Why did you end up in the ER in the first place? If you’re lucky enough to have a primary care doctor, they probably couldn’t see you for at least a week or two because they’re too busy. By busy, I mean filling out prior authorization forms - the bureaucratic stranglehold of the health insurance companies is immense. If you had abdominal pain the primary care doctor could easily order labwork and a CT scan and treat you outside the hospital - but now every CT scan is denied as a matter of fact - the only way to get it approved is an x-ray first, or an ultrasound, or getting the labs done, then a series of byzantine forms and “peer to peer” conversations with someone who is probably a retired psychiatrist and has no medical knowledge whatsoever and will lose their job if they let too many CT scans get approved. Easier just to say “go to the ER” and wash ones hands.
When I say lucky enough to have a primary care doctor, that’s because they’re all quitting. Due to the politics of covid, trust in the healthcare system and physicians is at an all time low. Patients yell, they are demanding, they are untrustworthy. 50% of the workload of a primary care physician is filling out spurious sick notes for work, for school, accommodation letters for the clinically lazy, emotional support animal letter requests, FMLA, short term disability, long term disability, etc. the bureaucratic nonsense is never ending. The “my finger hurts why is that I want an MRI” messages in the inbox are never-ending. The mental health crisis always makes its way into the primary care doctors office or the ER.
There are many failing institutions in the U.S. that are failing or have failed: the family structure, the system of employment for anyone with a low I.Q., the war on drugs, the criminal justice system. All of these failures lead to broken human beings who eventually end up at their PCP’s office or in the emergency room. One lonely night in the ICU as a trainee I realized the majority of our beds were taken up by hardcore alcoholics withdrawing to the point they needed to be put on a ventilator and sedated into a coma.
Doctors are also considered prey by the legal system. Patients are looking to sue and win the lottery. Our education system produces too many hungry lawyers. They are looking to get lucky, your medical malpractice insurer is looking to settle - it’s cheaper. The big scam now is that your malpractice insurer has the authority to settle with someone suing you without your permission. When you settle you get put in a national database of doctors who settled, your reputation is tarnished.
Why be a primary care physician? You are a tool of the health insurance companies. You get 15 minute visits (5 minutes in reality), unreasonable “metrics” with the only goal being decreasing compensation. Patients feel shortchanged, the medicine you practice is hurried, unsafe. Your inbox fills up with endless requests, the paperwork piles up, you get ever more burdened, and tired, and underpaid. In this endless grind if you make a mistake you will get sued. We are taught in medical school not to prescribe antibiotics needlessly as it harms people, but in reality that’s what patients want and now you get a customer feedback metric, which incentivizes hurting people.
It’s simply impossible to practice medicine in an ethical manner. It’s the same for allied health professions like nurses, lab techs, pretty much everyone except for the health insurance company execs who profit. Don’t get me started on the revolving door between the FDA and pharmaceutical companies. We get to pay for drugs like aducanumab that don’t do anything but bankrupt the system, but the officials who approve this corruption will get nice private industry gigs in a few years on the down low.
There is so much wrong and so much corruption at this point, the examples are endless. I could literally write a book on all that is wrong. But I don’t have to. The system is collapsing in real time. The next time you get sick, or a parent needs to be hospitalized, or someone you love gets cancer, you’re going to learn what the collapse of civil society means. Things are getting worse and worse and one day you will look around and wonder what the hell happened? Where did all the responsible adults go? The doctors pretend to care, the insurance companies pretend to pay, the hospitals pretend to be open, the drug makers pretend their drugs work. It’s all rotten from top to bottom.
Can we fix the U.S. Healthcare system? My opinion is no. There are too many interested parties and too much bureaucracy, and their goal is not the only goal that matters - taking care of patients. It will collapse and be replaced out of necessity by something that can do what it claims to do.
> Patients yell, they are demanding, they are untrustworthy.
This gets a lot of comment, but it's half the story. I get most of my medical care abroad, but have escorted family through through local medical visits. I've noticed a marked decline in empathy among medical staff the past few years, even in the secretaries at the front desk. This seems to be a general social trend, not just a problem of bad patients.
Reminds me of a friend who passed away from what was essentially doctor apathy.
While recovering from a major surgery started getting terrible abdomen pains. Doctors could hardly even be bothered to tell her to deal with it, completely dismissed her.
about a week later a new resident comes in, pokes and prods her a bit (no doctor prior could even be bothered to do that), looks horrified and orders some scans.
Her stomach had burst and was leaking into abdominal cavity the whole time, she later passed from the complications.
I gained a ton of sympathy for folks for fight and push back against doctors after that.
You hear both sides, likely the "doctors could hardly be bothered" might be in fact due to some doctors being overworked.
I was in the A&E (what is the ER in singapore and the UK I think) and I had severe chest pain due to chest infection. There were like 40 of us in there and like 5 nurses that one nurse just blew me off when I asked for pain killers because she didn't read my record properly and thought I took acetaminophen that morning. It took the pain getting worse to the point I was rocking and screaming for them to give me tramadol. that said, I sympathize with the situation, given they were running around and hardly able to fill out the paper work and do their normal tasks AND be attentive to the sick.
That said, hey I hear you. That doctor fucked up and it was on them yes, it does not absolve them. That said, things sure are getting worse in total across the system in the US, and bad attitudes doesn't explain nationwide scales. For that, you must look at systemic solutions, especially if you don't want more people to die in such situations again.
In case anybody is wondering whether there’s a game of telephone happening from mad family members, I was literally there watching this happen. I regret not speaking up.
It’s probably a runaway positive feedback loop. Someone is an asshole to you, you’re less likely to treat the next patient as well, leading to them treating the next nurse a bit worse.
It still pays well, and the system is setup to be very generous to physicians. Student loan forgiveness is available to physicians[0] and its not super hard to meet at least one of the qualifications, as physician demand has been intense for decades, so the debt load can be decreased significantly (and often outright forgiven after a set number of years) by just working the job.
The pay is also still super good. Even a primary care physician will most likely make 200K or more. Specialty physicians typically make even more than that, I've seen quoted anywhere between 300-700K, sometimes more.
And don't discount prestige. While jury is out if lawyers still garner prestige with the average person, being a board certified medical doctor certainly does, and I don't think this privilege in society should be discounted (and arguably, might even be deserved at times). This inevitably will drive at least some of it.
While physician assistants, nurse practitioners and other forms of care are eating at the very low end of a physicians duty, we're a long, long way from anything really upending them.
Taken all together, I'm not surprised. Though residency is grueling and the work is hard, it does seem to pay off in the long run, unlike alot of other things in society.
That said, nurses and PA's are also in super high demand, and I've seen some nursing salaries even edge out doctors in some cases when they do travel stuff, and of course you aren't married to your student debt the same way (all that fancy forgiveness is tied to actually being a doctor, after all) so if you get stressed, hate it, or otherwise give up the ghost on that career, its easier to move on
EDIT: I'm not saying these are good reasons, per se, but they certainly are, from all available evidence, reasons people become an M.D.
> The next time you get sick, or a parent needs to be hospitalized, or someone you love gets cancer,
Years ago my father had a stroke. Luckily there's a stroke ICU that was close. He got good care/attention there and for the week or so after (out of the ICU) before going home.
After that, to your point, pretty much a shit show. He was just a number. Care, consideration and compassion was effectively rationed. It not about health, wellness and outcomes. It's about money. Money. Money.
To me, the only short term solution is to stay healthy. Eat right. Exercise. Etc. That said, that's not where the masses are headed. Into the iceberg we go...
The last sentence is chilling. What can or will replace it? And how?
tbf, it sounds like you're just saying the US will collapse because while the health care system is a big part of it, the whole US is facing issues as you pointed out.
> Can we fix the U.S. Healthcare system? My opinion is no.
I am going to say that every large 'super' institution will end up in this problem ... Unfixable.
Whether it is military, judiciary or educational system -- they have the same issues as the healthcare system -- when they grow 'super-large' and become managed centrally (either directly or via near-centralized money flows).
It is the nature of end-days of human-driven society super-structures (gradual corruption, then selective-outrage decision making, then more corruption, then a form of centralized control that removes innovation/investment incentives, then the down-fall in quality of function/service, then the destruction).
So the only solution to that, and I am 'stealing' this idea from the US founding fathers -- is to avoid having these near-centralized super structures.
Many think that we need this superstructures (including near-monopolies in business) to build complex things: planes, vaccines, CPU chips.
But we do not, and we should find a political and economical systems that are effectively based on many localized 'guilds' and decision centers linked into ad-hoc-chains to create increasingly better outcomes (with the cost of some repetition, some anarchy, and some missteps).
Military and supreme court are the only institutions that I think should be centralized, but they have to be ran with checks and balances that are distributed across the many 'local' decision and power centers.
So that's the only way I can think of to avoid this constant periodic death of the human-led super-structures.
I'd like to add one more thing to this you probably experienced as well. My family has several people in medicine. All of them have done a stint in a hospital before quitting for greener pastures.
The homeless problem (now renamed "experiencing homelessness" as if this is a cure-all) has reached such critical mass that hospital beds fill up with patients that have no ailments. How do they do this? I'm sure you know. A homeless person who is either withdrawing, or cold, or hungry, or just a nuisance will come into the ER and tell the attending that they are suicidal. At this point a bunch of alarms go off. At least here where I live this means they are issued a bed immediately ahead of nearly all other patients and subject to 24 hour monitoring. They can, depending on hospital load, be given free room and board for up to 72 hours before a psychiatrist is mandated to give them a cursory once-over before sending them back to the street. They'll be back next week, once again suicidal, and once again consuming more resources than they will ever in their life time put back in.
The hospital can do nothing because turning down one of them who is actually suicidal would damage the hospital. So, people with actual real problems are pushed even further to back or left to line the hallways on gurneys because a homeless person was mildly inconvenienced by their, in all likelihood, self-imposed suffering.
Your notes on primary care are spot on. That has been my experienced as a layman with medical family. I know what they are going through yet I still feel shortchanged and often ignored by my PCP. Private clinics are no better.
Why did you end up in the ER in the first place? If you’re lucky enough to have a primary care doctor, they probably couldn’t see you for at least a week or two because they’re too busy. By busy, I mean filling out prior authorization forms - the bureaucratic stranglehold of the health insurance companies is immense. If you had abdominal pain the primary care doctor could easily order labwork and a CT scan and treat you outside the hospital - but now every CT scan is denied as a matter of fact - the only way to get it approved is an x-ray first, or an ultrasound, or getting the labs done, then a series of byzantine forms and “peer to peer” conversations with someone who is probably a retired psychiatrist and has no medical knowledge whatsoever and will lose their job if they let too many CT scans get approved. Easier just to say “go to the ER” and wash ones hands.
When I say lucky enough to have a primary care doctor, that’s because they’re all quitting. Due to the politics of covid, trust in the healthcare system and physicians is at an all time low. Patients yell, they are demanding, they are untrustworthy. 50% of the workload of a primary care physician is filling out spurious sick notes for work, for school, accommodation letters for the clinically lazy, emotional support animal letter requests, FMLA, short term disability, long term disability, etc. the bureaucratic nonsense is never ending. The “my finger hurts why is that I want an MRI” messages in the inbox are never-ending. The mental health crisis always makes its way into the primary care doctors office or the ER.
There are many failing institutions in the U.S. that are failing or have failed: the family structure, the system of employment for anyone with a low I.Q., the war on drugs, the criminal justice system. All of these failures lead to broken human beings who eventually end up at their PCP’s office or in the emergency room. One lonely night in the ICU as a trainee I realized the majority of our beds were taken up by hardcore alcoholics withdrawing to the point they needed to be put on a ventilator and sedated into a coma.
Doctors are also considered prey by the legal system. Patients are looking to sue and win the lottery. Our education system produces too many hungry lawyers. They are looking to get lucky, your medical malpractice insurer is looking to settle - it’s cheaper. The big scam now is that your malpractice insurer has the authority to settle with someone suing you without your permission. When you settle you get put in a national database of doctors who settled, your reputation is tarnished.
Why be a primary care physician? You are a tool of the health insurance companies. You get 15 minute visits (5 minutes in reality), unreasonable “metrics” with the only goal being decreasing compensation. Patients feel shortchanged, the medicine you practice is hurried, unsafe. Your inbox fills up with endless requests, the paperwork piles up, you get ever more burdened, and tired, and underpaid. In this endless grind if you make a mistake you will get sued. We are taught in medical school not to prescribe antibiotics needlessly as it harms people, but in reality that’s what patients want and now you get a customer feedback metric, which incentivizes hurting people.
It’s simply impossible to practice medicine in an ethical manner. It’s the same for allied health professions like nurses, lab techs, pretty much everyone except for the health insurance company execs who profit. Don’t get me started on the revolving door between the FDA and pharmaceutical companies. We get to pay for drugs like aducanumab that don’t do anything but bankrupt the system, but the officials who approve this corruption will get nice private industry gigs in a few years on the down low.
There is so much wrong and so much corruption at this point, the examples are endless. I could literally write a book on all that is wrong. But I don’t have to. The system is collapsing in real time. The next time you get sick, or a parent needs to be hospitalized, or someone you love gets cancer, you’re going to learn what the collapse of civil society means. Things are getting worse and worse and one day you will look around and wonder what the hell happened? Where did all the responsible adults go? The doctors pretend to care, the insurance companies pretend to pay, the hospitals pretend to be open, the drug makers pretend their drugs work. It’s all rotten from top to bottom.
Can we fix the U.S. Healthcare system? My opinion is no. There are too many interested parties and too much bureaucracy, and their goal is not the only goal that matters - taking care of patients. It will collapse and be replaced out of necessity by something that can do what it claims to do.