Current medical information, and as more practices are purchased by large health care systems, hospitals and such, more doctors are subject to Clinical Practice Guidelines. American College of Physicians have guidelines for most conditions, or AHA for heart disease, etc. The doctor who may have used his good judgement and experience before, is now required to prescribe x drug when y test is z level by the practice's owner.

I know! It was exactly this cookie-cutter approach that blew up my endometriosis and ultimately, the illness I'm struggling with now.

At this point, my GP is the only one who even acknowledges I'm sick, and is willing to try within his standard of care.

I also think that some of it is less profit-driven (on the part of physicians, anyway) and more fear of reprisals, such as lawsuits. I feel that many doctors truly do want to help, but they have this thing called a "standard of care," and if they don't treat to the norms in this, their malpractice insurance may go up or they may get sued. Therefore, they treat to what the recommended norms are. They order every test, and they treat any tiny thing that might be considered abnormal, even if it is a very mild abnormal, such as my "pre-hypertensive" one-time only BP of 120/80. In that way, I totally agree with the central thesis of Overdiagnosed, which I am reading right now.

However, I also find a really interesting dichotomy here. I have Hashimoto's thyroiditis and celiac disease. I had to battle for more than 20 years to get doctors to do the right tests to finally diagnose those as I got sicker and fatter. Every doctor I visited told me all my issues were related to my weight. I couldn't get a doctor to test anything other than the standard things: TSH, CRP, blood lipids, blood glucose because they had the preconceived notion that fat people were sick, and that every symptom I ever experienced came from being fat. That was my ongoing diagnosis: fatness. I even had one doctor point out that my CRP was very high (a sign of inflammation and potentially some form of autoimmune disease), but he didn't look any further than the abnormal CRP result, concluding that my weight was most likely contributing to my inflammation. I'm the one who went on and did the research of my symptoms over years, any abnormal test results, etc. in order to guide my doctors towards an appropriate diagnosis.

It took me 20 years to talk a doctor into testing my T3 and T4 and looking past my fatness. It took me about the same amount of time to finally get someone to look at my digestive issues and my history and to perform the proper tests for celiac disease.

Still, thyroid medication (especially the natural stuff I take) is cheap. There is no medication for celiac disease - quitting gluten is the solution. No money there for Big Pharma, so the Big Pharma execs sitting on the committees that set the norms for the standard of care that doctors so fear not meeting aren't setting standards for diseases that don't pad their pockets with tons of drug money.

The only true path for anyone in this healthcare system is to be as informed as possible and to fiercely advocate for themselves. It's a screwed up and harmful system.

Very good point, as we're witnessing a medical practice "Pac-Man" dynamic where large hospital groups have been acquiring smaller groups over the past few years. The larger groups have standards of care that are expected to be followed by all members and employees. Thinking about my experience, the doctor likely was making a recommendation consistent with his group's standards of care, and he is likely expected to make that recommendation. It will show up on the patient record as a hedge against any medical liability. What this means is that all patients must either be their own strong advocate or get a friend of family member to assist in the decision making. The medical professionals are giving advice, but the decisions must be informed and made by the patient.

Karen - well stated, and this is the reality that many patients are confronted with today. I don't believe the doctors are doing anything more than what they are told by their superiors. Some find it easier to simply "check the boxes" and follow the routine. Others go above and beyond for their patients. Bottom line, it's a new world where a collaborative relationship with one's doctors and a solid understanding of health and medical information by the patient is essential for success with today's system of health care.

Sometimes standard of care directives are great, like the ones that prohibit routine prescribing of antibiotics, but sometimes they lead in the opposite direction...

NoWhammies, you are so right. Most people don't understand the underlying power structure in medical practice these days. If a doc, or a group of docs, is associated with an HMO, they are not making a penny more if you come in and get lab tests and use 15 of their precious minutes having an exam. Because the insurance company pays them a set amount per patient, and they get the same, whether you show up or not.

The same is true for them prescribing meds. They make nothing off the meds they prescribe. Heck, they used to get all sorts of lovely stuff: treated to dinner at five star restaurants, trips, tchotchkes for themselves and their staff, just for listening to a presentation by a drug rep. But those things have been (rightly) severely restricted by law, now.

Docs are under pressure to see more patients, using the guidelines that are set up, for the most part, not by actual best practices, but by most efficient and least costly practices.

MickiSue, are you sure they're limited now? I thought they just have to be reported and that the reporting was more or less voluntary.

Nancy - it's related to the Sunshine Act and it requires any gifts in the form of food, beverages, or other to be reported by physician. Here's a link to check for anyone you know:
https://openpaymentsdata.cms.gov/search

Just to clarify a couple of points -

My husband is a cardiologist. He used to get all kinds of stuff from drug companies, from pens and socks (no kidding) and t-shirts to nice dinners and even weekends at Disneyworld. No more.

More important - my husband, and EVERY SINGLE doctor I know, has been sued, most (probably all) multiple times. Doctors get sued every day. If 98 year old grandpa dies, his doctor and every one else who was anywhere near grandpa at the time of his death - whether he/she was involved or not - will be sued. It's horrible. You trust your doctor with your care? Don't be silly. It's a bunch of lawyers who control your care.

They don't care about culpability. They just want quick money from settlements. My husband has NEVER settled, always against the advice of his lawyers. Every time he was dropped from the suit. The worst time was once when we were in the process of moving from one state to another. He was named in a lawsuit dating back a few years. At the same time, the company holding his malpractice insurance from that time went out of business. We were in a terrible position. We had not yet sold our house that we left, and were about to close on our new house. And we found out we had no insurance for the time of the lawsuit. It was hell. We were in danger of losing everything. It all worked out, but the stress was awful. (Not looking for sympathy...I just want people to know what their doctors are really up against.)

Laura: While I always suspected that, it is seriously disheartening to hear it confirmed. I can't imagine what it would be like to be a physician and have to work tethered by such constraints, but I certainly know what it's like to be a patient of people tethered by them.

Our healthcare system is very broken. We all have a a role in it being broken. Which is why I believe that we have to educate ourselves and fiercely advocate. Because lawyers control the entire world.

What I think is that there is still enough profit to be had in medical training and medical insurance and publications that we still have doctors.

Because really, if we're going to take a blood test or pictures and then diagnose based on a statistical norm, we don't need doctors. A decent camera-computer-software set up could do all of that, might want a nurse for the blood draw and some talk-through instruction. If that set-up isn't in place already it's merely for a lack of doing it; the tech exists.

At this point doctors have so little time with patients that a well thought out physical setup could probably garner exponentially more information in 5-10 minutes than a human could anyway.

I am one of those people who really believes that in any job, you train people well, you gear them to interest in their quality and their field which hopefully will lead to future self-edu, you make sure they have the resources they need and someone is available if they have an issue... and then you get the hell out of their way and let them do their job. And it's going to vary and it's going to be human-affected because they're a human. And that's a good thing.

Because if we aren't going to allow the 'human element' of doctors -- from decent exam time, to ability to do what they think is best or even 'work with' a patient to try different things -- then there is no point to humans. That element, that individual insight and intuition and flexibility, IS the human element that was worthwhile.

The other human elements are all lesser, not better, than technology can do -- detail of measure, speed of measure, etc. Those are the things that automation actually improves.

As long as doctors can be proxy priests and medical school and insurance and more can be insanely lucrative industries, we will probably still have doctors. But that isn't about the doctoring, it's just about the profit. To whatever degree we hogtie their 'human element' we render the need for them obsolete.

At this point going to the doctor is like 80 minutes of waiting followed by another 20 minutes of waiting in a room followed by a harried person who has 5-10 minutes as if your health is a sudden pop quiz and then they gotta move on. Given what's been said about the narrowing of doctor 'options' and human element, I think we could improve this system:

I go to the medical center where someone who can give instructions and if needed draw blood or whatever tells me to strip and walk into a room that takes a stupid number of camera / laser-light / blood measurements of everything imaginable. 5 minutes later I dress and enter another room where a ridiculously handsome guy (or gal) spends 5 minutes talking with me as if I am Truly Important To Them, wishes me well, and I go home feeling better about it all. The computer will follow up with a boilerplate report and assigned medications based on various readings. They will show up at a local outpatient counter, where I'll have to swipe my arm weekly anyway to make sure I'm taking all the drugs officially assigned me Or Else(tm).

No doctor needed.

If it sounds terrifyingly Orwellian, it is. But it's a logical extension of where we're going with it all.

PJ

Here is another fact. My PCP works for a health care corporation, he is also a friend and often complains that he is not able to do a decent job. He has to see a minimum amount of patients a day, He gets penalized if he doesn't meet his quota. It is far easier to prescribe some drugs and sent the patient his/her way, then sit down and listen and treat the patient right. He is often very stressed because he is not able to do his job right. He tried to open his own practice but the overhead was to much of a burden. He is a well known and well liked MD but I am afraid one day he just will stop because the stress will be to much.

Brilliant again as usual PJ! I love this and would actually want to see it, well except for the mandatory arm swiping.

I see people giving doctors a pass on their prices because of sympathy for medical school debt. Forgetting that docs themselves are in charge of medical education. There is every incentive to make medical education gold plated and have consumers pay for it, and none to keep the costs of medical education down.

Our admirable docs usually know what they want early in life. what if we went back to the apprentice system and had docs start work at 14 and learn as they go. Or whatever. If docs really got into the idea of the best education for the very least money, would it be different?

Not to pick on doctor prices. Hospitals, Insurance, drug and equipment businesses have the same thing.

And how much of it is because we consumers will pay the moon for "medical treatment." People gasp if you say, " As a responsible consumer, uh, no, that treatment does not sound like a good value to me and I'll pass."

Exactly, this is where we are headed in the USA at least. Government involvement making the health insurance companies fabulously wealthy while imposing Standards of Care, which are usually based on health beliefs developed to protect the insurer rather than on facts to protect the patients in many cases. We have another thread currently in the Dr. Bernstein forum that is discussing the ADA and the dietary recommendations for T2 diabetics with patient responses of frustration and alarm on a FB page because the "Standards of Care" in this case aren't working. This will become a part of all this, and if a patient is identified as difficult due to resisting the recommended care, insurance could be revoked for that individual.