not sure what you expect. Should articles which point out problems be written completely independently of the people creating solutions to those problems? Cos clearly that is totally unrealistic.
I'll ask you what I asked the other commenter: should articles which point out problems be written completely independently of the people creating solutions to those problems?
Even if it is an advert, it's not a shitty one. It presents scientific arguments and is well-sourced. It's about as a good as an "advert" as you'd ever get. Really, what more do you want from people?
Frankly, I'm just done with advertisements and commercial "speech" being normalized everywhere, including in articles, regular speech amongst humans, and more. I've been done with commercialism fake "culture" for a LONG time. And the more we have, the worse the pollution is with genuine conversations.
I think that's the real problem with articles like this. The moment I realized it was a commercial piece masquerading as a scholarly meta-article, I have to question all the previous discussion they have. Is it right? What are they trying to sell? What viewpoint are they trying to get me to follow?
Advertising is codified monetary deceit. We've moved long past "Buy my soda cause its yummy", to an ever-present dread of "if you dont have this, you'll be sorry" in a round-about way.
> should articles which point out problems be written completely independently of the people creating solutions to those problems?
If there's a commercial motive to use/buy/rent their shhit, absolutely yes.
> It presents scientific arguments and is well-sourced.
Depends. What are the biases of their arguments that the underlying commercialism is modifying? It now needs its own analysis to see if they were trying to sell me something different on dread or FOMO.
Greedy doctors and dentists are the worst, because they are half looking at your health and half looking at what they can get out of you and your insurance company. It erodes trust, is highly unethical, and is extremely common in the US. We need a German style health care system in the US ASAP.
I don't trust dentists. They push and push and push these extra treatments using guilt tactics and most of them are lies to empty your pocketbook. They are in no way like your doctor. Your doctor would never guilt you into a bypass surgery when you don't need it, but a dentist would.
I'm in a similar situation. I am looking for the right treatment of a vitamin b12 and folic acid deficiency, yet the amount of SEO spam and scams is just insane. I wish there was more signal in the noise of supplements, and further, in the field of medicine.
Insurance doesn't cover adult orthodontia either but that doesn't mean it's not evidence-based (just elective). And a laser-based cleaning technique sounds pretty elective.
Pretty good observation of the fact that it is hard to get actually good information on Google. You have to use `reddit.com` or something to actually get it since that's the one place with lots of user-history and good SEO.
More or less every time I go to the optometrist or the dentist I get a hard upsell on things: frames, contacts, whitening, lasering. It's painfully obvious and I can't find a place that doesn't do it.
Disappointing to see the OP using Google Forms to collect data for their beta testing product waitlist. OP clearly knows Google is bad but supports their business by using their tools anyway :(
This is a legal problem - allowing broadcast advertisements to the general public for pharma products is where the problem started. Before that, pharma had to advertise in targeting media directly addressing the medical profession only, e.g. JAMA, NEJM, various trade magazines, etc.
That's how this should be fixed - return to those limits. In an online environment that would mean limiting ads to doctors et al. on sites that require password and professional identification/validation. Otherwise information on drugs et al. should be presented only neutrally and scientifically to the broader public - marketing should be banned from the process.
> You're reading this in a year that starts with "2" so the only possible starting point is Google.
LOL. Seriously? Google the biggest known data whore, worst privacy invader on the Internet, whoring personal data out to any john willing to pay. Yeah. The year starts with 2 and Goog has been pimping your data for 23 years now and people still haven't learned they are not your friend.
The point is obvious but I'll spell it out for you using HIS own words. "Google almost convinced me to spend $400 on useless laser treatments". He presents himself as "in the know" because the year begins with "2" and anyone in the know would use Google to research an issue. LOL. HE then proceeds to place trust in an unethical company to give him information he needs to make a wise financial decision. Doh!
These are the same people driving around with WiFi sniffing equipment collecting terrabytes of data and then when caught claim it was not intentional. All that damned hardware got wired up by evolutionary means and the software got splatted onto the boot drive by a bird passing overhead. What crappy luck happening throughout the world like that.
But where does the author indicate that they don't think Google is unethical?
You're showing me that the author personally uses google, and that the author thinks the vast majority of people use google (which is true). Nothing about what they said suggests they think Google is ethical.
Honestly I don't see anything really wrong here. In the long run, you'll have people that get the treatment and people who don't, and over time you can compare these groups and outcomes. People will naturally gravitate toward the correct answer.
It would be nice if we could have an omniscient oracle to gate-keep us away from ineffective treatments - but we don't live in that universe. Instead we have (in the US) the FDA, which is staffed by smart, well-intentioned, and very fallible human beings, each with their own (well-intentioned) agenda. At the very least these folks are simply weeding out treatments with major negative outcomes, like killing the patient. So some placebos get through and called 'treatments' like LBR - unless there is some better treatment that you're forgoing, there's really not much harm except for the $400.
The folks that do a lot of research will make better choices than those that don't - but they will also help all those others make better choices over time as they communicate their ideas and results to the masses.
The title implies that Google is the culprit. The article paints a more nuanced picture. It blames Google for providing marketing results for a query about the validity of some dental procedure. It also shares some blame with the dentist for advising the procedure in the first place. However, consider the ending of the story. The author saw the marketing for what it was and turned to academic search engines for more reputable sources. Isn't that what we want?
I dislike Google for many reasons and generally avoid their products and services, but are they really to blame here? Google is a general purpose search engine whose business model fundamentally relies on including marketing in its results. It isn't a flaw in the algorithm; it's a feature. It's how they make money - and a lot of it at that[0]. If you want academic results, go to an academic search engine. That's exactly what the author did and it worked out fine. I'm down for an argument that we need academic works to be more accessible and digestible, but that's not really a problem with Google.
The other accused subject was the dentist, but I'm not so sure about that one either. There is a lack of consensus among medical professionals on many treatments and procedures, and this story could simply be another example of that. Medical professionals are humans, each with their own experiences and biases. Besides, it's not like the academic results cited by this article determined that the treatment was snake oil. Maybe the author's dentist had her own experience with the procedure and honestly concluded for herself that it was worth the $400. Maybe she was biased by anecdotal evidence or her own theories. Maybe she doesn't value $400 as highly as the author. Maybe she simply values dental hygiene more than the author. This is a great example of why it's important for medical professionals to act as consultants and for patients to make the final decision.
IMO, the big problem here isn't Google or the dentist. The problem is how much trust people have in those two as sources of accurate, unbiased medical information. If you're making a significant medical decision, you shouldn't accept a single source of information - even if it is academic - and you certainly shouldn't trust marketing material. Get second opinions. Do a little academic research. It's easier than ever before.
That said, if a $400 laser treatment for your gums isn't a "significant medial decision" to you, then feel free to just follow your dentist's advice. That's up to you.
I feel at this point that dentistry is closer to chiropractics and homeopathy than actual science.
Many years ago I wasn't in the best financial position and went to the dentist. He identified a number cavities needing filled and quoted a hefty sum, and I put off the procedures because I couldn't afford them. I diligently saved for 6 months to pay for them and when I went in for my next checkup, I asked about them. What cavities? No your mouth looks fine.
I've had similar situations with my children, getting quotes for thousands of dollars worth of work. Getting second opinions and using different insurance changes those quotes and scope of work dramatically.
At this point in my life, I don't trust dentists at all. I'm sure they're not all crooks but how do tell?
This is a great article. How do we fix it? We are experiencing late stage capitalism at every turn in our lives. I don’t know where to start. Regulations? But Google has moles in every level of government. A real search competitor? It feels impossible to think it could happen at scale. There is a niche for a company that is like the original Google and that could grow. How can we help it succeed?
I don't know that you can fix this. This is what people want. They need to feel like they've researched and made intelligent decisions, even when they haven't. After all, doctors aren't in it to make them feel better, it's all just some big conspiracy to make them more money (sarcasm).
My wife is an oncology surgeon and it's absolutely mindblowing the things her patients tell her or later post on Facebook. One of her latest winners is someone that flew cross country to California to get things like 3D Bio-Scans.
3D you say? That sounds useful. It's a 3D image of you, your cancer, your organs, etc, right? No. I'm taking this straight from their website:
> It has four FDA-approved technologies in one: Pulse Oximetry, Body Composition, Heart Rate Variability (HRV), and Galvanic Skin Response Devices;
Not a damn one of those is going to tell you anything about cancer. And then there's thermagrams, where they basically check your skin temperature to try and diagnose internal medicine, like cancer, colitis, gluten allergies, etc. And people just buy this shit up.
It really just reminds me of Steve Jobs' quote on television:
When you’re young, you look at television and think, There’s a conspiracy. The networks have conspired to dumb us down. But when you get a little older, you realize that’s not true. The networks are in business to give people exactly what they want. That’s a far more depressing thought. Conspiracy is optimistic! You can shoot the bastards! We can have a revolution! But the networks are really in business to give people what they want. It’s the truth.
> This was my motivation for starting GlacierMD: I wanted to give consumers the information they needed to make evidence-based health decisions. And although I lost that battle (spectacularly) I'm still fighting the war! If this is a topic that interests you, I'd urge you to
This characterization makes it sound like a good thing. In reality, the doctor’s responsibility is being pushed to the patient because they are overbooked in the name of economic efficiency.
As a patient with complex, non-specific medical condition, I can tell you how miserable this is.
I can’t count on doctors _at all_ to move the process forward. It’s always me, reading articles on PubMed and coming up with ideas.
I’m not medically trained nor am I scientist. It’s a lot of legwork for me normally, but the ways that being sick limits me make it much harder.
Further, the emotional and intellectual overhead required to negotiate with medical professionals is high.
Back when I could afford to, I saw a neurologist at an office that didn’t accept insurance. She choose to see fewer patients and give them more time, as well as spend time doing research to look for new clues and ideas.
This worked really well and I made progress with her.
The rest of the American medical system? Gatekeepers that block access to potential treatment pathways until you can convince them it’s worth a try.