The Triumph of New Age Medicine, part deux, courtesy of The Atlantic

By oracknows on July 5, 2015.

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly "skeptical," the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine "skeptic" Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled "Does the Vaccine Matter?" It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. I myself asked the question whether The Atlantic (among other things) matters. It didn't take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis' work was represented as meaning we can't believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled “The Triumph of New Age Medicine.”

Now The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled “The Evolution of Alternative Medicine.” It is, in essence, pure propaganda for the paired phenomena of "integrative" medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It's the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: "Hey, this stuff isn't quackery any more! We're scientific, ma-an!" You can even tell that's going to be the central message from the tag line under the title:

When it comes to treating pain and chronic disease, many doctors are turning to treatments like acupuncture and meditation—but using them as part of a larger, integrative approach to health.

No, that's what they say they are doing (and—who knows?—maybe they even believe it), but what that "integrative" approach to health actually involves is "integrating" quackery like acupuncture with scientific medicine. Elsewhere, in her introduction to the article in which she explains why she did the story, Rothenberg Gritz describes a visit to the National Center Complementary and Integrative Health (NCCIH), which is how the National Center for Complementary and Alternative Medicine (NCCAM) was renamed last December:

After visiting the NIH center and talking to leading integrative physicians, I can say pretty definitively that integrative health is not just another name for alternative medicine. There are 50 institutions around the country that have integrative in their name, at places like Harvard, Stanford, Duke, and the Mayo Clinic. Most of them offer treatments like acupuncture, massage, and nutrition counseling, along with conventional drugs and surgery.

One notes that the renaming of NCCAM to eliminate the word "alternative" was a longstanding goal of NCCAM, its supporters, and "integrative medicine" advocates. The reason is obvious: "Alternative" implies outside the mainstream in medicine, and that's not the message that proponents of integrating quackery into medicine want to promote. One can't help but wonder if it was a retirement present for Senator Tom Harkin (D-IA), the legislator most responsible for the creation and growth of NCCAM who retired at the end of the last Congressional term. Whatever the case, the name change was, as I put it, nothing more than polishing a turd.

Be that as it may, no one, least of all here at SBM, argues that "integrative" medicine is "just another name for alternative medicine." It isn't, as most integrative MDs use conventional, science-based medicine as well. The problem with "integrative" medicine is that, to paraphrase my good bud Mark Crislip, mixing cow pie with apple pie does not make the apple pie taste better; i.e., mixing unscientific, pseudoscientific, and mystical quackery like acupuncture and much of traditional Chinese medicine does not make science-based medicine better. Rather, it contaminates it with quackery, just as the cow pie contaminates the apple pie.

Basically, integrative medicine is a strategy for mainstreaming alternative medicine, even though the vast majority of alternative medicine has either not been proven scientifically to be efficacious and safe, has been proven not to be efficacious, or is based on physical principles that violate laws of physics (such as homeopathy or "energy healing). Indeed, if the term "integrative medicine" were not thus, it would be a completely unnecessary moniker. The reason is, to paraphrase Tim Minchin, Richard Dawkins, John Diamond, Dara Ó Briain, and any number of skeptics, there is no such thing as "alternative" medicine because "alternative" medicine that is shown through science to work becomes simply medicine. Thus, newly validated medical treatments have no need to be called "integrative" because medicine will integrate them just fine on its own. That's what medicine does, although admittedly the process is often messier and takes longer than we would like. Integrative medicine, like alternative medicine before it, is a marketing term that is based on a false dichotomy. Only unproven or disproven medicine needs the crutch of being "integrative," a double standard that asks us to "integrate" unproven treatments as co-equal with science-based medicine even though they have not earned that status.

Unfortunately, this is a false dichotomy that Rothenberg Gritz promotes wholeheartedly. The only hint of skepticism is a brief passage near the beginning in which she refers to Paul Offit's 2013 book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine and briefly quotes him saying what I've been saying all along, that "integrative medicine" is a brand, a marketing term, rather than a specialty. She also noted his criticism in his book of what is now NCCIH, and includes a quote by Dr. Offit about Josephine Briggs (the current director of NCCIH) that she "certainly was very nice" and assured him that they "weren't doing things like that any more" (referring to "things" NCCCIH studied in the past, like distance healing, and magnets for arthritis). This is, of course, hardly even a criticism at all, but rather getting Dr. Offit to state for her Dr. Briggs' frequent claim that NCCIH doesn't study pseudoscience any more. It's a claim she made when Steve Novella, Kimball Atwood, and I met with her five years ago, and, yes, back then Dr. Briggs was also very nice to us, although she did rapidly turn around and, in a painful fit of false balance, use that meeting as evidence of her even-handedness in meeting with both critics and homeopaths. It's a claim embedded in the 2011-2015 NCCAM strategic plan, which I now like to characterize in talks as "Hey, let's do some real science for a change!" In any case, Rothenberg Gritz's account isn't false balance. It's no balance at all, with the token skeptic role taken by Dr. Offit.

Revisionist history about NCCIH

Advocates for "integrative medicine" have used a variety of talking points over the years, and Rothenberg Gritz hits most of them in her article quite credulously. Indeed, it is very clear from her introduction that she was predisposed to believe. Early in the article, she tells the tale by looking back to the early 1990s, when she was in high school and her father was a family physician who was clearly into some woo, including Transcendental Meditation, Ayurveda, and the like, even going so far as to incorporate them into his practice. The inescapable implication is that she considers her father a trailblazer for what is now integrative medicine.

Unfortunately, it is very clear that her knowledge of history in this area, particularly how NCCAM/NCCIH came to be, is sorely lacking, which leads her to parrot the version of history that integrative practitioners want you to believe:

Back in the 1990s, the word "alternative" was a synonym for hip and forward-thinking. There was alternative music and alternative energy; there were even high-profile alternative presidential candidates like Ross Perot and Ralph Nader. That was the decade when doctors started to realize just how many Americans were using alternative medicine, starting with a 1993 paper published in The New England Journal of Medicine. The paper reported that one in three Americans were using some kind of "unconventional therapy." Only 28 percent of them were telling their primary-care doctors about it.

And:

Enough Americans had similar interests that, in the early 1990s, Congress established an Office of Alternative Medicine within the National Institutes of Health. Seven years later, that office expanded into the National Center for Complementary and Alternative Medicine (NCCAM), with a $50 million budget dedicated to studying just about every treatment that didn't involve pharmaceuticals or surgery—traditional systems like Ayurveda and acupuncture along with more esoteric things like homeopathy and energy healing.

Now there's some revisionist history! The word "alternative" was just popular because there was so much other "alternative" stuff (alternastuff?) going on in the early 1990s! But it's not the 1990s any more; so "alternative" isn't as cool as it used to be. Of course, the word "alternative" as applied to quackery dates back at least to the 1960s.

Longtime readers know how NCCAM really came about. One wonders if Rothenberg Gritz ever came across Wally Sampson's classic 2002 article, "Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded" or Kimball Atwood's "The Ongoing Problem with the National Center for Complementary and Alternative Medicine". Even if you buy into the false notion that NCCIH (née NCCAM) has completely reformed itself and doesn't study or promote quackery any more, a history lesson is important. What really happened matters.

Basically, Sen. Tom Harkin was a believer in a lot of alternative medicine. Thus, in 1991 he used his power as the chair of the Senate Appropriations Committee to create the precursor to the NCCIH. His committee declared itself "not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices" and, to "more adequately explore these unconventional medical practices," ordered the NIH to create "an advisory panel to screen and select the procedures for investigation and to recommend a research program to fully test the most promising unconventional medical practices." This advisory panel became the first incarnation of NCCIH, the Office of Unconventional Medicine, which was quickly renamed the Office of Alternative Medicine (OAM).

This next part is very important. NIH didn't request this new office. There were no scientists and physicians in the NIH leadership clamoring for such an office. Congress didn't respond to a "groundswell" of support to establish this office. The NEJM article cited by Rothenberg Gritz wasn't even published until nearly two years after Harkin had already started the wheels rolling and a year after the founding of OAM. No, a single powerful senator with a proclivity for quackery used his power to get this enterprise off the ground, and he continued to nurture it over his remaining two decades in the Senate. The OAM was, in essence, imposed on a correctly-unwilling NIH, and has been ever since. Indeed, after she left as NIH director, Bernardine Healy revealed that she had considered the project to link research scientists with true believers in therapies like homeopathy to conduct experiments as foreshadowing nothing but disaster, but conceded that the NIH had "had no choice" because it couldn't refuse to carry out a mandate from Congress.

And, make no mistake, Harkin was big into quackery, not to mention being in the pockets of quacks:

Harkin had been urged to take this legislative step by two constituents, Berkley Bedell and Frank Wiewel. Bedell, a former member of the House, believed that two crises in his own health had benefited from the use of unconventional medicine: colostrum derived from the milk of a Minnesota cow, he held, had cured his Lyme disease; and 714-X, derived from camphor in Quebec by Gaston Naessens, had prevented recurrence of his prostate cancer after surgery. Bedell, giving evidence of his Lyme disease recovery at a Senate committee hearing, observed: "Unfortunately, Little Miss Muffet is not available to testify that the curds and whey which she was eating are safe." Wiewel had long been a vigorous champion of immunoaugmentative therapy for cancer, scorned by orthodox specialists; made in the Bahamas, this mixture of blood sera was finally barred from import by the Food and Drug Administration. Wiewel then began operating from his home in Otho, Iowa, an agency called People Against Cancer, a referral service for cancer treatments that orthodox medicine considered questionable.

Harkin, having lost two sisters to cancer, was susceptible to an interest in alternative therapies. Soon after sponsoring the law that launched the Office of Alternative Medicine, Harkin himself became a true believer in an unorthodox "cure." On Capitol Hill, Bedell introduced the senator to Royden Brown of Arizona, promoter of High Desert bee pollen capsules. Harkin suffered from allergies; persuaded by Brown to take 250 bee pollen capsules within five days, he rejoiced that his allergies had disappeared. The senator did not know at the time that Brown had recently paid a $200,000 settlement under a consent agreement with the Federal Trade Commission, promising to cease disguising television infomercials as objective information programs and to stop including in his scripts dozens of false therapeutic claims for his capsules. These promotions also averred that "the risen Jesus Christ, when he came back to Earth," had consumed bee pollen; a more recent customer, Brown's infomercial declared, was Ronald Reagan. Brown later wrote Hillary Clinton, warning that her husband should begin dosing with bee pollen lest he develop fatal throat cancer.

So NCCIH started out at the urging of two quack constituents of Harkin; then Harkin became a believer himself. Not surprisingly, it soon became clear that the OAM was not intended to rigorously study alternative medicine, but rather to provide a seemingly scientific rationale to promote it. The office was initially set up with an acting director and an ad hoc panel of twenty members, many of whom Harkin hand-picked, including advocates of acupuncture, energy medicine, homeopathy, Ayurvedic medicine, and several varieties of alternative cancer treatments. Deepak Chopra and Bernard Siegel were also included. Critics of quackery were consulted and considered for panel membership but—surprise, surprise!—were not selected. These pro-alt med panel members became known in the OAM as "Harkinites."

Against this background, the first director of the OAM, Joseph M. Jacobs, almost immediately ran afoul of Harkin by insisting on rigorous scientific methodology to study alternative medicine. To get an idea of what Jacobs was up against, consider that in 1995 the inaugural issue of Alternative Therapies in Health and Medicine featured not just one, but two, commentaries by Senator Harkin, "The Third Approach" and "A Journal and a Journey". In these two articles, Harkin basically introduced the new journal as a "journey—an exploration into what has been called 'left-out medicine,' therapies that show promise but that have not yet been accepted into the mainstream of modern medicine." and explicitly stated that "mainstreaming alternative practices that work is our next step." Unfortunately, he had a bit of a problem with the way medical science goes about determining whether a health practice—any health practice—works and railed against what he characterized as the "unbendable rules of randomized clinical trials." Citing his use of bee pollen to treat his allergies, went on to assert, "It is not necessary for the scientific community to understand the process before the American public can benefit from these therapies." It is an attitude that did not change. In 2009, Harkin famously criticized NCCAM thusly:

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

Truly, this was a profound misunderstanding of how science works. Also, the reason NCCAM had failed to "validate alternative approaches" is because they were, largely, pseudoscientific quackery that, as expected, failed scientific testing.

Ultimately Jacobs resigned under pressure from Harkin, who repeatedly sided with the quacks. It also didn't help that Jacobs complained about various "Harkinites" on the advisory panel who represented cancer scams such as Laetrile and Tijuana cancer clinics. That Jacobs became tired of fighting and finally resigned is especially noteworthy given that Jacobs himself had been picked to run OAM precisely because of his openness to the idea that there were gems to be found in the muck of alternative therapies. Meddling by Harkin was a theme that kept repeating itself. Later, in 1998 after the then-NIH director had tried to impose more scientific rigor on the OAM, Harkin sponsored legislation to elevate the OAM to a full center, and thus was the NCCAM born. Not coincidentally, the NIH director has much less control over full centers than over offices.

Bad science and revisionist history about how alternative medicine evolved into "integrative" medicine

The key message promoters of unscientific medicine hammer home again and again is that they're not quacks. Oh, no. They're real scientists and don't use medicine that's not scientifically proven. Rothenberg Gritz drives that point home thusly:

But I was intrigued by the NIH center's name change and what it says about a larger shift that's been going on for years. The idea of alternative medicine—an outsider movement challenging the medical status quo—has fallen out of favor since my youth. Plenty of people still identify strongly with the label, but these days, they're often the most extreme advocates, the ones who believe in using homeopathy instead of vaccines, "liver flushes" instead of HIV drugs, and garlic instead of chemotherapy.

In contrast, integrative doctors see themselves as part of the medical establishment. "I don't like the term 'alternative medicine,'" says Mimi Guarneri, a longtime cardiologist and researcher who founded the Academy of Integrative Health and Medicine as well as the integrative center at Scripps. "Because it implies, 'I'm diagnosed with cancer and I'm going to not do any chemo, radiation, or any conventional medicine, I'm going to do juicing.'"

As I characterized it, "We're not quacks! We're not quacks!" Later Rothenberg asserts:

The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they're scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they'd incorporate any other evidence-based medicine.

Except that that's not the case. Here are a couple of examples that I like to use to show why this characterization of integrative medicine is a delusion.

First, I like to cite a certain medical society that I've butted heads with on more than one occasion and whose leadership really, really doesn't like me, namely the Society for Integrative Oncology, declaring that it has "consistently encouraged rigorous scientific evaluation of both pre-clinical and clinical science, while advocating for the transformation of oncology care to integrate evidence-based complementary approaches. The vision of SIO is to have research inform the true integration of complementary modalities into oncology care, so that evidence-based complementary care is accessible and part of standard cancer care for all patients across the cancer continuum." Would that this were true! If that truly is the case, then how does SIO reconcile itself with the fact that its current president, Suzanna Zick, and immediate past president, Heather Greenlee, are both naturopaths, one of whom authored official SIO guidelines for the integrative care of breast cancer patients? (Even more depressingly, Zick is a naturopath working in the Department of Family Medicine at my old alma mater the University of Michigan Medical School.) That alone puts the lie to any claims SIO has of being scientific, given that naturopathy is a cornucopia of quackery and pseudoscience. In particular, homeopathy—or, as I like to call it, The One Quackery To Rule Them All—is an integral part of naturopathy as a major component of the curricula of schools of naturopathy and is a required component of the naturopathic licensing examination (NPLEX). If you don't believe just how quacky naturopathy is, read what they say to each other when they think no one is watching; learn about how full of pseudoscience their education and practice are, as related by a self-described "apostate"; and how unethical their research can be.

Despite all this, it's not just integrative oncology that's embracing naturopathy. (There's even a specialty now known as naturopathic oncology that's advertised by places like the Cancer Treatment Centers of America.) Meanwhile a whole host of integrative medicine programs offer the services of naturopaths, including Kansas University, UC Irvine, Beaumont Hospital (in my neck of the woods!), the University of Maryland, and, of course, the Cleveland Clinic, where a naturopath runs a traditional Chinese medicine clinic, just to name a few.

Now, here's where the second point comes in. It goes way beyond naturopathy, whose tendrils have become firmly entwined with those of "integrative oncology," perhaps more so than with other specialties. If, as its advocates claimed ad nauseam to Rothenberg Gritz, integrative medicine is all about the science, then its approach is all wrong. Let's put it this way. They themselves admit that many of the modalities they are using are unproven. If they truly accept that, then for them to offer such services outside of the context of a clinical trial would be as unethical as offering a non-approved drug or unproven surgical treatment to patients. Yet, there are quite a few academic institutions out there offering reiki, which is just as quacky, if not more so, than homeopathy, given that it postulates the existence of a "healing energy" that has never been detected and in its particulars is no different than faith healing, except that it substitutes Eastern mystical beliefs for Christian beliefs. Under the banner of "integrative medicine," academic medical centers are offering high dose vitamin C for cancer, anthroposophic medicine, and functional medicine. Indeed, there are academic medical centers out there that offer everything from acupuncture to chiropractic to craniosacral therapy to naturopathy. Heck, the University of Maryland offers reflexology, reiki, and rolfing, none of which have any good evidence to support them, while more integrative medicine programs than I can keep track of offer acupuncture and various other bits taken from traditional Chinese medicine, even though acupuncture is nothing more than a theatrical placebo.

In other words, integrative medicine puts the cart before the horse. Hilariously, Rothenberg Gritz inadvertently undermines her own praise of the science of integrative medicine by relating that Dr. Guarneri, whom she just represented as a paragon of science who only wants to use scientifically validated treatments, offers onsite massage therapy, herbal baths, craniosacral therapy, and acupuncture, the latter two of which are pure quackery. (Oh, and she teams with naturopaths, as well.) Indeed, craniosacral therapy is such ridiculous quackery that Guarneri's offering it pretty much eliminates any chance I'll buy her claim of adhering to science in her practice of "integrative medicine."

My amusement at this aside, especially irritating is Rothenberg Gritz's description of acupuncture. After noting that chronic pain is one reason why people seek out alternative medicine, she writes:

One reason pain is so hard to treat is that it isn't just physical. It can carry on long after the initial illness or injury is over, and it can shift throughout the body in baffling ways, even lodging in phantom limbs. Two different people can have the same physical condition and experience the pain in dramatically different ways. As the Institute of Medicine report put it, pain flouts "the long-standing belief regarding the strict separation between mind and body, often attributed to the early 17th-century French philosopher René Descartes."

This may be why so many chronic pain sufferers are drawn to traditional medicine: The Cartesian idea of mind-body duality never found its way into these ancient systems. Acupuncture, for instance, has been shown to help with problems like back, neck, and knee pain. But it's very hard for science to figure out how it works, since it involves so many components that are mental as well as physical. The technique of inserting the needles, the attitude of the practitioner, the patient's own attention—all of these are built into the treatment itself. In Acupuncture Research: Strategies for Developing an Evidence Base, researchers note that ancient Chinese physicians saw the mind and body as "necessarily connected and inseparable."

Note that the study to which Rothenberg Gritz links is the acupuncture meta-analysis by Vickers et al., which so failed to show what it claimed to show that one SBM post wasn't enough to explain why. It required discussion by Steve Novella, Mark Crislip, and myself, much to Vickers' dismay.

The funny thing is, mind-body dualism is not a part of modern medicine, making it odd that the IOM would get it so very, very wrong 11 years ago. Remember, the concept of dualism posits that consciousness (the mind) is, in part or whole, something separate from the brain; i.e., not (entirely) caused by the brain. Now, if there's anything modern neuroscience has taught us, it's that dualism is untenable as a scientific hypothesis, that the "mind" is wholly a manifestation of the function and activity of the brain—or, as it's sometimes stated, the brain causes the mind. In other words, science-based medicine rejected mind-body dualism a long time ago. Of course, as we've discussed here more times than I can remember, when rigorously studied acupuncture has never been convincingly shown to do anything more than placebo. Indeed, the reason why acupuncture "outcomes" (such as they are) are so dependent on practitioner and patient is because acupuncture is placebo.

In fact, my retort to Rothenberg Gritz's outright silly argument about mind-body dualism is that it's the integrative practitioners who emphasize mind-body dualism, whether they realize it or not. After all, they have a whole category of therapies known as "mind-body" medicine, an implicit acceptance, at least on some level, of dualism. Nor does their overblown appropriation of epigenetic studies as evidence that the "mind heals the body" (or, as I like to refer to it, wishing makes it so), which infuses so many alternative medicine practices, help. In actuality, given that the vast majority of alternative medicine practices, when rigorously studied, do no better than placebo, this new emphasis is basically integrative medicine rebranding the pseudoscientific practices it "integrates" as "harnessing the power of placebo." Since placebo effects require that physicians in essence lie to their patients (albeit with good intent), it's not for nothing that Kimball Atwood and others have dubbed the placebo medicine as practiced by integrative medicine practitioners as a rebirth of paternalism in medicine due to the lure of being the shaman-healer.

The rest of the article is full of the same old pro-integrative medicine tropes that I've seen over and over and over again. For example, Mark Hyman, the "functional medicine guru" now trusted by Bill and Hillary Clinton who regularly mangles science about autism and cancer while advocating anecdote-based medicine, opines that we have "an acute-disease system for a chronic-disease population," that the "whole approach is to suppress and inhibit the manifestations of disease," and that "the goal should be to enhance and optimize the body's natural function," whatever that means—and whatever "functional medicine" is. (For a reminder, it's useful to look at the late Wally Sampson's multi-part analysis of what functional medicine is claimed to be here, here, here, here, and here.)

Rothenberg Gritz also relies on the ever-annoying "science has been wrong before" canard, listing all sorts of areas where medicine got it wrong before getting it right, as though that justifies integrating alternative medicine into science-based medicine because, I suppose, science could be wrong about that too. It does not; it's a fallacy. She also parrots the charge that doctors haven't thought enough about prevention, a claim that has always irritated me. After all, what are vaccines, but prevention? What are diet and drugs to treat elevated blood sugar but prevention of diabetic complications? What are antihypertensive drugs but a means to prevent the complications of hypertension, such as heart attacks and strokes? What are smoking cessation programs but a means of preventing cancer, heart disease, and chronic obstructive pulmonary disease, the three most deadly consequences of smoking? (Note how integrative medicine only defines "prevention" as non-pharmacologic, or "natural," approaches.) Yes, it's difficult to practice some forms of prevention because making lifestyle changes, such as losing weight, drinking less, smoking less, and exercising are hard. Patients don't want to do them and have a hard time achieving them. I've yet to see much evidence that "integrative" medicine will do any better after having appropriated lifestyle interventions and rebranding them as somehow being "integrative."

What is integrative medicine, anyway?

Perhaps the most inadvertently telling passage in Rothenberg Gritz's article comes near the end:

After months of speaking to leading integrative doctors and researchers, I found that I was still having trouble summing up exactly what integrative health was all about. It's not a specialty like obstetrics or endocrinology. There are integrative training programs and certifications out there, but none of them has been universally recognized throughout the medical profession. "At this point it's really a self-declaration," Nancy Sudak, the chair of the Academy of Integrative Health and Medicine, told me. "And nobody has a tool kit that includes absolutely everything. It largely depends on who you are as a practitioner."

In other words, integrative medicine is a brand, not a specialty. Pretty much every other specialty has a definition of what it encompasses that is clear. Integrative medicine is this fuzzy entity about which I can't help but recall the words of Humpty Dumpty in Lewis Carroll's Through the Looking Glass, who said scornfully, "When I use a word, it means just what I choose it to mean—neither more nor less." So it is with integrative medicine, which is why last week integrative medicine could be defended on using a fallacious argument that science-based medicine is "nonsense" or that "Western medicine" has lost its soul, while this week I can sit back and grit my teeth reading an article regurgitating the advocate line that integrative medicine is just as scientific as science-based medicine.

Rothenberg Gritz is correct that integrative medicine has evolved, but it hasn't evolved in the way she thinks it has. In her final paragraph, she wonders whether the rise of integrative medicine is a result of cultural shifts (which is possible) but comes to an untenable conclusion that it may be the only way to treat chronic disease. In actuality, it is only the language that has evolved. I was half-tempted to steal the introduction to a post on how integrative medicine is a brand not a specialty, where the evolution of integrative medicine is described, but instead I'll just give you the CliffsNotes version instead.

Basically, starting around the late 1960s and early 1970s, in a bid to gain respectability for what was then called quackery or health fraud, the term “alternative medicine” was coined, which didn’t have all the harsh connotations of the usual language. Around that same time, James Reston, a New York Times editor, wrote about his experience undergoing an emergency appendectomy while visiting China in 1971. His story was represented as successful “acupuncture anesthesia,” when it was anything but, stimulating popular interest in “alternative” medical approaches. However, the word “alternative” implied that this was not “real” medicine, that it still was somehow unrespectable (which it was and still is, for good reason). Consequently, in the 1990s, around about the time Rothenberg Gritz was in high school admiring her dad’s woo-filled medical practice, a new term was born: complementary and alternative medicine (CAM). The idea was that you need not fear these quack medical practices because they would be used in addition to medicine, not instead of it. This term contributed greatly to the increasing embrace of CAM by medical academia, but it was still not good enough for its advocates. After all, the word “complementary” implies a subsidiary status, that CAM is not the main medicine but just icing on the cake, so to speak.

That did not sit well with advocates, who wanted their woo to be fully part of medicine, even though they didn't have the evidence for that to happen naturally. Thus was born the current term "integ
rative medicine." No longer did CAM practitioners have to settle for having their quackery be merely "complementary" to real medicine. They could use this term to claim co-equal status with practitioners of real medicine. The implication—the very, very, very intentional implication—was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the "integration." Thus was further advanced the false dichotomy that has been used to justify alternative medicine from the very beginning, that a physician can't be truly "holistic" unless he embraces pseudoscience.

The true evolution of integrative medicine is not that it has become more scientific. Rather, it is that its advocates have gotten much, much better at branding quackery as being medicine under the guise of being "holistic" and "patient-centered." It's a false dichotomy that I reject and that Rothenberg Gritz clearly doesn't understand.

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An interesting article from NYT, concisely and clearly written:

http://tinyurl.com/otnpsxx

Apparently, no chi, no chakras....

I agree - that New York Times article is interesting, concise, clearly written, and has no chi, no chakras, and no mind-body duality.

Orac is just way behind the curve on integrationist medicine, and needs to have an open mind and think outside the box of pharma-drive healthcare.

For instance, did you know that probiotics are good for preventing social anxiety?

"Now a new study, published in the journal Psychiatry Research shows that consuming these “good” bacteria in fermented foods may also help curb social anxiety. The study, from College of William and Mary, included more than 700 students (mostly women) enrolled in an intro psychology class. Each participant filled out a questionnaire about his or her consumption of fermented foods, like yogurt or sauerkraut. They also answered personality questionnaires designed to tease out patterns of neuroticism (a personality trait) and social anxiety. In the end, researchers found that people with neurotic personalities were more likely to experience social anxiety, and that eating fermented foods was tied to a lower likelihood of symptoms."

http://abcnews.go.com/Health/probiotics-ease-social-anxiety/story?id=32…

Sound rock solid to me.

I am planning to start eating lutefisk for mood elevation, since we know Scandinavians are happy-go-lucky and devil-may-care.

I suspect that one of the reasons that chronic pain sufferers are proan to using alternative therapies is that many doctors are not very good at supporting those patients emotionally, and the patients are often not getting enough information about what is going on, and when they do, it is sometimes not offered proactively.

I am an anecdote about this problem. I had two major surgical procedures. Afterwards, I developed severe pain, not just at the surgical site, but in a large area in a dermatomal distribution. The pain lasted for a very long time, and did not fade away to a level I would consider reasonable for about a year and a half. It was not ameliorated by any medication, not even narcotics. I was able to figure out what was happening to me because a paper appeared in Nature shortly after my surgery describing the neurons responsible for that syndrome. When I spoke about this at my next visit, the fellow nodded his head yes and said that it tends to get worse the higher up you go.

To me, that is just not acceptable. This was a major academic cancer center, and I think they should have been more proactive with pain management, and I should have at least heard of that syndrome before having to find out about it myself. Basically, nobody else would have been able to do that.

That is the one and only criticism I had about my care there, and I think it is at least part of the reason for the persistence of alternative therapies for pain.

I would say that eating kimchee, at the very least, would lead to social isolation.

Back in the 1990s, the word “alternative” was a synonym for hip and forward-thinking. There was alternative music and alternative energy; there were even high-profile alternative presidential candidates like Ross Perot and Ralph Nader.

The word "alternative" leads to the question, "Alternative to what?" and the follow-up, "Is the alternative better than the thing it is supposed to replace?" Most of the time the backers of the "alternative" can give a somewhat coherent answer to the first question, but "alternative" is not always better. Alternative music, like any other genre, has its gems among a lot of crud. As for alternative presidential candidates, suffice to say that Ralph Nader is a Berserk Button in certain circles. "Alternative energy" has fared somewhat better, but there are still issues with consistency. "Alternative medicine" is like alternative presidential candidates: harmless at best, and often quite damaging. It's also quite telling that "alternative medicine" and "traditional medicine" are somewhat synonymous, and contrasted with standard science-based medicine.

Some of the idiots I survey use 'alternative' and 'natural' interchangeably. Oddly though, 'traditional' is sometimes used for woo as in TCM or to designate SBM in contradistinction to New Age, altie, natural woo.

But then again, their language skills aren't exactly enviable.

Dr. Finfer #4,

A couple of questions.

First, continuing from a discussion on the previous comment thread, why do you think it is up to the doctors to provide emotional support? This puzzles me, and since you are an actual MD unlike the other commenters, I would be interested in your take on the matter.

I look for competence from doctors and emotional support from friends and family. For those without, I would think clergy for the religious or someone trained in social work or counseling would be more appropriate.

Second, if I understand correctly, there never was an effective intervention for your pain? It sounds like you got some satisfaction from figuring out what was going on, which makes sense for a professional, but even then there was nothing to be done but wait. But I wonder how much that would have helped a layperson-- intractable pain for an indefinite period is hardly something most people would accept.

And yet, it doesn't work.

@Dangerous Bacon #3: well, we all know about the wondrous powers of bleach, don't we! ;) I'm sure lye must be just as good.

@shay #6: not if you're Korean.

Seriously, though: I think Dr. Finfer has hit the nail on the head. People fall for woo because its practitioners do what too many doctors should be doing, but don't: talking to their patients and taking their concerns seriously.

I don't blame doctors; I can count on one hand the number I've known who truly didn't give a damn about their patients. I blame the workings of the healthcare industry that make it impossible for physicians to give their patients the kind of time and attention they want to give them. If we would actually pay physicians to talk to their patients, and listen to their concerns, I think a lot of people who are into woo would stop.

First, continuing from a discussion on the previous comment thread *plonk*

FTFY.

DB:

Scadinavians are probably more well-balanced on average, and lower in anxiety and neuroses than most ethnicities. My hypothesis: they don't repress their moodiness with forced cheerfulness. You see more angst, because they're clearing out the tubes. The can be pretty funny, and know how to have a good time on Svenskarnasdag. Google "Ole. Lena, Sven" for Scandi-humor:

Ole was on his deathbed and implored his wife Lena, "Lena, ven I'm gone, I vant you to marry Sven Svenson".
"Vy Sven Svenson?" his wife asked. "You've hated him all of your life!"
"Still do," gasped Ole.

But, no, do NOT eat the lutefisk...
_______
That William and Mary 'study' is about par for the course for academic 'scientific' psychology. So much bogus causal 'reasoning'...

@ sadmar:

I wonder how much vaunted 'national differences' in personality have to do with the latitude at which the culture originated and how cloudy or sunny it is on average:
if you live at ( frigging- or is it Frigging?) 60 degrees North, you'll spend most of your winter in the dark! Being miserable and drinking hard liquor. -btw- Do people with light eyes may have more problems with alcohol dependence- I seem to have read something along that line?

Then we have Russians.
HOWEVER they do eat fermented food.

Zebra #8:

The physician is the team leader and the one with the medical license. It is ultimately his/her responsibility to see that things are done. I tend to use physician as a contraction, and what I really mean is the physician or designee, but it is the physician who does the designating.

Emotional support really needs to come from anyone who a patient interacts with, but it is the physician who sets the tone. There are support groups and other things for those who need it, but they tend to come after the immediate recovery when a surgical patient can easily get around on his/her own. It is the physician and staff who have to get the patient to that point.

Places like the one where is was at typically have teams for everything, including pain management. I was given lots of things to read, but I do not remember anything that would have clued me into the fact there that there are pain syndromes that do not respond to meds and asking me to call if I had an issue. That is all that most people need. Once I realized what was happening, I was able to just deal with it. I do admit that before that point, I had used kind of a lot of narcotics, but I used the knowledge to just stop them and get through it. I am not sure it would have been so easy for patients with no medical training.

As for clergy, I have no use for them.

You are correct. There are currently no drugs that address the type of pain that I had. It's called cutaneous hypersensitivity. It sounds similar to post-herpetic neuralgia. There probably has not been enough time since the description of those neurons for a drug to come to market. I do hope someone is working on one. After five years, I still occasionally have some pain, just enough to remind me that something was done. It is just a minor annoyance now.

if you live at ( frigging- or is it Frigging?) 60 degrees North, you’ll spend most of your winter in the dark! Being miserable and drinking hard liquor. -btw- Do people with light eyes may have more problems with alcohol dependence- I seem to have read something along that line?

Then we have Russians.
HOWEVER they do eat fermented food.

There is apparently actually something to the blue eyes and alcohol dependency connection. I first heard of it, though, in a context that made me think it was just a bit of raving on the part of a particularly (in)famous late professor in our department.

I was in Old Russian Lit, sitting next to my friend Olga, while Omry was on one of his epic digressions, and had somehow gotten on the topic of Mussorgsky, and how he "drank very much" in order to "get closer to the soul of the Russian people," and how it didn't work out for him.

Olga says to me, under her breath, thinking he wouldn't hear, "That's my methodology."
..."What is? Getting drr-unk? ...You have... dark eyes?"
"Um, dark green."
"Yes, well, then you must be careful. It is the light-eyed people, you see, who become alcoholics. The dark-eyed Mediterranean types might drink very much, but they do not become alcoholics. Just as long as you don't eat the SOMA MUSHROOM!"

*blank, slightly terrified stares*

FWIW, I have almost-black eyes, and I'm pretty sure I drink more than Olga, although I did notice some empty vodka bottles sitting around when I was apartment-sitting for her a couple years back.

And speaking of digressions, I am sorely tempted to turn this into a Sven and Ole thread, but I am biting my tongue fingers.

Are you telling me that there are more than 6 Scandiwegian jokes? I am deeply skeptical.

#14 Dr Finfer,

"cutaneous hypersensitivity"

Maybe you mean cutaneous hyperesthesia?

@ JP:

I read about the light eyes/ alcohol at a news site: it was supposed to be based on research but we all know how _trustworthy_ that can be. I can't seem to find it: it was about whether certain illnesses/ problems were associated with lighter eyes.

Interestingly enough, the part of my family with very light eyes seems to be rather resilient to alcohol - even the guy who had horrible war experiences only drank on weekends. My father had no interest in alcohol- the rest drink/ drank on and off, mostly at social events I can personally not drink for months and then have three a night for a week or two.

And yes, we could probably go on and on about how various cultures respond to alcohol but then, that wouldn't be very nice of us, would it? Lots of jokes as well
-btw- I believe that my families' ancient stomping grounds were at about 52 degrees but there HAD to be something Mediterranean way back.

@Panacea:

Bingo on the industry critique!

It IS trickling down into the physicians, though, as the young MDs who feel they need to take time with patients are giving up on primary care and going on to specializations. The Taylorized quick-turnover system is now so well established, new PCPs kind of self-select for being OK with that, and you get these young Drs. who just DO NOT LISTEN.

When Dr. Finfer says MDs are "not very good at supporting those patients emotionally" we may get an image of cold, haughty, disregard — but the young don't-listen Docs I've had of late are cheerful, upbeat, 'nice'... Giving emotional support isn't about attitude, the practitioner actually has to DO something. To me, it's worse that these guys blowing off my concerns are NOT grumps. It sort of whipsaws me when the Doc seems positively engaged, but then just gives a superficial quickie answer and disappears. In my case, the chronic complaint (sore-throat, laryngitis) the Dr. blew-off time and again turned out to be related to a potentially life-threatening condition (Barrett's)...

Setting his answers aside though, zebra poses a good question: why should it be up to doctors to handle the emotional aspects of patient care? The Alt-Med practitioners who are taking time, listening to the patients, engaging them pro-actively ARE NOT DOCTORS! (They're glorified physical behavioral therapists spewing a lot of false information.) So it doesn't take a Dr. to get that part of the job done.

As you said, sbm is delivered by an industry. There are already divisions of labor at the health clinics that have largely replaced the old-school, one-or-two MD private-practice for primary care. It's the INDUSTRY that's responsible for listening to patients, getting all the info (physical and mental/emotional) about their maladies into their files, providing them the emotional support they need to deal with dealing with chronic physical ills at the clinic. The industry falls short because doing those things costs money, tit can can get away with not doing them, and it doesn't care if sCAMmers thrive as a result as long as that isn't messing with the bottom line in the next quarterly report.

It's not Doctors failing so much as medical practice as a whole, so lets re-position the encounter from 'patient-doctor' to 'patient-clinic.' MDs aren't the logical personel for the task.of 'patient relations', their expertise and training lies in a very different direction... So, I think primary care practices ought to have 'patient relations' medical staff to assist MDs — a sort of combo LCSW/PA/NP who can take the time, knows how to listen, knows enough medicine to get the right info to the MD, and can extract from the MD the concrete info they'll need to inform the patient about what's up in an emotionally supportive way.

I.e., the sbm delivery system COULD figure out a way to offer much of the positive experience patients are getting from quacks without spreading the woo of vitalism, magical thinking, etc.

@ JP- Come to think of it, resilience to alcohol might have been useful to my ancestor who manufactured gin. Kept him out of product.

Come to think of it, resilience to alcohol might have been useful to my ancestor who manufactured gin. Kept him out of product.

"Don't get high off your own supply," as they say.

Here's the eye color & alcohol study.

#19 Sadmar,

How would your plan have helped with your anecdote? That wasn't about emotional support, just poor diagnosis.

Perhaps it is the PCP that is the unnecessary layer of bureaucracy in the system.

Denice:
If you live at 60 degrees North, you’re likely the descendant of generations of forebears quite used to spending most of the winter in the dark. They've figured out, and passed down, lot's of things to do in the dark besides drink and be miserable... including even a few not involving wanton getting of jiggy.

Now if you look at Yonnie's picture, you might think he's slow,
But he seems to know, 'Bout cows and dogs and everything,
And when you talk about my Yonnie, you speak of the best,
I found out lots of things about that boy,
He's so different from the rest.
Holy Yumpin' Yiminy
How my Yonny can love,
When he kisses me, oh what yoy, makes me feel so oh! by Yiminy!
He bane my sweet Papa, I bane his Turtle dove,
He no bane much on reading books,
And he bane worse when it comes to looks,
but holy Yumpin Yiminy, how my Yonnie can love.

.
Now, it seems the Rooskies do love them from Vodka, but THE most drunk state in the U.S. is Wisconsin, which is full of Germans. In contrast, the much more Scandinavian Minnesota next door only allowed 3.2 beer until fairy recently. And for the Germans, we're talkin' more Bavaria than anything, and that ain't that far North... (For the record, I have a Germanic surname, and predominantly German ancestry, and NO Scandinavian blood... so I'm talkin' 'bout my own peeps, here... But, no, I ain't touchin' sauerkraut any more than I'm getting within a furlong of kimchee...
Bratwurst, on the other hand, totally rocks...)

zebra #22:

It's about taking the time, listening, taking what I had to say seriously... The problem with assembly-line sbm that's alienating the patients turning to Alties isn't just 'lack of emotional support', it's a functionally callous attitude leading to missed diagnoses.

I'd see the MD, complain about the chronic sore throat repeatedly, and every time he'd say, 'well it's just post-nasal drip' give me a two-week Rx of anti-histamines and another routine appointment in 3 months. No follow up on whether the Rx helped, no continuity between visits registering the problem wasn't going away. I think he only looked at his own medical records on me, because if the data had been coordinated with other providers I'd seen in referrals, he'd have noted that when I'd had a 'routine' upper and lower about a year earlier, the gastroenterologist had noted the problem with the stomach sphincter, and the lining creeping up into the esophagus (though HE hadn't explained what that meant symptomatically, so _I_ couldn't correlate that to the throat problems).

I know several other personal horror stories much worse than the anecdote I've related — failures of sbm delivery that were totally inexcusable, as no House-like mysterious diagnostic issues were involved, just Drs. too busy/distracted/disconnected to observe what should have been obvious, had they known their patients at all.

Oh, Scandinavians can definitely drink. Just ask bimler.

But, no, I ain’t touchin’ sauerkraut any more than I’m getting within a furlong of kimchee…

That is a mistake.

RE #4 and #8 there seems to be a lot of demand for "bedside manner" and handholding by physicians when the vast amont of education and expense involved in training an MD seems wasted when they basically sit there fielding the same questions that could be answered by a specialist LCSW or some kind of nurse or medical assistant. How much is spent and wasted on low level hypochondirasis and pep talks which could as well be provided by motivational therapists who would also perhaps be quite a bit better at it than most physicians anyway?

@ Barefoot:

Agreed.
And this is where the woo-meisters step in: so much of what they promulgate are pop psych solutions for everyday problems that a person might elicit from a trusted friend or relative especially when things aren't awful enough for calling on a therapist, nurse or social worker.

Like AoA/ TMR, woo-centric outlets/ businesses cater to groups of like-minded people with gripes and axes to grind- obviously, facebook and other social sites work well for them.

@zebra - I agree, it is possible to have ineffective treatments and ones that aren't backed by science that don't depend on qi, chakras, mystic energy, or the power of gods. It would be perfectly appropriate for someone to take those clinics to task for making statements and promising results that are not backed by evidence.

Sadmar #24,

Sorry, I should have been more explicit. It's the part where the person you talk to reports to the non-specialist MD that I'm questioning.

Why not let the person who spends time with you pass along your information to a specialist? Maybe that person could be trained by someone like yourself to write a clear, compelling narrative. There are lots of very smart people who can fill that kind of role for a reasonable price.

Barefoot #26,

You must have an exceptional bedside manner; I have been excoriated here for suggesting exactly that. See the comments on the previous post.

And for the Germans, we’re talkin’ more Bavaria than anything, and that ain’t that far North…

I know several people who either live or have lived in Munich, who tell me that beer is legally considered food in Bavaria. The standard beer serving there is one liter, compared to 0.3-0.6 liters elsewhere, depending on country.

Yes, the Scandinavians do drink. The Swedish word for beer is ö;, which is cognate with "oil". In Sweden it comes in three grades, ranging from lättö; (light beer, both in alcohol content and excise tax) to starköl (strong in both senses). The Swedes have other ways of dealing with winter darkness: I understand they were the ones who started the tradition of putting lights on Christmas trees.

But if you are really looking for hard drinkers, head across the Gulf of Bothnia to Finland. From what I hear, the average Finn will drink the average person from any other country under the table.

I was really hoping that your second use of the meditating doctor picture in this article would have his pants on fire. (photoshopped of course. I'm not an advocate of self-immolation or spontaneous human combustion.)

#17
zebra

"July 6, 2015
#14 Dr Finfer,

“cutaneous hypersensitivity”

Maybe you mean cutaneous hyperesthesia?"

When I did a quick Google search for that term just now, most of the links I got were for a syndrome like that in cats.

None of the people caring for me used that term, but it is an apt description. It was like being on fire all the time. The slightest touch made it much worse.

Just to reiterate my original point, I can understand how people in the position I was in gravitate towards things like acupuncture. They are desperate, and if they don't get what they need from their doctors, they will try anything.

I was able to supply the information I needed myself. Very few people will be able to do that. Personally, I wonder why, in a big center like that, the pain management group does not visit every surgical patient at least once before they leave the hospital. It seems to me that might be a good idea.

When I did a quick Google search for that term just now, most of the links I got were for a syndrome like that in cats.

More telling is the fact that this was the only response Z. had to your actual comment, which he solicited in the first place.

Medical training is what allows a doctor to be able to discern the difference between someone in need of a pep talk an an authority figure telling them everything is alright, and somebody who actually needs treatment or referral to a relevant specialist- and which specialist as well.

Trying to come up with some system that replaces the GP with a network of nurses, physiotherapists, personal trainers, motivational speakers, and such would create more problems than it would solve

Re the McArdle article, not at all surprising that she'd write an article from the point of view that having or not having health insurance is no big deal. Her position on such topics can be summarized by the title of an article she wrote recently for Bloomberg View:

"[Obamacare] endures. Let's hope the Supreme Court's legitimacy survives too."

As I recall, she was having health problems about the time she left The Atlantic. Don't know exactly how she paid for the care, but my guess would not be cash.

Are you telling me that there are more than 6 Scandiwegian jokes?

Don't know how many this makes total (as told to me by a Swede):

Q: Why do Norwegian cars have windshield wipers on the inside?

A: Make engine noise with tongue protruding from lips (a/k/a a "raspberry").

The premise of Firesign Theater's 1974 record "Everything You Know is Wrong" is that the manager of a nudist trailer park in the California desert has put out a record containing his proof that aliens have lived among us for many years (pretending to be Indians). At one point during his narration, the phone rings, and he answers in exasperation: "Nude Age Enterprises! I'm busy!".

Not exactly apropos, I know, but the memory makes me chuckle almost whenever I header the phrase "New Age".

The record is hilarious, and holds up beautifully, by the way.

Ach, I just learned, by coincidence, that Phil Austin, one of the four members of Firesign, died on June 18 of cardiac arrest, a complication of cancer. Phil was perceded in death by Peter Bergman. Very sad news! They were simply amazing.

Be careful what you wish for. It is coming and Horatio is exactly correct.

Google "collaborative care".

The push is to remove physicians from patient contact has started and it is going to be relentless all based upon financial considerations. Patients be damned.

sad to hear it...i love their stuff on records.

Zebra,

I am more and more disappointed in what I read in your comments. In order to make your argument (which I have long since lost track of what exactly it is) you place yourself in more and more indefensible, reductionist arguments.

"...why do you think it is up to the doctors to provide emotional support?"

I am not sure who is insisting on this other than you but perhaps you missed the part where the doctor-patient relationship is one between two human beings. And it is a large part of the "art" of medicine. So do I want compassion from someone that provides it without enough clinical knowledge understand what they don't know, a charlatan "selling" me compassion along with a lie or the doctor who is the one treating my condition. I'll take the doctor thank you very much because he is the one most likely to use it to my benefit.

In contrast, the much more Scandinavian Minnesota next door only allowed 3.2 beer until fairy recently.

You would perhaps care to document this? Limiting sales in, e.g., grocery stores is not the same as "disallowing." (Moreover, as I've mentioned before, "3.2 beer" is ABW, which is about 4% ABV, or right about ordinary bitter.)

I'm waiting for an outbreak of Sven and Ole jokes. When I first moved here, I'm sure I did many a head tilt when folks would tell me those jokes.
Michael Finfer, MD--I'm not an MD, but rather a veterinarian who works in science, and I too had to diagnose my own post surgical chronic pain problem, despite mentioning it to the nurse practitioner many times during followup. I never saw the surgeon after the day of surgery. I wonder if it would have made a difference. Damn thing still hurts, too.

not a troll #43

It is a puzzlement, really, how I could ask:

"Dr. Finfer #4,

A couple of questions.

First, continuing from a discussion on the previous comment thread, why do you think it is up to the doctors to provide emotional support?"

It's not like Dr F said, in the clearly referenced #4 comment,

"I suspect that one of the reasons that chronic pain sufferers are proan to using alternative therapies is that many doctors are not very good at supporting those patients emotionally"

I don't know, maybe I'm having some kind of delusional psychosis where I just imagined that he said that. Maybe I need to have a compassionate PCP diagnose me.

Or maybe you should lay off the sauce a little?

@ Barefoot #26

How much is spent and wasted on low level hypochondirasis and pep talks which could as well be provided by motivational therapists who would also perhaps be quite a bit better at it than most physicians anyway?

I'm agreeing there is some true in this, for whatever my opinion is worth.
As the previous threads hinted at by zebra may indicate, I am however very negative about the possibility of an easy fix
(that's not a reason not to try, but I'm very upset when presented with "just do that" solutions*, so I like to have details - this part is for zebra).

In an ideal, enlightened world, people would be well-informed and self-aware enough as to which specialist they need to see, be it a therapist or a bona fide yoga teacher.

In a somewhat closer-to-real world, the primary care provider or, heck, why not, if their training is sufficient for it, an AP or RN could provide the info and do the referrals. It's supposedly how the healthcare system should be working in my country, more or less.

In the real real world, hypochondriacs and people in need of talking** end up at the PCP office; or because doctors don't have time enough for their patients, these people end up at the office of some naturopath/chiropractor/guru...
I believe it's this issue you, Barefoot, are talking about (and also zebra - at least this part of his/her posts was clear).

I see two big difficulties with this issue:
- limited resources: it may not be true where you live, but competent specialists (notably therapists) are in short supply around me, and I was under the impression it's true as well for North America. Or it may be that a good number of people simply don't know that these specialists exist and how to find them.

- patient compliance: for various reasons, these hypochondriac or talkative patients end up at the doctor office. How do you convince them to go seek help somewhere else? And somewhere legit, to boot, ideally.
Especially if that they need is some therapist. There is a strong negative connotation attached to mind illness.
Not about therapy, but exercise: I know it took two decades for people to convince my dad to join some sort of sport class. And it was not his doctor, but my mom who eventually succeeded.
Well, I will admit compliance is far from impossible. It's just going to take efforts on all sides of the issue, not just on the MD side.

* in French, it's known as the Yaqua mentality (nothing to do with the Yaka languages)
** and let's not forget that being in need of medical attention and being in need of talking are not mutually exclusive, so these people may actually have a perfectly valid reason to visit the doctor.

@ zebra

I have been excoriated here for suggesting exactly that.

No, you haven't - made this suggestion, I mean. Or if you did, it was lost in the middle of your other pronunciations.

You started about the yoga teacher being better at making people move than the doctor (technically true, but, to repeat my objection, one doesn't go at the doctor's place with the same motivations as one goes to the yoga teacher's - see compliance, above); you continued on how the doctor's antechamber is filled with mentally ill and fat people who should better be somewhere else rather than in front of very-important you, and finished on how the woo-prone at the mainstream doctor's place should be given the snake oil they secretly really want, and stat, and too bad if it's ineffective. There was some mumbling about saving money, I'll grant you that.
And just at the end, you reversed position and stated that the doctor should receive the fat people and try to talk them into changing their lifestyle anyway.

No therapist anywhere. The yoga teacher may count, except for the part where you failed to explain how people en route to the doctor's office will suddenly veer off to the closest yoga room. As you framed it (or so I understood), a decision made at the doctor's suggestion, a doctor whose advice these "yoga-prone" people are mistrusting. And to top it, an advice given free of charge, after a quick glance by someone, don't know who, to be sure these people were not about to collapse just now (and thus, unequivocally determining that they are not "true" patients).

Now, if you feel like presenting again your opinion in a clear and concise manner, be my guest. But after the last few months trying to get something coherent out of you, I don't have high hopes.

@palindrom (40),

Sad to hear that. I have fond memories of that group and a couple of their records on vinyl.

When I got my first mini-van in the 80's, I put on a recording of "I Think We're All Bozo's On This Bus". With the front and rear speakers going, it was an almost surreal experience!

I don’t know, maybe I’m having some kind of delusional psychosis where I just imagined that he said that. Maybe I need to have a compassionate PCP diagnose me.

Or some sort of neurotic repression of your only response's being the droolingly idiotic "maybe you mean cutaneous hyperesthesia?"

Or maybe you should lay off the sauce a little?

And the predictable, revolting collapse continues apace. You have nobody but yourself to blame for the fruit of your perpetually sophomoric attention-whoring.

Helianthus #47,

Blah blah blah... maybe the problem is that some people work hard to use fewer words, and some people don't work hard to understand, and use lots of words to hide that they don't understand?

"Motivational therapist" doesn't mean a psychiatrist or even a psychologist, although we do shortchange mental health everywhere, and those services should be more available.

A yoga teacher is a "motivational therapist", just like many other jobs which involve getting people to exert or extend themselves. Think about a drill sergeant for the marines or rangers-- people sign up, but that doesn't mean they will continue through the pain and pick themselves up from the failures. They need "motivation" to continue with the "therapy". It's about getting people not to quit, not getting them to start.

Now, I can explain how we might improve things in my opinion, but not if you are going to continue misunderstanding (intentionally or not) what I am saying and being oppositional without explaining what you don't understand.

I seem to communicate pretty well with people who are not part of the little minion corps.

Blah blah blah… maybe the problem is that some people work hard to use fewer words, and some people don’t work hard to understand, and use lots of words to hide that they don’t understand?

Oh noes! It's the return of the "filibuster" creeping thing!

Tremble in the Face of Its Power!

I seem to communicate pretty well with people who are not part of the little minion corps.

Examples?

Narad,

I'm flattered and all that but your little crush is getting kind of embarrassing. I have a very serviceable wife whom I love more than life itself, after all, and I have resisted temptation for more decades than I care to think about. I'm just not that into you.

Zebra #46.

How did you know I have blue eyes? But I assure you, except for that time in college, I rarely drink. [To quantify because doctors always look surprised after they ask me "how rare?" and I say about six drinks a year, I am leaving open the possibility that my definition of rare may not match most people's.]

In response to your reply, I took Dr. Finfer's remark about emotional support as an observation. You appear to have taken it to the extreme as if it was an edict for doctor/patient relationships; similar to your "recipes for fat people" binge that you were on, on the last thread.

I get making a point but you pick the most absurd black and white, opposite end of the spectrum illustrations to further your arguments and it just makes me shake my head.

Maybe I am due for one of those drinks now.

I have a very serviceable wife

That made me a little verklempt.

I’m flattered and all that but your little crush is getting kind of embarrassing.

"Crush"? No, Zohnnycakes, I'm merely a documentarian.

It is true that I find a certain amount of amusement in seeing just how many ways you can come up with to make a fool of yourself, but that's small potatoes.

Now, I presume that you concede that the assertion "I seem to communicate pretty well with people who are not part of the little minion corps," in context, is precisely equivalent to the statement "you people are too stupid to recognize my brilliance," given that the best response you could muster was invocation of having "a very serviceable wife."

Hey, here's an idea: Maybe she could chime in! I mean, she does know and admire how you spread your profound intelligence far and wide, right?

#39 You don't know what busy is, Cox.

That and the Giant Rat of Sumatra were best beloved.

All hail Marx and Lennon!

The first stage play I was in in college was a kind of pop culture collage that included a section where the ensemble cast acted out some of 'The Wall of Science" from "Bozos" — IIRC, I portrayed a Hot Lump, a colliding moskweeto, and a small dying creature... We didn't get up to Fudd's Law (or Teslecle's Deviant, but then we fell over without being pushed.

I wonder if the whole 'quantum' multiple-timeline thing came to some theoretical physicist listening to the interrupted flashback sequence near the end of "Nick Danger" while dosed.
https://youtu.be/RwG5c9IsgbA?t=19m49s

It galls me a little so few young-uns know Proctor and Bergman, given what passes for 'comedy' these days...

Zebra,

You have my apologies. The last thing I wanted to do was to make this personal. I am really not a troll.

I merely ask you to consider that there is a middle ground here and that many people who want a human being as a physician are not looking for them to be their BFF or mother/father figure. Or their yoga instructor.

I wonder if the whole ‘quantum’ multiple-timeline thing came to some theoretical physicist listening to the interrupted flashback sequence near the end of “Nick Danger” while dosed.

It didn't, and perhaps it would help if you took the time to try to figure out what it means before reaching for the pop-culture fantasies.

@Dr Finger - sorry about your pain - sounds a lot like what I was left with on my foot after an ankle surgery - a light touch would feel like someone drove a hot spike through my foot. I suffer from a chronically painful condition and the pain was managed by my primary care doctor originally because I was diagnosed while uninsured. Have had the misfortune of having to replace doctors while being on pain management now. I have learned that there can be some serious jerks in medicine.

When it comes to "alternative" - Mr Woo loves the stuff, of course. When I was first diagnosed, he googled my disease and cure and spent as much as three hundred a month on pills, books, potions and crazy diets to fix me. Took me to faith healers... when they failed to heal me they suggested exorcists (I refused)!

Alternative will always be around. As long as there is a desperate patient and a creative huxter, there will be alternative medicine.

Doctor Finfer. Curse you, auto correct!

@Narad #61

Didn't it? How do you know? Some linear time-thing since physicists were positing stuff about this over a decade before "Nick Danger" was recorded? C'mon! I know the J.J. Abrams Star Trek and Terminator: Genesis are just silly fantasies, but if you can prove Ted Theodore Logan and William S. Preston, Esquire didn't go back in time, transport the physicists to San Dimas in 1989, get 'em high, and play the whole Firesign catalog through several times before dropping them back in their own time-space continuum, watch the end of Excellent Adventure again, then prove Bill and Ted Jr. aren't going to do that NEXT week.
http://tinyurl.com/onf333q

Re #44. The 3.2 law in MN does NOT apply to establishments with a liquor license, and it's still on the books. In 45 states, beer is beer, no matter where you buy it. In Colorado, Kansas, Minnesota, Oklahoma, and Utah general establishments can only sell 3.2. Some smaller municipalities in MN don't like to issue liquor licenses, so there are "bars" that only serve 3.2. The POINT was related to a humorous tangent coming off a lutefisk joke by DB — Scandinavians aren't big boozers. Or perhaps you've never heard of certain Norwegian-American Congressman from Minnesota named Andrew Volstead?
https://youtu.be/NLKwfHxq-zk?t=7s

One other thing for the moment, Z.:

Did you ever manage to figure out what "interlocutor" actually means?

@Narad #61

Didn’t it? How do you know? Some linear time-thing since physicists were positing stuff about this over a decade before “Nick Danger” was recorded? C’mon!

My comment was not an invitation to further "banter." If you are wholly clueless about MWI – which seems clear – I can only suggest that you not make a fool of yourself by invoking it.

Not A Troll #60,

Thank you-- I guess that drink worked?

I assume you can understand that I am a little testy about people saying they "can't figure out what zebra is saying" when it appears they haven't read very carefully. Let's start again.

Dr F seems to have understood my point, and answered it. What he meant was that there should have been support as part of the service provided, not necessarily by someone with an MD or the surgeon. Pretty much consistent with what I and some others are saying.

Now, as to your "middle ground", I don't know. You say:

"many people who want a human being as a physician are not looking for them to be their BFF or mother/father figure."

To me that's pretty vague, and at the core of the vagueness is the term "physician". Which is one of the things at the core of my argument.

I want someone to give a correct diagnosis, do good surgery, properly calibrate medication, and so on. If those functions turn out to be optimized by using AI, or a brash and unpleasant human, why should I care?

Consider Sadmar's report of doctors being superficially pleasant but missing important and probably obvious signs.

Sadmar, don't take #66 personally-- Narad obviously doesn't handle rejection well; the bitterness will pass with time.

Oh, dear, the Zony is down to attempts at parasitism.

Hey, Z., did you ever own up to the Colossal Shay Blunder?

Zebra,

Then I guess my only option If I want to visit a practitioner with ample time and the ability to be an active listener with enough compassion to elicit answers from me in order to be able to "give a correct diagnosis, do good surgery, properly calibrate medication, and so on" is to see someone who is not trained as a physician while likely paying for unproven/worthless treatments.

Not a troll #70,

You seem to be stuck in a circular-reasoning-loop here.

If you want to see a "physician", meaning a traditional MD GP or PCP, then that's what you want. Your choice, but I don't see how that relates to what I said.

I can imagine each of the three items I listed being provided by different specialists who have specialized training not necessarily identical to current MD training. Indeed, it is obvious that you don't really have to talk to your surgeon; certainly in ER situations a patient may be unconscious and have no available medical history, but still the work gets done.

So, either you have an argument that there will be better outcomes because you have a long, face-to-face talk with the traditional MD PCP, or you really do want that kind of in loco parentis reassurance because it is a time of stress and fear-- which is certainly an understandable human reaction.

My point again, is, that there is really not an argument for getting that comfort from a very expensive and not appropriately trained practitioner.

There was no circular reasoning; it was a straight path from the body of your prior comments.

Compassionate care and medical care are not mutually exclusive as you seem to keep wanting to define it.

If you want to narrow it down to "getting comfort" only, that appears to support Orac's stance of not introducing woo into medicine because it is the only thing it offers if that. Non-MD providers can be as crappy as any MD as far as attitudes.

There's a common view that people go to CAM practitioners because they make more sympathetic noises than regular doctors. I suspect it is more because, to my knowledge, a CAM practitioner has never in recorded history said to a patient, "I'm sorry there is nothing more I can do for you". As I have said here before, I think these false promises have more to do with the popularity of CAM than the time spent with the patient or bedside manner.

Anecdotally, I saw two alternative practitioners some decades ago. The first was for a whiplash injury after a car accident, and a friend highly recommended an osteopath/acupuncturist (i.e. a UK-style osteopath), in a trendy part of North London.

The young man I saw was practically taciturn and didn't make eye contact. After a very brief history he mumbled something, then cracked my neck and back, stuck some needles in me and left me for half an hour. The practice was very busy, with two receptionists and several other patients. I guess if you can pack patients in if you needle one while back-cracking another, without wasting time on small-talk.

The second CAMster was a TCM practioner; an ancient (and very grumpy) Chinese man in silk robes, who barked questions through a translator, wordlessly stuck needles in and sent me away with a bottle of epedra tablets. So much for empathy and bedside manner in both cases. I have had far more friendly GPs, who have on occasion been very helpful too.

Maybe my experiences are unusual, but I have seen no sign of the extended time and sympathy CAMsters are supposedly able to provide patients. Isn't it just homeopaths who have the legendarily long consult where they ask about everything from your dreams to the color of your feces?

Anyway, Given proper triage, I agree that we could probably use qualified doctors a great deal more effectively. Why get someone paid $200,000 pa to do a job that someone earning far less can do just as well? It's the triage bit that concerns me.

"I agree that we could probably use qualified doctors a great deal more effectively."

Yes, in America, we use them as typists.

"It’s the triage bit that concerns me."

This, a 1000 times. [an Americanism. It means I agree with you whole-heartily]

So, Zebra, what's your solution?

If you're not comfortable typing it in English, feel free to type it in the language you are most comfortable in, or simply copy-paste the link from CollectiveEvolution and we'll sort it out.

Not a troll 72,

"Compassionate care and medical care are not mutually exclusive as you seem to keep wanting to define it."

Sadly, we are back to misrepresenting zebra's position. Of course you can get the care you say you want-- just go to a concierge service and pay out-of-pocket.

My issue is with the design of the system if we consider it a Public Good, and we must acknowledge that while it is not treated as a Public Good in the US, it is financed in large part by the Public Purse.

#75

What is CollectiveEvolution?

And what is my solution to what?

Krebiozen,

I believe it was you who once gave me the figure that 80-90% of symptoms for which people consult doctors would resolve without intervention.

If you then add in the cases you cite where conventional medicine can't really help much, and acknowledges that-- the false negative problem seems much more manageable.

And for Not a troll as well: What's circular is saying that we need traditional MD trained people to do triage because only traditional trained MD can do triage.

It's the 21st century; get on board.

My point again, is, that there is really not an argument for getting that comfort from a very expensive and not appropriately trained practitioner.

So, basically, this whole production number boils down to your agreeing with Orac.

Good that that's finally settled.

My issue is with the design of the system if we consider it a Public Good, and we must acknowledge that while it is not treated as a Public Good in the US, it is financed in large part by the Public Purse.

"It"? (What happened to the "majority" part, BTW?)

Why, Zebra, the "method of improving things" you alluded to in post #50, since you are so fond of referencing posts

Will you share it with us unworthy knaves, even if we don't understand your brilliance, or simply ignore this request because you are incapable of articulating it, or will you find another way to prevaricate?

There was no circular reasoning

That's just Z.'s new mantra, which he's very enthusiastic about.

I should go to a CAM practitioner or a concierge service since I want a doctor to get the care I say I want? I am not sure you understand what I want. Compassionate care and emotional support are not the same thing although emotional support is probably derived from compassionate care in most cases.

So, instead of assisting doctors to reach a better standard of compassionate care we will go multiple levels down in clinical knowledge to do what? Fill out checklists at the door to identify that we have MDD before a differential diagnosis is even performed?

Not everyone who disagrees with you is misreading what you write. I think I know what happened in my case and that was following you down the tangential route of what is wrong with healthcare today instead of focusing on the subject matter of what is wrong with fake care bleeding into clinical care and how to stop it.

There is so much structurally wrong with healthcare in the US that I could go on for hours. However, to keep it on topic, I don't know how introducing fake treatments is going to make it better just because the providers of it come a lower price point than physicians. And if that is not what you are saying that is fine but your argument blended into that.

Per your most recent statement "we need traditional MD trained people to do triage because only traditional trained MD can do triage." I am not sure what your point is. We train people for a reason. Would you say it is circular reasoning to say that we need astronauts to go up in space stations because they are trained to be astronauts? Any fool can walk into a space shuttle, right?

Sorry. I didn't ID that my comment #83 was for Zebra.

Not a troll 83,

I think you are in fact misunderstanding what I wrote. Do you know what "concierge" means in reference to medical practice?

You can get exactly what you want, as long as you pay for it-- I believe someone suggested in the previous thread that you can have an MD talk to you for an hour for $500, which sounds about right in terms of annual earnings.

And if you don't find her compassionate enough, you can go to a different concierge practice and pay another $500.

So I am in no way suggesting you see an "alternative" practitioner if you don't want to. I'm suggesting a different structure for the system that's paid for by taxes and tax expenditures, and by insurance that people other than yourself contribute to.

#34 Dr. Finfer

I totally understand your anecdote. This scenario is what turned my niece into an anti-vaccinating, woo-embracing quack-a-loon wierdo. (And that's being nice!) Don't get me wrong, I love her with my whole heart, but she was taken in by an "integrative medicine" doctor who "paid attention" to her and helped her with her several "conditions" that no other doctor had been able to help her with. (IMHO -and be it known that I am no MD, I'm just related to several- she has several autoimmune issues that *were* relatively ignored by mainstream medicine doctors. What set her over the edge was when she got pregnant; heaven forbid a doctor who ignored her for so long touch her baby.) Now she "treats" herself and her family with strange foods and ways of life...You know, amber beads, oils, burning candles, homemade toothpaste, you get the idea...

I used to sort of pooh-pooh her experience. Until I got chronic migraines. Now that I have something that "mainstream medicine" doesn't actually like to work with because there is no easy or obvious solution, I'm getting shoved around from doctor to doctor and no one wants to listen to me either. If I didn't know better or have a good foundation in science, I might do the same thing she did and find someone who would listen. (And yes, she's suggested chiropractors, acupuncture, and homeopathy for my migraines, as well as a diet overhaul to eliminate everything from, dairy, to soy, to caffeine, to bell peppers.)

Sucks that it's this way these days. That's what happens when we are dealing with a generation of people who was told they were special just for showing up. (It's all about ME ME ME!!) Combine that with our crazy healthcare system that allows for 10 minute visits with our caregivers, and it's a major problem.

...meant to add: All of that to say: Anecdotes do not science make, but they may, in part, explain certain trends. Unfortunately.

Zebra,

I appreciate you looking out for my interests by directing me somewhere else, but why can't I get what I've already paid for? The anecdotes here do not mention how their diagnoses were incorrect or missing because their physician spent too much time with them or that they were too much of an active listener.

My dilemma is not how to get what I want by paying in addition to what I already pay, but of how to not pay for something that is a horrible return on my investment not to mention could damage me for the rest of my life.

Sure, I would rather pay a private doctor than pay a heath group CEO so he could shunt me (or others) off to see a NP/PA but I don't have much of a choice in that now, do I?

[This is nothing against mid-level providers. I am sure there are those who are better than physicians, however, I have not found one, ever. Nor even to a standard of care I would call acceptable. Perhaps it just the luck of the draw.]

So what is your idea of an optimal health care system? You've mentioned a lot of issues and a few things you'd like but I don't get a complete picture from it.

Maybe there's a gap in the market in the US for a no-woo medical insurance company with reduced premiums. Or does that already exist?

I agree with Dr Finger that un-managed pain is a reason that many patients end up in non-evidence based medicine. I was silly enough once to hand over $600 dollars to the local chiroquactor who 1. Bagged the neurosurgeon who operated (successfully) on my lower back. 2. Promised to fix the fibromyalgia in my upper back in 10 sessions. He didn't and after 9 sessions i decided not to go back as I wasn't happy with him shoving his knee into my lower back. Everytime I walk past I want to go in and ask for my money back.
Anyway, I was wondering if maybe some sort of model like an outreach worker (counselor who visits the patients home say once a week) would be a good model to stop the drift to woo. I've had one for chronic depression for a year or so and I've noticed that I tended to be a lot more honest about what was going on with her than my Psychiatrist. My Psychiatrist is great and I've been with him for years but it's just the way it is.
By the way if you ever want to deter someone from woo one of the best ways I've found is to ask the person recommending their acupuncturist, reiki practitioner, chiro etc to foot the bills and promise to pay them back if the treatment actually works. Most people won't put their money where their mouth is.

Krebiozen,

There is a huge gap in the US market for competitive plans even without their paying for woo. I didn't mean to misrepresent; most insurance plans are not paying for woo treatments at the present time. Sometimes they don't even pay for proven treatments such as CPAP supplies.

However, I am at a loss as to what they are paying for in routine care except for large administrator & pharmaceutical company executives salaries and physician's student loans (whole other rant).

I would be fine paying for my own infrequent GP visits and lab tests if not for the ridiculously inflated prices driven up by insurance (which does not pay nearly the rate a cash paying customer is charged because of their contracts) and having to watch my doctor type for the entire ten minutes I am allowed to speak with him.

But as they say, it is what it is. Lesson learned - do not take your health for granted.

nodrog,

That's a good way to deter people from going on about their alt med recommendations. I'll remember that.

who visits the patients home say once a week) would be a good model to stop the drift to woo. I’ve had one for chronic depression for a year or so and I’ve noticed that I tended to be a lot more honest about what was going on with her than my Psychiatrist.

Wait, this is a thing that exists? Can you tell me more?

Wait, this is a thing that exists? Can you tell me more?

This.

Orac, I love your work on the insane anti-vaccers, but I did have a valuable referral to what the Stanford Medical Center calls its nearby "Complementary Medicine Clinic" after beginning a many years' regimen of essential blood pressure medication. I learned a breathing technique that allows me to drop my blood pressure (systolic) by about 20 points in as many minutes. There's nothing mystical about this technique. It's a feature of all mammals. Based on that experience, I'm convinced that some complementary practices are just that ... complementary to standard medical practices.

Not a troll #89,

What you and I disagree about is the role of the GPMD in the system.

You are looking at it from your personal perspective-- you trust MD more than NP/PA, and you are also looking for that human compassionate interaction. I am looking at it from a scientific one-- how will the greatest good be delivered to the greatest number.

First, please go back and read my #78.

Then, you might be interested in this:

https://www.theranos.com/test-menu

I don't know if all the technology is absolutely perfect now or not, but it will be-- this is stuff we do well. We can't fix chronic pain, but we are whiz-bang experts at micro-engineering, and getting better all the time.

So, maybe you could come up with your own plan for a low-cost system that incorporates modern tech (not just these tests) and people trained to listen to you and pass on the report to specialists if you fall outside some established parameters.

Now, I contend that those people don't need to demonstrate that they can stay awake for 16-hr hospital shifts, or play around at doing surgery, or memorize all the bones in the body, and so on. They just have to be smart and capable of being trained to be compassionate and discerning listeners.

There are yoga teachers like that, if you think about it.

nodrog #91

"By the way if you ever want to deter someone from woo one of the best ways I’ve found is to ask the person recommending their acupuncturist, reiki practitioner, chiro etc to foot the bills and promise to pay them back if the treatment actually works. Most people won’t put their money where their mouth is."

Sure, but why don't we do that with the "insurance company" for conventional medicine as well?

Perhaps because there is actual evidence that conventional medicine will work, as opposed to the other "treatments" mentioned.

#98,

But we have all these people reporting on how it (conventional medical practice) didn't work for them.

If my auto mechanic misdiagnoses a problem and replaces an expensive part, but doesn't fix the malfunction, it is not a defense to say that "replacing that part has been shown to work sometimes".

I learned a breathing technique that allows me to drop my blood pressure (systolic) by about 20 points in as many minutes. There’s nothing mystical about this technique. It’s a feature of all mammals.

If as you state it's a known feature common to all mammals, what would qualify the use of this breathing technique as 'alternative' or 'complementary' rather than science-based?

But we have all these people reporting on how it (conventional medical practice) didn’t work for them.

Insert obligatory reference to problems with airplanes not being evidence magic carpets can fly.

If my auto mechanic misdiagnoses a problem...

...then the problem is your auto-mechanic's misdiagnosis, not a failure of the solution he recommended to correct it.

Zebra.

Link is nice but if my state allowed me to order my own labs I would have already been doing so for the past several years.

Read #78 and will only say that sometimes needy, histrionic people become ill. I think it approaches 100% when science catches up with how to identify their disease. And even still, the truly needy can be triaged to someone other than the MD by the MD so I'm confused on your issue of why they wouldn't see a MD first

You make your own assumptions. I don't trust physicians anymore than I trust anyone else. What I trust is that their training and experience increases my odds for a proper diagnosis and treatment. I also trust that if they are engaged in a human interaction (compassionate care) this also increases those odds. But if it ends up b/t the yoga instructor diagnosing me or Dr. Google, I will take the later. I can read hundreds of opinions there and for free.

"I am looking at it from a scientific one– how will the greatest good be delivered to the greatest number"

Hmm, as if I am not. I hope you look into this as just "replace most of the doctors" is a rather naive stance. I'll be curious on your thoughts after you find out that much of what is being driven at the ground level in healthcare delivery today is being driven by business inventions not scientific ones, including the loud calls for "Cheesecake Factory" medicine (which I see as one of the main reasons physicians are so pressed for time).

Also, do you have something against MDs? I notice that you've disparaged their training more than once without mentioning improving it; just get non-MDs to do perform their role. And have you thought of improving the clinical skills of the non-MDs?

Somewhat OT: I've worked in hospitals for thirteen years and have seen some of the best and worst from both MDs and non-MD providers. I will tell you that humility in their interactions with each other goes a long way. But I guess in the new tech healthcare world, humility will be archaic. Having worked in tech for as long as hospitals, I've found that computers are ALWAYS correct - at least according to them and the people who afford them that status.

Not a troll 102,

I can't follow the paragraph referring to my #78 at all.

I also don't get the Cheesecake Factory reference.

We are back to the basic disagreement which you aren't really addressing. You trust MDGP to provide the best diagnosis and treatment. I trust MD who specialize to do a better job than MDGP. This is a no-brainer to me.

I criticize the training because it is simply not necessary for the service that is provided. If you are going to work in an ER, you probably need all the heroic stuff. But checking out little snowflake's sniffles and telling out-of-shape fat people that they are fat and out of shape, not so much. If you disagree, I'm happy to hear whatever evidence you have.

And of course I don't mean you should get a diagnosis from a yoga teacher; it should be clear from what I've said-- someone with the personality and abilities of a (serious) yoga teacher would be suited to the role of gathering information and providing compassionate contact for people with medical concerns. People like that in general, like some nurses as well.

And why exactly is it we can't order tests and get various results directly? Or see a price list for what we are "buying"?

Oh crud. The thirty pound cat is back...

@zebra - what everyone is missing... did you ever watch "House?" Loved that show. He insisted patients always lie. As a patient, in fact, a patient who was once in a while quandary of a medical puzzle, I can tell you it isn't that we lie. Sometimes we do not notice symptoms, do not know normal functional ranges or shrug off abnormal as "normal for us."

Though you might think it totally great to put an intelligent yoga instructor or friendly barista with a smart phone in as a triage coordinator to save money, when my primary care doctor, who knew me, because we had that doctor-patient relationship, established by previous visits, assured me that there was something wrong and we had to figure it out it is just as likely the friendly yoga instructor would have let me quit looking.

See, there was a symptom that I had had since my teens (I was then forty) that I had grown so used to that I didn't think to tell it to a doctor. It would have put us in the right organ system straight away. People are terrible at self-diagnosis. We misremember, over emphasize, get our time lines confused...

I would want at least a nurse running triage, which is how it is now, anyhow. I believe our biggest cost overruns come from very different places in the system compared to other countries.

My reference to #78 is based on the fact that not everything called a somatoform disorder is that. Some have been and continue to be diseases which lack scientific evidence - or are from deficiencies in clinical skill set of the intake provider as per my concern.

"I trust MD who specialize to do a better job than MDGP."

So do I, however, that wasn't apparent to me from what you wrote earlier. As far as MDGPs being intake workers, I don't buy that any smart person is going to be adept at that without training and/or experience. But I will check out evidence for/against MDGPs in their current role.

Cheesecake Factory Medicine

In my state, I am required to have a licensed medical person order my labs. (in some states you can request your own online and they send you to an affiliate for a blood draw). In addition, the labs here are all based on the insurance model so no transparency. But I agree with you. We should be able to see prices for everything in medicine.

We should be able to see prices for everything in medicine.

Define your terms. Rack rate?

And of course I don’t mean you should get a diagnosis from a yoga teacher; it should be clear from what I’ve said– someone with the personality and abilities of a (serious) yoga teacher would be suited to the role of gathering information and providing compassionate contact for people with medical concerns.

Gathering what "information"? Do you think "someone with the personality and abilities of a (serious) yoga teacher" is going to be able to tell offhand the difference between a diastasis recti and an abdominal hernia? Who's the "referral" going to be to, ultrasound, surgeon, or PT?

Narad @106,

Lol. You had to ask. My head hurt after submitting my comment thinking about this very thing.

"Should" and "achievable" are two different things when everyone when price is fluid. I would settle for knowing what Medicare & Medicaid pay by state for the most common, standard procedures and having private pay patients presented with estimated charges beforehand when possible."Estimated" meaning with the knowledge bill could go up for complications.

Not a troll #105,

I guess I really have to spell things out, but I don't know unless you ask. How do you get from

"80-90% of symptoms for which people consult doctors would resolve without intervention."

to "somatoform disorder"???

I would settle for knowing what Medicare & Medicaid pay by state for the most common, standard procedures

You could start here (my referrals include CPT codes, although I can now schedule some specialst appointments without a referral).

and having private pay patients presented with estimated charges beforehand when possible.

I was initially reminded of a WSJ story from way back when I subscribed; it might be the one referred to here, but I'd have to see the whole thing (it started on the front page, bottom left column).

The upshot was that it is possible even for individuals to negotiate these prices in advance, but it's obviously a pain in the ass at that scale. If one G—les, e.g., amish+hospital+negotiating, there's more background to be had on how this self-pay groups tries to deal with the system.

It was the word "symptoms" plus my unfortunate habit of postponing seeing physicians for years while expecting my symptoms to get better (can't image someone running to their doctor for every sniffle) that made me think it.

However, I hope Krebiozen weighs in with what he meant when he wrote it..

Btw, good, balanced article here on MDs vs PA/NPs - some of the comments are great too. [Note: requires registration.but it's free].

http://www.medscape.com/features/content/6006318

Since the debate is inconclusive, I'll stick with requesting to see an MD at my primary care office until I am forced to do otherwise.

Well, Zebra, it's been fun but this isn't really the blog for this discussion so I'll bow out now. Hopefully, we'll both get what we are looking for in medical care.

zebra,

And why exactly is it we can’t order tests and get various results directly? Or see a price list for what we are “buying”?

I think you already can, though it depends on the state you live in. I am certainly aware of people in the US getting all sorts of bizarre tests done, though perhaps they are facilitated by a woo-friendly MD.

However, having worked in clinical biochemistry for a couple of decades, I have serious reservations about people ordering their own tests and interpreting the results.

Firstly, even some doctors get confused over which test is appropriate, and even more confused over interpreting results. I trained for three years (full-time and evening classes) studying physiology, cell biology, genetics, microbiology, biochemistry, hematology and more I have forgotten, and passed several exams before I was considered to be capable of advising doctors on what test to request and interpreting the results, and that's just one pathology specialty!

I have frequently seen people on-line suggesting completely inappropriate tests, and on one forum a woman had set herself up as a self-proclaimed expert (she was taking an evening class!) and was horribly misinterpreting the results that parents of autistic children were sending to her. She was using adult normal ranges and, for example, telling them their children were acidotic and hypercalcemic and recommending a low calcium diet - for growing kids! It may seem simple, but I promise you there is more to ordering and interpreting tests than it may appear.

Secondly, if you start doing tests as a sort of fishing expedition (which is very tempting) you will undoubtedly find something abnormal that is of no clinical significance. I have seen that over and over - it's an occupational hazard in pathology - one colleague measured his own serum creatine kinase level, which was elevated, and underwent a raft of further investigations, including a muscle biopsy, to rule out anything nasty. It turned out there was nothing wrong with him. A former boss found his serum bilirubin was elevated, and also had to have invasive tests, including a liver biopsy IIRC, before he found it was Gilbert's Syndrome, an idiopathic condition that is of no real consequence. I had my IgG subclasses measured and ended up spending years following up some low levels that are probably of no significance at all. False positives that have to be followed up can be a serious problem.

You do seem to have a very low opinion of the level of expertise required to work in health care. I think you are mistaken in this.

I am beginning to wonder if zebra is projecting. Perhaps zebra runs to the doctor for every sniffle and assumes everyone else does as well.

I ended up ignoring an autoimmune disease for thirty years.

Not a Troll (formerly TrUTH),

However, I hope Krebiozen weighs in with what he meant when he wrote it..

I read years ago that about 90% of conditions for which patients see their GP are self-limiting and do not require treatment. The difficulty is that without medical training of some kind it is impossible to identify which 10% do require further investigations or treatment. You can't just throw up your hands and send them all to a yoga practitioner on the grounds that most of them will be OK. Some will have serious underlying conditions that greatly benefit from early diagnosis.

I'm reminded of the prenatal screening for Down Syndrome* that I was involved with a few years ago. Only 1 in 600 pregnancies are Down Syndrome pregnancies, but the only sure way to find out is to do amniocentesis and cytogenetics, which carries a risk of miscarriage. You clearly can't do amniocentesis on every pregnant woman, so instead we did a blood screening test that identified the highest risk women. This was only 75% sensitive, and had a high false positive rate (I aimed for 5%), meaning that with 5,000 births a year we had about 250 women a year who were reported as positive screen and recommended to have amniocentesis, and only about 5 of these would actually be carrying a Down Syndrome fetus.

That may seem wasteful, not least in causing serious anxiety to 250 women and their families every year, but I attended a talk by a professor who had worked it all out, in terms of the costs and benefits. Despite costing hundreds of thousand of pounds, it was cost effective, supposedly**.

My point is that triage/screening of one sort or another is the basis of modern medicine. Missing serious conditions can have serious repercussions and expense further down the line, and what might seem tedious and time-wasting can sometimes be the most effective way of doing things.

* I won't get into the ethics of terminating Down Syndrome pregnancies. I figured I was proving information for an informed choice.

** Given the large proportion of Muslims of childbearing age in that area, I wonder how many women actually terminated any pregnancies. I never found out - not my department.

Gathering information and making an accurate diagnosis are two different things. My primary care provider's CMA gathers a lot of information, but I'd prefer to have an MD or an NP actually review the information and, based on training and experience, tell me what is wrong.

I am beginning to wonder if zebra is projecting. Perhaps zebra runs to the doctor for every sniffle and assumes everyone else does as well.

I ended up ignoring an autoimmune disease for thirty years.

Yah, I am not exactly the type to run to the doctor for every "sniffle" myself, nor are most of the people I know. Heck, this past fall I was coughing for pretty much three months straight, but I know from past experience that I am prone to lung infections, especially when grieving or otherwise under emotional stress, and that doctors typically can't do anything about them; they eventually resolve on their own. Now, maybe I should have gone in, given the length of my misery, but for whatever reason, I didn't. I do know enough that if I suddenly developed a fever, I'd have gone in.

What zebra's whole shtick basically boils down to is this: he fancies himself some sort of Übermensch, and he considers all those inferior sniffly whiny overweight slobs cluttering up his doctor's office to be a personal affront to his dignity or something. More to the point, he imagines that time and money which belongs to him is being taken away and given to them.

He thinks doctors are paid too much, considering they're just chumps who're real good at memorizin' stuff, not Idea Men like himself. This is presumably just some sort of base socioeconomic envy. He is smarter than doctors and everyone else*, so why are they getting paid so much money?

*Let's not forget his "physics woo" nonsense, which ended with him up and running the f*ck away.

^ if I had suddenly developed a fever.

Mrs Woo,
I am so sorry that happened. AI diseases are bad enough when you know what they are; much worse before you have a Dx.

Narad,
Sorry; I missed your last comment until I backtracked. "Notify me of followup comments" doesn't email me for some reason. Thanks for the links! Although it is kept pretty well hidden, I understand that in my state providers can't charge more than Medicare rates for private pay patients. Unfortunately I found out too late to be of any service to me before, and I hope to not have to confirm in the future.

Good on the Amish for getting their rates.

and he considers all those inferior sniffly whiny overweight slobs cluttering up his doctor’s office to be a personal affront to his dignity or something

I have a strong sense that his imaginary triage provider would have classified my previous example into "beer gut" rather than arriving at one of the correct choices ("do sit ups" is badly wrong advice for a diastasis).

Of course, if the imaginary triage provider had a grain of sense, the correct referral would have been to the PCP. Nothing like streamlining "the system."

Let’s not forget his “physics woo” nonsense, which ended with him up and running the f*ck away.

Don't forget this bit of residual asshurt.

Narad, I think you should stick to doing elementary numerical calculations and stay away from the logic department.

Don’t forget this bit of residual [a**]hurt.

Nor this.

@Not a Troll - it is probably extreme, but you can start living around symptoms and adapting to them as "normal for you." In my case, the disease finally got painful enough to be intractably painful, and that was what sent me looking for treatment. The symptoms that were best clues to look were long since accepted and ignored as normal to me, and pain that made me sick was lower abdominal radiating into lower back, hips and down legs - a lovely place that can be a lot of possibilities.

I was ready to announce it was just hormones or psychosomatic or something when the first tests found nothing. If we were using the zebra model of healthcare, we already would have referred me to a Pilates class or something by that point, and maybe a weekly meeting with the spiritual guide of my choice.

I have a real problem, and a real doctor who had treated me for seven years knew there was something wrong with me. A zebra would have put me in an exercise class. I probably would have let them.

I guess I am trying to say, thank you for the sorry, but I am using it for a real world example of why we need real trained medical personnel interacting with people seeking medical help and not some thing that lets them just share what they think they need to. Sometimes patients lose sight of some of their own answers.

Not A Troll,

I appreciate your engagement in what turned out to be a constructive, mature, dialogue. Interesting reference; I thought there were some good points but not a coherent refutation of the so-called "Cheesecake Factory" basic concepts.

Krebiozen,

How do you get from

Z: “I trust MD who specialize to do a better job at diagnosis and treatment than MDGP.”

K: "You do seem to have a very low opinion of the level of expertise required to work in health care."

zebra,

How do you get from
Z: “I trust MD who specialize to do a better job at diagnosis and treatment than MDGP.”
to
K: “You do seem to have a very low opinion of the level of expertise required to work in health care.”
?

I didn't, I got there from your implication that it would be an easy matter to train up a yoga instructor to do triage (unless I misunderstood, which seems quite likely), your continual gripes about how much physicians get paid and your apparent opinion that anyone can figure out the right test to order and interpret the results accurately.

"The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration," Oring

Well Jefferson knows what he is talking about. If another doctor can come to the conclusion that flu vaccine efficacy is 'implausible at best' the problem is with vaccine believers like you who can't accept the evidence.

Get out of the medical church and start learning about science

Krebiozen 126,

"unless I misunderstood, which seems quite likely"

Can't argue with that, since you have the other stuff wrong as well.

-I said you could educate people who have the combination of intelligence and interpersonal skills that a serious yoga teacher or perhaps a nurse, or other category (EMT? Engineer?) would have to perform the interaction with the patient requested by several people. There are already NP and PA, who are not MDGP, so this is hardly a far-fetched idea.

-I said, I believe to you in the previous thread, that people with MD training could make the same amount but with more benefit to the population. (But I also think some of the traditional MD training is superfluous for specific functions.)

-I never said "anyone could figure out the right test to order", if by that you mean with respect to a specific symptom. But, there are already standard sets of tests (like cholesterol) that go along with the (scientifically determined to be useless) "yearly checkup". And, there are clearly established guidelines for what might be a problem. There's no reason someone needs an MD license to monitor one's own cholesterol, at a few dollars a pop. Or see if you have an STD, and so on. And other than fear of losing income, there's no reason to restrict companies like Theranos, if they are FDA vetted.

A very recent anecdote ( to illustrate why we need physicians/ professionals)..

I am not a medical professional BUT I have studied various subjects that are relevant AND have had to deal with diverse serious medical issues involving elderly relatives, nervous middle-aged men and assorted cats of all ages.

I am usually a good observer of physical details.

My very large cat was suddenly coughing and breathing rapidly and I could not get a vet at his usual provider; unfortunately the emergency group here is difficult to deal with so I reviewed everything I knew
that could be important - his recent history and actions, respiratory issues in general and whatever warning signs I knew of REAL trouble (therefore, no choice BUT emergency).

My head was swimming with details and possibilities however two strong ones stood out although there were also contradictory indications ( despite not having a stethoscope I listened to his breathing, I looked at his gums, tried to count respiration rate/ heart rate etc) I remembered two establishments near my home and tried to get someone to speak to about this- and I found one.

Going over all of these signs and examining the cat, he came to similar conclusions as I did : the cat didn't need oxygen but an intervention was necessary. The most likely problems could be asthma and pneumonia for inhaled oil ( used for hairball issues) or food BUT there was neither wheezing nor fever. He thought other serious issues were not very likely because of what else he observed so he treated the two main possible problems with a steroid injection and antibiotics ( injection and liquid). So far, so good.

Even though we came to somewhat similar conclusions, he just SAW the entire situation many times more clearly than I did because of his training and experience. This was so apparent to me. He also had instant access to meds.

Another anecdote
Mr. Delphine really loathes getting needles. It is a battle every autumn to get him in for his flu shot. Most years, I am successful in persuading (read: nagging) him to get 'er done.

Several years ago, he didn't do it and he got the flu. Mr. Delphine has taken exactly 4 sick days in 22 years with his employer. When the flu hit, he was so sick that he ended up missing a week. At the end of the week he was better. Within a few days he was worse. He coughed one night until he vomited and then once his gut was empty, he coughed until he dry heaved. This went on until dawn, whereupon he passed out on the bathroom floor.

I took him to the nearest walk-in clinic that morning. They were extremely busy. First line here is often NP. She was young and seemed overwhelmed. She spent all of 2 minutes with Mr. Delphine. Did not take his temp. Did not take notes. She did listen to his chest. She said, "This is probably a virus, we are seeing a lot of it, rest, fluids, yadda." Dismissed.

Meanwhile, back at the ranch, my Mum had arrived for a visit. She gave my husband an equally cursory exam (she's a retired GP) and then insisted we all trundle off to the ER. Note, I had to barf a lung to miss school, so when my mother says "let's go to the hospital" we go to the hospital.

Pneumonia, both lungs affected.

Experience and training matter.

I said you could educate people who have the combination of intelligence and interpersonal skills that a serious yoga teacher or perhaps a nurse, or other category (EMT? Engineer?) would have to perform the interaction with the patient requested by several people.

Yes, Z.'s usual model of clarity. Would you care to define "perform the interaction with the patient requested by several people" and state how "you could educate people who have the combination of intelligence and interpersonal skills" and in what?

And other than fear of losing income, there’s no reason to restrict companies like Theranos, if they are FDA vetted.

Accompanied by a model of elegant simplicity, of course.

Second, if I understand correctly, there never was an effective intervention for your pain? It sounds like you got some satisfaction from figuring out what was going on, which makes sense for a professional, but even then there was nothing to be done but wait. But I wonder how much that would have helped a layperson– intractable pain for an indefinite period is hardly something most people would accept.

I am a layperson with terminal cancer. Yes, it helps to understand what exactly is going on with my body even if it can't be fixed. Not understanding what is going on adds an extra layer of fear and anxiety, and explanations at least make me feel that I have a grip on my situation.

There is a lot of contempt in this thread for the idea of emotional support. I do not expect or want my drs to be my BFF. I do expect them to behave with the empathy appropriate to the seriousness and scariness of my situation, even when I am weeping or (on one occasion, after taking a drug that made the world start spinning and undulating) screeching.

I can say that almost all of them have behaved kindly and appropriately. The exception is my surgeon, who thought it was hilarious to joke about how my hair looked after I started chemo. When I say that I expect emotional support, I mean simple things like knowing not to do that.

At the risk of insulting the engineers on this board, I have to say that profession is not exactly celebrated for its interpersonal skills.

@zebra

I said you could educate people who have the combination of intelligence and interpersonal skills that a serious yoga teacher or perhaps a nurse, or other category (EMT? Engineer?) would have to perform the interaction with the patient requested by several people.

OK, by this whole "requested by several people", are you talking about:
- the triage of would-be patients at the physician's office, a step a few of us here have been concerned about,
- training people to act as counselors/lifestyle coach/emotional supporters as talked about by a few posters, notably in the context of post-operation/pain management?

With the latter, I would be mostly in agreement. The former may need more details.

Helianthus 135,

The problem is "the physician's office", which everyone seems to be stuck on.

I say we can eliminate "the physician", by which I mean-- so it is really clear-- MD General Practitioner, MDGP.

Now, I'm sure some will expect me to write out a complete curriculum for training, and then they will say "but that's PA, and this is NP, and nitpick this, and nitpick that". Be my guests if you like, but the basic idea is that there will be a person who talks to the patient and writes a report, and passes on the information to an MD Specialist if indicated.

So, you eliminate the MDGP expense, you have better "compassion", "communication", whatever, and you have the most qualified person doing diagnosis and treatment. And, this process will include all the advances in testing like the reference I gave.

So now you can argue if you like that the MDGP spending seven minutes is going to catch the "mysterious rare deadly disease", but my Intake Specialist spending twenty will miss it. Meh, I would say this can quickly be figured out and adjustments made.

@zebra

I’m sure some will expect me to write out a complete curriculum for training

That would be excessive, but you must understand we need a few details to flesh out your "intake specialist"

, and then they will say “but that’s PA, and this is NP, and nitpick this, and nitpick that”.

Well, you are describing someone with skills, among other things, about basic anatomy, symptom identification and management, patient management/handling, and basic disease containment.
I have this feeling a PA or NP's curriculum would cover most of these. Please note it doesn't necessarily detract from your thesis.

So now you can argue if you like that the MDGP spending seven minutes is going to catch the “mysterious rare deadly disease”, but my Intake Specialist spending twenty will miss it.

Well, if the MDGP know what to look for and not your IS, no matter that, the IS is going to miss a lot of rare and not-so-rare stuff.
There is right here another issue with your thesis: the 7-min MD vs 20-min IS.
You cannot shift patient reception/treatment from the MD to your IS and simultaneously claim that the IS is going the be able to spent more time with patients. If the MD was seeing 50 patients a day, the IS is going to see 50 patients a day. Unless having more IS than MD, but then the money saving effect is gone.

Helianthus 138,

I don't think "if MDGP knows what to look for but IS doesn't" is a useful comment-- we have no evidence to that effect.

Remember, the IS is a specialist, so maybe will actually be better at "triage". You know, their education would be intense in that specific skill.

As to cost of more IS-- maybe you are correct; we will use 4 IS to replace 1 MDGP. But I didn't say we are trying to reduce total cost by eliminating the MDGP, although I think we might.

Remember, the goal was to get more personal interaction and more information, which this achieves. If it is at equal cost, that's good.

@zebra

I don’t think “if MDGP knows what to look for but IS doesn’t” is a useful comment– we have no evidence to that effect.

Well, I would have thought that before replacing one specialist by another, it would be a good idea to have some evidence the new one is good at the job.

I may have no evidence the IS would be bad, but you don't have any evidence he/she would be good, either.

I was seeing my comments more as listing prerequisites/issues which will need to be addressed while implementing the job of your triage specialist.

But I didn’t say we are trying to reduce total cost by eliminating the MDGP

One of your questions in the previous threads was why use a specialist at 500 §/hour rather than a cheaper one.

There's still no financial reason to eliminate the MD/GP -- it's more efficient medicine to refer someone to a general practitioner than a specialist for routine ailments.

Healthcare offices already have a screening function for patients; it used to be done by the RN, now it's done by the CMA.

Helianthus 140,

I already said if you want to have a serious discussion I am happy to do so, but if you want to tell me that somewhere I said something which maybe someone (like you) misunderstood, you are wasting everybody's time.

Do you understand what I am saying about a triage specialist now, and do you want to discuss that? Does what I said about same cost for better service make sense to you?

You haven't provided any evidence that this will in fact provide better service at lower cost . Why pay a specialist to look at my horrible cough and congestion if it turns out that all I have is a bad sinus infection?

Didn't need a specialist to diagnose Mr. Delphine's pneumonia. Just a GP who knew that his symptoms + rales + tap tap on the back indicating fluid equaled time for an Xray and culture.

My daughter is very thin, like, underweight thin. She is 4. She is in the 8th percentile for weight and the 70th for height. You can see her ribs, her arms and legs are like twigs. The pediatric allergist we saw expressed concern about her weight and asked a bunch of questions. I know it's not a concern, she's just thin, because her GP has been plotting her growth since birth and guess what, she's always been long and lean. Her GP also knows that she's meeting all of her milestones and eating well, and that her parents, whom he also sees, were equally skinny as kids.

There is value in that type of relationship.

Delphine, I was thinking of your husband's experience. On the one hand what financial or medical sense does it make to refer me to a specialist for what turns out to be a sinus infection -- on the other hand, is a triage specialist qualified to tell if I what I have is in fact a great deal more serious?

Why pay a specialist to look at my horrible cough and congestion if it turns out that all I have is a bad sinus infection?

I don't think zebra realizes that GPs do more than make referrals to specialist, and that they do treat many illnesses and conditions. Of course, I may be wrong, as the striped one has never been clear and easily understood.

If I am wrong, and if there is any merit to zebra's proposal (whatever it is), it should be an easy sell to any HMO.

shay: "At the risk of insulting the engineers on this board, I have to say that profession is not exactly celebrated for its interpersonal skills."

:-p ;-)

Delphine, my younger son was also always thin. When he was four my stepsister (who is also quite slim) accused me of starving him. No, he is just thin. In high school he was called "Twig." He is now a six foot tall 130 pound systems analyst/applied mathematician who can really rock out a well tailored suit. He actually had that suit made instead of buying a table for his apartment. (by the way he has the same build as my brother and nephew, and all three share the same birthday (okay, different years)).

and all three share the same birthday (okay, different years)).

No kidding; my brother, my paternal grandma and I all share the same birthday, also different years. The odds must be crazy.

It is kind of funny. My brother was delighted when his son was born on his birthday. Then my younger son was. Also my boys are two years minus four days apart in age.

I decided it that is was our family curse to have summer pregnancies (most of the birthdays are in September and October).

No kidding; my brother, my paternal grandma and I all share the same birthday, also different years. The odds must be crazy.

Not really. In a random group of 24, the odds are about 1/70 that 3 will share a birthday. See -
https://en.wikipedia.org/wiki/Birthday_problem for a good discussion of the basic birthday problem, and -
http://mathforum.org/library/drmath/view/56650.html
to see the math for a 3rd person (make sure to read to the end, the first answer given is wrong).

@shay:

Well, you know what Simon Baron-Cohen believes about those in STEM professions.

Although I don't entirely agree- and see possible problems with his overall theory- I do think that he has a least a grain of truth about systematising/ empathising individuals as extremes.

6 kids in my family. 3 born in July. 3 born in January.

Cue the puerile sniggering. :)

It is kind of funny. My brother was delighted when his son was born on his birthday. Then my younger son was.

Yeah, I'm the youngest, so I was born on my grandma's 60th birthday and my brother's 2nd birthday. (December 30th.) I have been asked more than once, "Do the people in your family only f*ck once a year or something?" But, in fact, my brother was born two weeks early, and I was born two weeks late. (I was just NOT GOIN' OUT THERE YET, nope, sorry. I mean, I did eventually have to leave, just like in college when they kicked me out with a degree.)

AND -btw- anecdotally, I have quite a few relatives who are somewhat talented in mathematics, an engineer, a fellow who works in high tech film recording/ editing, accounting types
BUT not one fits the stereotype ( Asperger-like, cold, less social) - however there are lots of artistic interests and leanings including design, architecture, restorers etc Several can draw realistically well including yours truly.

Chris, honey, I was thinking of you when I posted that -- but in a previous lifetime, I supervised a department full of engineers.

They were...interesting.

decided it that is was our family curse to have summer pregnancies (most of the birthdays are in September and October).

Or you live where it's really cold in January and February and there's not much else to do.

shay: "They were…interesting."

As many of us few women in the College of Engineering during the 1970s we had a saying about the choices for dates: "The odds were good, but the goods were odd."

"Or you live where it’s really cold in January and February and there’s not much else to do."

Northern tier of the USA. Of course it was a joke after I endured two pregnancies during a pair of very warm summers, and very few homes have air conditioning.

Reality check: Primary care in the U.S. is broken. MDs aren't given enough time with patients to properly employ the medical knowledge they possess, nor to develop proper doctor-patient interpersonal relationships. (Patient disaffection having actual medical consequences). More broadly, the system fails at what holistic medicine actually IS (not what quacks claim it to be): consideration of the psychological states of patients with physical maladies.

The criticism of the "Intake Specialist" idea is flawed in that it pits worst-case scenarios of an IS, against a platonic ideal of the GP that is continuing to fade in the real world. That is, a problematic IS could be better than what many of us have now.

The devil, of course, is in the details. zebra overstates in suggesting an IS can "eliminate the physician". But we would still need GPs — it's just that every patient wouldn't see an MD every time they go to the clinic. Which is already the case, of course. The IS concept can be seen as rationalizing and refining the situation that is already 'on-the-ground' including providing more specific training for the role.

A 'reasoned' approach to the subject ought to bracket zebra's personal style, and consider the proposal on it's own merits — which means, in part, seeking merit in aspects of it that may not accrue to the whole as presently stated.

zebra wrote: "the goal was to get more personal interaction and more information, If it is at equal cost." The problems I see with that — before we can argue the GPMD vs IS question properly — are how we define and measure "equal cost", and how we set a level of what an appropriate overall cost would be. However, given what the U.S. spends on healthcare vs. outcomes, compared to other industrialized countries, it seems hard to argue we couldn't do better on the interaction and information angles via some sort of systemic reform.

Johnny's #146 is far too glib. zebra's proposal is a general concept, and HMOs are only in the market to 'buy' some specific implementation of that. Which I hear some are now doing, though perhaps badly. That is, if you just shift patients from MDs to PAs and/or NP as a cost-cutting measure — without increasing contact time, or expanding/focusing the training of those practitioners on interactional issues, or establishing a system where practitioners can build relationships with patients over time (vs. the patient seeing whoever is up next at the walk-in clinic), then, yeah, that's going to make primary care worse, not better. Alas, I fear that's where we're headed. I'd suggest we be open-minded about ideas to prevent that, and to actually improve things instead.

But I didn’t say we are trying to reduce total cost by eliminating the MDGP

One of your questions in the previous threads was why use a specialist at 500 §/hour rather than a cheaper one.

I already said if you want to have a serious discussion I am happy to do so, but if you want to tell me that somewhere I said something which maybe someone (like you) misunderstood, you are wasting everybody’s time.

Ah, yes, poor misunderstood Z.:

I just don’t want pay more or spend more time waiting for a doctor because he is playing psychiatrist or sharing recipes with some fat person. That is why we have yoga teachers and nutritionists or dietitians

Do you realize what a hateful person this makes you appear to be? Is it outside of the doctor’s realm to discuss someone’s mental health issues or diet?

As for being hateful– ok, I guess it’s hateful of me to want the tens of millions of people in the US who have no health coverage to have access to care. (Instead of wasting money paying overly-trained doctors $500/hr to give “annual checkups” to healthy people, and, now, apparently they will also be sharing their favorite recipes.)

Next up:

The problem is “the physician’s office”, which everyone seems to be stuck on.

I say we can eliminate “the physician”, by which I mean– so it is really clear– MD General Practitioner, MDGP.

Who does the "intake specialist" refer me to for a cat bite? The ED? Much better idea than marching over to my PCP for an Augmentin prescription.

Oh, and why do I want my medical records scattered over all the specialists whose time I'm going to be wasting (in addition to my own) based on the "intake specialist" "talk[ing] to the patient and writ[ing] a report"?

sadmar,

I wanted to remain of this until Orac opens a thread on the subject
but let me say that I have considered the ideas that Zebra has floated including the attacks on doctors.

I tried to focus it down to one subject in our discussion because he was throwing a lot of them out there, but in doing so I did not want to give the impression that I think this is the only problem or the main solution for primary care.

I'm all for ideas on fixing things but I am not into ideas being sold as altruism but wedded in greed. [Note: I don't mean Zebra as I don't know him, but if I had to guess I would say he has a good heart but got burned badly by doctor(s).] It is those actually pushing for and implementing these "solutions" that scare the heck out of me. They are the very people that exacerbated them in in the first place and we expect them to make them better. Why?

Nor am I interested in having their ideas further erode quality in healthcare. Please look into the debacle in the 1980s that was HMOs brilliant plan to replace all of the specialists with GPs. It ended very badly. This is simply a remake of this at the first point of contact.

The criticism of the "defense of the MD” idea is flawed in that it pits worst-case scenarios of a "primary care practice" against a platonic ideal of the "IS" that has yet to be delivered. Very little of this problem resides with MDs. I understand that a lot more people finish med school than there are openings in residencies. Why? Why is med school acceptances so limited and expensive? And, why are GPMDs seeing patients for 10 mins? Their choice or the megalomaniacs in charge of them? You do know that many people become MDs because they want the same human interaction as patients want, right? Where I go for primary care there is an hour new pt visit w/MD and those with more complex issues and/or symptoms are assigned more time for visits (20 - 30 mins). I happen to think it works quite well as long w/exception of him being a typist.

The trouble is that many of the ideas that might work are entirely off the table for discussion because they are not the most profitable or cheapest (when .gov pays the bill). What Zebra wants is already happening and will accelerate so while I already know that what he wants in practice he will have, but what I want (which very similar to his idealized version) I will never have.

JP #93 Yes such a thing exists in some Private Psychiatric Hospitals in Australia (you need level 2 Health Insurance). The Albert Road Clinic is where I went (and so did the conservative minister https://en.wikipedia.org/wiki/Andrew_Robb ).
If you or a relative have severe mental illness I would highly recommend checking and increasing your health insurance. The Public System is pretty broken.

#97 Zebra My experience with conventional medicine has been that Medical Doctors don't tell you outright that they can absolutely fix the problem. Even with Depression where I can see that giving a patient hope might not be such a bad idea. They phrase things pretty carefully with words like 'might'.Any practitioner who tells me they will fix the problem with no caveats I treat like any financial spruiker who tries to sell me a 100% Guaranteed way of making money - I run a mile.

Johnny’s #146 is far too glib. zebra’s proposal is a general concept, and HMOs are only in the market to ‘buy’ some specific implementation of that. Which I hear some are now doing, though perhaps badly. That is, if you just shift patients from MDs to PAs and/or NP as a cost-cutting measure — without increasing contact time, or expanding/focusing the training of those practitioners on interactional issues, or establishing a system where practitioners can build relationships with patients over time (vs. the patient seeing whoever is up next at the walk-in clinic), then, yeah, that’s going to make primary care worse, not better. Alas, I fear that’s where we’re headed. I’d suggest we be open-minded about ideas to prevent that, and to actually improve things instead.

Well, I wasn't really shooting for glib, but more for frustration.

It seems zebra wants to get rid go GPMDs and have 'Intake Specialist' sort the masses amongst specialist. Where? In what setting? For what types of conditions?

It's sounds sorta like every emergency room I've been in, and there it works as well as can be expected, in that setting. Of course, the intake people mostly decide which order people see a doctor, not if they see a doctor, but the general idea is the same.

But if I have, say, a rash that doesn't go away and the OTC creams aren't helping, then what? Do I make an appointment with an IS? Is it a walk in? Where? Does the IS decide if I see a GP or a dermatologist? Is zebra really suggesting getting rid of GPs, and every rash goes to a dermatologist?

As with any process (or any proposal, really), the details matter. Health care is provided in a lot of settings, and a wide variety of locations, for a wide variety of conditions. Small private practices, small clinics, big hospitals, major 'disease centers'… do all of these need an IS?

The striped one may be on to a good idea, but I'd really like to know what that idea is. But at this point, it's as if he's said 'it's red, and it has 4 wheels'. It could be a little red wagon, or a new red Mustang, or a big red Ram truck. There's only one of those I'd like to have.

I understand that a lot more people finish med school than there are openings in residencies. Why?

Gazoogling it, the Match Day/SOAP number was 412 graduating med students in 2014.* The AAMC addresses this quicky "FAQ" (PDF) on the subject. This is one salient bit:

"MYTH: Simply increasing the number of medical school graduates will fix the physician shortage.

"FACT: Increasing the number of medical students is a necessary first step to addressing the doctor shortage, but a doctor cannot practice independently without residency training (GME). Unless Congress increases Medicare support for GME, the number of physicians per capita will actually decrease.

"America’s physicians are also aging—more than one-quarter are over age 60 and likely to retire in the next 10 years and need to be replaced. In 2006, the nation’s medical schools recognized the emerging physician shortage and committed to taking the first step in resolving the problem by expanding enrollment by 30 percent. While medical schools are on track to achieve that goal by the end of the decade, there has not been a proportionate increase in residency positions. In fact, the number of first-year U.S. M.D. and D.O. students soon could exceed the number of first-year Accreditation Council for Graduate Medical Education (ACGME)-accredited residency positions. Without an increase in Medicare GME support, there may not be enough residency positions for the additional medical school graduates we need to address the growing physician shortage. Some students already are having trouble finding residency positions, with 412 students not matching in 2014.''

Now, there's proposed legislation, which seems to have had a habit of dying in committee: h[]tps://www.govtrack.us/congress/bills/114/s1148.**

It also looks as though these figures don't include international students. The basic deal seems to be that the shortage isn't that bad at the moment (unless you're sitting on the loans), is going to get worse eventually, and the present bottleneck is federal funding.

* Or 425, according to these guys: h[]tp://www.modernhealthcare.com/article/20150318/NEWS/150319897. I haven't been able to sort out the tally for 2015.

^ "addresses this in a"

The striped one may be on to a good idea, but I’d really like to know what that idea is.

There isn't one. His whole shtick is popping into topics that he knows nothing about, declaring that he has The Solution, and then complaining that people are too stupid to see his brilliance.

He does not respond to those who observe that he plainly hasn't thought about* what he's feigning to have The Answer To unless it's to complain about their failure to understand his crystalline prose or to whine about too many words make Z.'s brain hurt "filibustering."

The key ingredient, however, is that he demands respect; as I've noted, HE'S GUMBY, DAMMIT. He's also spent a lot of time earning negative returns on the seed investment.

One might note that he's been reduced to nothing more than ridiculing Krebiozen, who exhibits what I can only describe as preternatural patience. So, he's stuck looking for new marks who govern comport themselves appropriately. Give it time; bad faith and a clockwork brain is a deterministic machine.

* At this point, I've come to the conclusion that it amounts to simple cowardice over not being able to think.

Hey, this reminds me of something:

The unlicensed doctors are generally assigned to examine Dr. Fata’s patients and complete write-ups of their exam.

After all, having only one level of "intake specialist" doesn't really make any sense in terms of the Z. "model," now does it?

sadmar@158

However, given what the U.S. spends on healthcare vs. outcomes, compared to other industrialized countries, it seems hard to argue we couldn’t do better on the interaction and information angles via some sort of systemic reform.

Honest question here, how different is the actual model of care from other developed countries. I was under the impression that as far as what providers offer which services we were pretty similar and the differences (and problems) mostly arise from the money issues (oversimplified as insurance bloat). Point being, if it's the financial aspect that's broken, it seems like any plan to replace or supplement GPs without fixing the underlying problem would just result in the same issues under a different name.

Given the huge unlikelihood of meaningful insurance reform it's worth exploring other avenues but I think zebra places a lot of unfair blame on GPs for something that's not really their fault. I get the feeling that zebra has never worked in healthcare. Consider someone with a persistent cough. Do they get sent to a pulmonologist, infectious disease, some other specialist or are they turned away at the door?

None of these seem ideal, going immediately to a specialist is going to rapidly overwhelm them (note that many specialities are already hurting for physicians. One hospital around me recently lost their pediatric neurologist and so almost every neuro kid needs to be transported to a different hospital). Turning everyone away risks missing diagnoses. Does the IS have the ability to order labs or other diagnostic tests and prescribe beta agonists, steroids, antibiotics or other meds? If so aren't they just becoming GPs themselves?

I think there's certainly a place for GPs, whether they are MDs,NPs, or PAs. They idea of replacing them with someone who only shunts patients to a specialist ignores the (very important) function that they perform by dealing with bullsh*t and minor things and thereby significantly reducing the load on specialists. Can you imagine if every kid with a runny nose and a fever got shipped to an infectious disease specialist?

Johnny 163,

But if I have, say, a rash that doesn’t go away and the OTC creams aren’t helping, then what? Do I make an appointment with an IS? Is it a walk in? Where? Does the IS decide if I see a GP or a dermatologist? Is zebra really suggesting getting rid of GPs, and every rash goes to a dermatologist?

Capnkrunch:

"Does the IS have the ability to order labs or other diagnostic tests and prescribe beta agonists, steroids, antibiotics or other meds? If so aren’t they just becoming GPs themselves?"

You can't just plug one element into the existing system, and you can't use the same terminology with the same connotations, and say "but it can't work because...."

The question is whether MDGP, meaning someone who goes through the conventional training, but doesn't specialize or work in an ER (or hospital setting) is the best choice to provide the services being discussed. (The question is also whether even some specialists need to go through all of conventional training.)

In effect, although it obviously isn't going to happen overnight, you have to start from (almost) scratch in designing the system based on 21st century technology and conditions, rather than clinging to an essentially 19th century paradigm.

So, for example, and we are talking about the USA, you could have more specialists, who then get payed less. (It's called supply and demand.) Jobs for those out of work GP.

I would think you people with all the expertise would be able to solve the details better than I, if you can let go of preconceptions.

In effect, although it obviously isn’t going to happen overnight, you have to start from (almost) scratch in designing the system based on 21st century technology and conditions, rather than clinging to an essentially 19th century paradigm.

So, for example, and we are talking about the USA, you could have more specialists, who then get payed less. (It’s called supply and demand.) Jobs for those out of work GP.

I would think you people with all the expertise would be able to solve the details better than I, if you can let go of preconceptions.

So you want to make vast changes to the delivery of health care, including new job functions, pay cuts, and a new customer interface, you have a half vast idea of how it would work (see what I did there?), and you want the minions to figure out the details. Then what? Shall we lobby congress to make your system the law of the land and erect a 554 foot tall zebra statue on the National Mall?

Yeah, I'll get right on that.

“Does the IS have the ability to order labs or other diagnostic tests and prescribe beta agonists, steroids, antibiotics or other meds? If so aren’t they just becoming GPs themselves?”

You can’t just plug one element into the existing system, and you can’t use the same terminology with the same connotations, and say “but it can’t work because….”

This is failure beyond my wildest dreams. Which bits of terminology here are going to need different "connotations"?
"Diagnostic tests"? "Antibiotics"?

Johnny 170,

It's all relative. Remember that I am proposing this as an alternative to Orac's suggestion that we pay GPMD more-- or rather, the same to see fewer patients-- so they can spend more time with each.

Orac has yet to explain how this would work. If GPMD see 6/hr now, and they reduce that to 3/hr, what happens to the other 3 patients? Sounds like it would require twice as many GPMD, and so we would double the expenditures for that service.

The part about you guys figuring things out was me trying to be polite, which is not reciprocated, apparently.

What I suggested for the "specialist problem" raised by you and capnkrunch seems to me completely obvious. It's just the market at work, which you strangely enough see as a "pay cut". Fewer GPMD jobs, more people become specialists, competition reduces individual income. What's the problem?

And other questions people are throwing out have obvious answers as well if you think about them, again, without trying to shoehorn things into existing structures and relationships.

You asked, I answered. Yes, if the IS can't figure out the rash, then you go to a specialist. How is that different from the GPMD not figuring out the rash? Who is more likely to figure out the rash in a 7-minute encounter, the specialist or the GPMD?

What I suggested for the “specialist problem” raised by you and capnkrunch seems to me completely obvious. It’s just the market at work, which you strangely enough see as a “pay cut”. Fewer GPMD jobs, more people become specialists, competition reduces individual income. What’s the problem?

You don't understand how medical education works, for one thing. Not that that's ever stopped you from grandiose bloviating.

^ Further illustrated by this weirdness:

The question is whether MDGP [sic], meaning someone who goes through the conventional training, but doesn’t specialize or work in an ER

Emergency medicine isn't a specialty? Who knew?

Or does everyone have to become a subspecialist in the Great Z. Reform?

Narad,

Thanks for the links. In reading more about this, I ran across references to how the current shortage is due to misallocation by location not to numbers, and a law in Missouri to allow medical school graduates practice as physician assistants. I have my doubts about this but time will tell.

Well, Zebra, jumping back in.

It isn't your alternate solution that is causing the problem. It is the antagonism that goes with it.

Per the subject matter, Narad reminded me of your quote:

I just don’t want pay more or spend more time waiting for a doctor because he is playing psychiatrist or sharing recipes with some fat person.

So you would like to see a MD too, not a mid-level? The question is who makes that determination? Do you want to decide for others? You stated that if I wanted more time with a physician to go concierge, but they don't exist in my area. However, many people that want to see a mid-level instead of a MD or even quickly see an MD, can go to an Urgent Care center and coming soon Walmart and Walgreens clinics.

I prefer the choice to trigage myself by going to Urgent Care for small things. I do not want nor do I want to see others assigned to a mid-level as their main provider with option go to a specialist only at their discretion without their consent. One, because I know what I am getting by going to UC, and two, regardless of how much they say it is the doctor's guild complaining about quality of non-MDs, I can't ignore the quality difference I have experienced and have seen working in hospitals. And for talk of giving mid-levels more training (which they want comparable incomes for) then we are approaching the question asked up-thread of why not train them as MDs then.

The quality thing is bothering me a lot because I am not sure that the conclusions are correct about the same outcomes b/t NP/PA (in the future yoga instr.) and MDs if they are not under the same time constraints as the MD. If a MD was given more time and has better outcomes than them, the MD could be the better quality option then, no? I can't research this now as TimeW is fragging my internet connection which somehow is tied to busy cell phone traffic but I wanted to float the question.

Not a Troll (formerly TrUTH) #160:

Far, far too much of our discussions of current problems in medicine focuses on doctors, as if they're fully in charge of what they do, acting as autonomous individuals, when in fact they're better seen as cogs in a larger machine.

_I_ don't blame MDs (in general) for problems in primary care. I blame the insurance companies, and the corporatized providers. But social systems wind up with members who self-select in part on the basis of "fit". So when you write, "You do know that many people become MDs because they want the same human interaction as patients want, right?" I'll reply, "Yes, but you do know that many of those people are driven out of PCP work by their employers or just quit out of frustration with the patient load, and younger PCP physicians tend to be chill with the quickie system, right?" Which is to say the insurance industry has been 'making' and 'choosing' PCP docs in it's own mold for the last several decades.

You wrote, "what zebra wants is already happening," I don't think so. AFAIK, the primary care 'solution' being pushed by TPTB is to replace a significant number of patient contacts now handled by PCP MDs with being seen by a PA or NP, for the purpose of cutting costs to fit available public funding and/or the industry's desired profit margins. This push is absent several key elements of zebra's IS concept:
• The IS must be given significantly longer visit times than MDs have under current patient loads
• The IS stays with the patient over time, developing a rapport allowing the IS to better interpret the patient's complaints in ways that point toward more accurate diagnoses
• The IS has been given training specific to this task; that is the not strictly bio-physical aspects of precise diagnosis, but the psychological/communication aspects of interpreting patient reports in light of their ongoing history with that individual. That is, the IS differs from a PA in that her task is to refer, not to treat. So her education and knowledge base would concentrate on the former, as the latter can be largely left out.

IMO, what's muddling zebra's proposal is that the idea of eliminating GP/MDs altogether and relying on 'specialists' altogether is conjuring up different definitions of 'specialist'. The vast majority of PCPs I've encountered lately carry the formal label 'internist' and do, if fact, operate as specialists, since their focus is on the common major illnesses I mentioned above. If the IS does not treat (I'm not clear where zebra is on that, not that that matters), then we wouldn't be eliminating all that many MDs, as the IS would be sending patients of to the internist most of the time anyway...

So what I'M talking about is NOT anything from which MDs need to be defended. It pits a alternative structuring of medical services that does not yet exist against actual common scenarios of primary care practice as patients experience it today. Of course TPTB are likely to falsely appropriate the idea(s), and "further erode quality in healthcare" should they consider them at all. Properly implemented, they would improve outcomes over time, but NOT lower costs. In contrast, implementation would require costly initial overhauls in several areas.

If it's true that the only things on the the table for discussion are the most profitable or cheapest, we're screwed no matter what. This is politics, a social struggle. The negotiating table rules the exam table. We need to get control of the first to affact the second. In order to get a seat at the negotitating table, we'll need a persuasive answer to "what are you going to do with the exam table?" What do you think makes the most persuasive pitch:
• maintaining the status quo?
• going back to Marcus Welby, MD style practices?
• trying a more modern and rational approach?

Under the present system, good primary care (for adults, anyway) requires doctors to perform too many functions outside their training and likely to run counter to their dispositions, while denying them the time to do them regardless of their skills and desires.

A bit over ten years ago, I had an advancing, long-term life-threatening condition that "fell through the cracks" because one specialist didn't bother to explain the details of a diagnosis, the word either didn't get properly passed to my PCPs records or flagged once there, he didn't LISTEN to me and failed to register my continued reports of persistent symptoms as a concern, blowing them off as trivial each time, and when I finally concluded I needed to get a 'second opinion' two MORE physicians told me there was nothing there — and BTW the key symptom was chronic laryngitis, and NONE of these docs bothered to actually look down my throat at my larynx.

Opinion #3 was from a pulmonologist, whose 'diagnosis' struck me as so off-base and surreal, I actually laughed derisively to his face in reflex reaction. His voice dripping insult, he said, "I guess I could refer you to an ear, nose, and throat specialist... if you insist." I did insist and the ENT doc had the problem nailed within five minutes after I walked into his office...

But here's the deal: I hadn't been all that concerned about the PCP having no answer to my throat problems, and was just suffering along with them as a 'sh!t happens' nuisance until they got so bad I was having regular coughing fits and/or losing my voice in class. I was so embarrassed by having students witness these episodes, and the reduction of my effectiveness as a teacher that I became so doggedly determined to find medical relief I kept going in the face of resistance that would otherwise have lead me to throw in the towel. If I hadn't had a job that required me to do a good bit of talking in front of a group, I wouldn't have done anything. And if I hadn't been so upset as to find a previously unknown resolve to follow through in spite of the obstacles, I would now probably be dying or dead.

So I've been thinking about issues with primary care for awhile, including variations of a role for an IS-type practitioner. I'm convinced an 'average-case-scenario' IS — framed in realistic application of the characteristics I noted above — would have been MUCH more likely to get me quickly and easily to the right MD, instead of, you know, telling me I didn't have anything to worry about when I was actually on the fast track to esophageal cancer. Whether getting to such pragmatic effective reforms will ever be realistic in terms of political conditions is up to us: our dedication and skill in building a movement for change.

sadmar 176,

Excellent exposition. Conveys the concepts extremely well, as usual. (I was going to use your case as an example myself, in fact.) A couple of points:

I can't seem to find the "common major illnesses mentioned above". But whatever they are, there could still be specialists for each, so why not eliminate the label "internist" as well.

The question of "treatment" is certainly open for discussion. Along with lifting restrictions on having various tests done, we might also loosen up the whole "prescription" business. I wonder if that child who died from an ear infection might have done better in a world where, at the pharmacy where the parents were buying homeopathic nostrums, even the pharmacist might have been allowed to slip them some Amoxicillin, telling them it was a well-tested traditional remedy related to naturally-occurring fungi.

Zebra, as Narad pointed out, emergency medicine is an actual specialty. Another theory shot to sh!t.

The question of “treatment” is certainly open for discussion. Along with lifting restrictions on having various tests done, we might also loosen up the whole “prescription” business. I wonder if that child who died from an ear infection might have done better in a world where, at the pharmacy where the parents were buying homeopathic nostrums, even the pharmacist might have been allowed to slip them some Amoxicillin, telling them it was a well-tested traditional remedy related to naturally-occurring fungi.

That's a fantastic idea. Idiot.

How is creating specialists for every common ailment going to improve access to healthcare? That sounds like a horribly inefficient way to distribute resources.

Gee, the things I miss when I ignore Zebra. Homeopathic nostrums are sold over the counter in pharmacies, far away from the pharmacist's counter. They are also sold in health food stores where there is no pharmacist, but often some helpful person who is completely clueless.

I wonder if that child who died from an ear infection might have done better in a world where, at the pharmacy where the parents were buying homeopathic nostrums, even the pharmacist might have been allowed to slip them some Amoxicillin, telling them it was a well-tested traditional remedy related to naturally-occurring fungi.

Jeezums - that might possibly be the stupidest thing I've hear from the Zorse yet, and that's saying something. Oh well, that's what killfiles are for!

@shay

Delphine, I was thinking of your husband’s experience. On the one hand what financial or medical sense does it make to refer me to a specialist for what turns out to be a sinus infection — on the other hand, is a triage specialist qualified to tell if I what I have is in fact a great deal more serious?

It's a delicate balance, isn't it? We don't always get it right, and sometimes, the consequences are dire. Better to err on the side of caution, methinks. I think in my husband's case, lack of experience + lack of time equaled missed diagnosis. And it was an easy one, my mother didn't even have a stethoscope or anything. Elevated pulse, sweating buckets, fever over 104F, and the tap tap tap on the back. She didn't know for sure, but experience taught her, time to take a deeper dive.

Hey shay, are you from the South? I can't recall, I think you are?

No, Ah'm a damyankee, but I've been stationed there twice... Virginia and North Carolina.

And my mamma was from Texas

Thanks. Mr. Delphine and I are debating the usage of "y'all" vs. "all y'all."

This is our idea of Saturday night entertainment at this point.

Zebra, that little girl, her name was Hope, and she would have done better in a world where parents didn't think their ability to Google somehow superseded umpteen years of education. Hope would have done better in a world with parents who didn't think it was a oh f&cking kay to watch their child suffer for two weeks before they sought qualified care. You're not going to fix stupid/narcissistic/ignorant by doling out amox over the counter, sorry.

Homeopathic nostrums are sold over the counter in pharmacies... in health food stores where there is ... some helpful person who is completely clueless.

They are also sold in quackerpractors' and naturopaths' offices, again by someone who is completely clueless.

sigh... Shouldn't have come back reading the thread.

@ zebra

So, for example, and we are talking about the USA, you could have more specialists, who then get payed less. (It’s called supply and demand.)

First, you want regular MD going into specialization and then being paid less for being specialists. Care to explain why any sane person would want to waste time learning a job which is not paying as well as his/her current job?

We already have a penury in my country of anesthesists and other specialized MDs and nurses, outside of the big earning fields (mostly esthetics). There is no need to give the remaining ones even less motivation for staying at school.

more people become specialists, competition reduces individual income.

Second, "supply and demand". It doesn't work the way you think it does, you oaf.
If now everybody has to go see a specialist, you increase demand for specialists. Thus, at worst you increase the price the specialists may ask for, at best, enough MD become specialists to sponge up the displaced demand.

By making every - or almost every - doctor into a specialist, you didn't increase supply: each specialist is, well, specialized in a specific field. They are not going to be in competition. It's already the case between ophthalmologists, dentists and MD. A dentist doesn't steal a customer from a ophthalmologist when he is treating a cavity .All you did was splitting the initial market.

Why do I feel that zebra invented the non-specialized specialist?

even the pharmacist might have been allowed to slip them some Amoxicillin, telling them it was a well-tested traditional remedy related to naturally-occurring fungi.

To start with, not-so-minor nitpick, an antibiotic is useless against fungi. Sorry, but precision matters. Drugs are not sugar pills to be given at random.
To continue, so you want medical people to lie to their patients. You are also assuming the people buying homeopathy are too stupid to read what's written on the antibiotic box.
To finish, you are also assuming the pharmacist would have been able to do an accurate diagnosis, for all we know without even seeing the sick baby.

And sure, let's just deregulate the selling of potent drugs. It's not as if the medical field was not already catching a lot of flak for overprescribing antibiotics, among other classes of drugs.

tl;dr: Narad is right. You are either a full-fledged troll or too stupid to think before dropping your sh!tty ideas here.

I'm beginning to think we should be congratulating zebra. Somehow he has discovered a way to make solutions so concentrated that even at 30C dilution there would be readily measurable stupid.

sadar,

II think you conceptualized most of what you just wrote from your own thoughts but if you say you extrapolated from it from Zebra's writings, I can't disagree. I am just happy that Zebra was able to narrow down his thoughts; I've had a hard time keeping up.

We agree on many things with some caveats,

"...requires doctors to perform too many functions outside their training and likely to run counter to their dispositions

Absolutely. But when you write this I think of billing, MOC exams in addition to CME, meetings, etc. that are business functions not the psychosocial demands of their jobs, and I base it on what GP/PCPs are writing in their comments (too much time on KevinMD I guess). For the young MDs, I see a lot of idealism and fear they don't anything better than what they see now.

"...‘solution’ being pushed by TPTB is to replace a significant number of patient contacts now handled by PCP MDs with being seen by a PA or NP..

I see that too and it is why I become so adamant when someone states something that sounds just like this without details. But I also see something that sounds eerily like your IS idea being pushed in the drive for "patient centered medical homes" and "accountable care organizations". The sad part is that they sound good in theory (as does the mythical IS, however, no insult intended - it is just mythical right now) but those models approach the physician mainly as a people manager of others not as clinicians. I wish I could obtain better information that isn't business-speak and not limited to psychiatrists but this is all I could find at present. Pay particular attention to the image in the post.

http://1boringoldman.com/index.php/2015/06/20/requiem/

[Note that it speaks volumes that most of the available information is in business-speak which if you have been in business is generally known as horse-shit until revised by workers to be practical].

I am sorry about your experience with your PCP. I have been burned too but not to that extent. What I would like is for the bar of performance for PCPs to be raised, not a lowering of standards to in general to meet volumes or profitability standards. Even still that would not get rid of individual cases of misdiagnosis. I just hope to lessen them.

I meant what I wrote about agreeing with Zebra's idealized vision; I want good quality care for the most people too but am wary of visions without detail. IS may or may not be it. I am for experimenting and quite against mandates. But to get there, and to overcome our political opposition, we need to band together and not pit MDs and patients against each other.

[Orac, do you know why I have never rec'd notifications of follow-up comments via email? Thanks.]

I can’t seem to find the “common major illnesses mentioned above”. But whatever they are, there could still be specialists for each, so why not eliminate the label “internist” as well.

The "label" internist? This is a specialty, too. A residency in internal medicine (three years) is a prerequisite for a fellowship to subspecialize, which appears to be what you "think" you "mean" when using the term specialist.

You want to be a rheumatologist? Two more years. Gastroenterologist? Three more years.

Hey, since the whole idea is a product of your turgid imagination, howsabout a round of Play the Intake Specialist?

"Hi, Intake Specialist Z., I went out for a smoke at work the other cold winter day, and when I came back in, my right forearm was blue and white half the way up. It's never happened before. What do you think?"

Remember, Intake Specialist Z., you're not a "GPMD." Oh, and they don't exist any more. Because this The Big Plan.

I'll wait.

In the meantime, I'd suggest that the label that really needs to go is your very own utterly brain-dead, blobular coinage "GPMD."

Mr. Delphine and I are debating the usage of “y’all” vs. “all y’all.”

The latter is indefensible, as I've noted previously. There's a literature.

“Hi, Intake Specialist Z., I went out for a smoke at work the other cold winter day, and when I came back in, my right forearm was blue and white half the way up. It’s never happened before. What do you think?”

Were you in your basement room, with a needle and a spoon, and another girl to take your pain away?

I spent 5 years south of the Mason Dixon (went to Gtown, I lived technically below the Mason Dixon) and this is a polarizing topic. Almost as bad as vaccines.

Not really.

I won the argument, I have found the bottle of whiskey we'd lost since we moved. #winning

Along with lifting restrictions on having various tests done, we might also loosen up the whole “prescription” business. I wonder if that child who died from an ear infection might have done better in a world where, at the pharmacy where the parents were buying homeopathic nostrums, even the pharmacist might have been allowed to slip them some Amoxicillin

Yes, "we" would do oh-so-much better in a world in which pharmacists could make the wrong choice of front-line antibiotic with no concern for possible allergy, no knowledge of the extent of the invasion or whether the strain was resistant, lie to the patient's parents, and promote antibiotic resistance all in one fell swoop.

Well played.

Orac, apologies on the typo in my name last time as well. Will ensure I use this name forever.

On the amoxicllin vignette, this is a story I made up and I'm sticking to it, so don't come after me to testify on a 20+ year old fictional account.

Pharmacist with young child screaming in pain in the middle of the night. Takes amoxicillin susp from shelf. Treats child who is better for several days but then not. Tries again. Clears but then comes back again and he finally decides to take child to MD. The pediatrician tells him he better d@mn well not treat his child on his own ever again because it is stupid for many reasons including messing up ANY culture the MD was inclined to order. It's ok he spoke to him like this; they were friends. And the pharmacist learned his lesson. The End.

My Dad once set a bad break himself, we didn't have many alternatives at that time (it was the arm of one of my sisters). It not only didn't get better, it got a lot worse, is the long and short, and the orthopedic dude once they finally got to a qualified place, well he was spitting nails. We do what we can and what we know. Sometimes we know less than we thunk.

The part about you guys figuring things out was me trying to be polite

Oh, dear, did you strain yourself? Or are you now ignoring the First Rule of Holes? Because, y'know this pissy little shіt trip...

which is not reciprocated, apparently.

... has already been deployed:

JP,

It’s rather ungracious of you to respond that way over a word quibble when I am agreeing with and expanding on your basic point.

It's the same thing but now in reverse as you attempt to retreat but can't resist the excuse that everybody else was just too damn ignorant to recognize the "invitation" to seek the stamp of approval of appropriately kowtowing to your brilliance.

an antibiotic is useless against fungi

My mistake, I misread zebra's sentence. He/she was talking about the origin of amoxicillin, not the target, so that's something he/she got about right.
(let's not split hairs about synthetic vs natural origins).

Helianthus,

1. I'm glad you're on this thread.
2. And, I am glad you clarified your misreading. Although I did cut you some slack because I thought you might be making the point that how would the pharmacist know if the little girl had a fungal infection or a bacterial one.

My mistake, I misread zebra’s sentence. He/she was talking about the origin of amoxicillin, not the target, so that’s something he/she got about right.

He was talking about the ability of the deregulated pharmacist to psychically infer which lie would allow him or her to pass off the wrong antibiotic to the "woo-inclined" parent and magically prevent the death of Hope Delozier.

Because that's what the imaginary "intake specialists" essentially "do." So he won't have to wait in line. And spending less for better outcomes. Because "GPMD."

And spending less for better outcomes. Because “GPMD.”

LOL. Have you ever written ads for political campaigns?

Here, let's have a little fun with the Incredible Shrinking Zony:

It’s all relative. Remember that I am proposing this as an alternative to Orac’s suggestion that we pay GPMD [sic] more– or rather, the same to see fewer patients– so they can spend more time with each.

OK, where is this "suggestion"?

It actually originates here, but Z.'s cognitive gelatin didn't really set up until this. Behold "Orac's suggestion":

Yes, there are problems with conventional medicine. Doctors often spend too little time with patients because the reimbursement system requires that they see lots of patients to be able to make a living.

Anybody have any other candidates? Zony?

^ OK, AAFP does recommend amoxicillin for acute otitis media.

Naturally, the deregulated pharmacist will do the whole follow-up shebang and ultimately be ready to hand for consultation with the "intake specialist":

After some indefinite period of time, "Hi, some pharmacist gave us a traditional remedy related to naturally occurring fungi, but things haven't cleared up. Could we have some more? We don't believe in modern medicine."

@ Narad / Not a Troll

He was talking about the ability of the deregulated pharmacist to psychically infer

Oh, my initial apologizing comment included a remark as to how "penicillin comes from a fungus" was the only acceptable part in zebra proposition #177.
Snide remarks are out of place while apologizing (when digging a hole, etc), so I left it out.

And yes, in the case of Hope Delozier, Amoxicillin would have been the first choice. Except in case of bacterial resistance or patient's allergy to penicillin. Or if the infection was viral or fungal. Funny how medical care is more complex than just giving some drug.

I'm sure the deregulated pharmacist or the intake specialist would think of the right additional lie* to say to have the right microbiological test done.
For the allergy test, the pharmacist may have to be very inventive.
Good luck to the next pharmacist the parents will see if he start saying a different lie.
Where are the Illuminati when you need them? They are supposedly good at handling several layers of lies.

* the idea of people carrying around mislabeled drugs - even if it is just the oral description of such - is highly appalling to me, beyond words. As a biologist/chemist, I freak out whenever I see an unlabeled recipient with some unknown content.
A few years back, a nurse killed a little boy in a French hospital because she didn't take the time to read the label of a IV bag and gave him magnesium chloride instead of glucose. The bags were mixed up in a poorly labeled drawer.
We really don't need more confusion about what compounds are inside a given pillbox. There are already too many occasions for errors.

To give back to Caesar what belongs to Caesar:

Except in case of bacterial resistance or patient’s allergy to penicillin. Or if the infection was viral or fungal.

When I first replied about the issues of giving antibiotics over the counter, I didn't remember of the possibilities of allergy or fungal infections, until other posters mentioned them; although as a microbiologist I was taught about those.

But, eh, I'm not a GPMD, just a specialist.

Not A Troll 191,

" if you say you extrapolated from it from Zebra’s writings, I can’t disagree."

You may not be aware of this, but sadmar is a "specialist". As I suggested earlier, IS would probably take a course or two from such a person, where they would develop the skill of "listening" and then consolidating and articulating the information in a useful form.

"What I would like is for the bar of performance for PCPs to be raised,"

Which sounds like Orac's (non-)solution; please see #172. So far, everyone including you is asking me to give details-- perhaps next what color we paint the clinic-- but you as well offer no suggestion on how to achieve anything but status quo. Where will the money come from to double the number of GPMD?

Not A Troll 197,

Interesting story. Why would a parent with the means, and part of the medical establishment, not seek treatment from a GPMD who is also a friend, though?

And doesn't that question inform the problem of people living on the margins who have far more cause to seek alternatives?

Maybe, that CVS clinic with an IS could be a more welcoming place, and afford them access to all the technology that didn't even exist 20 years ago?

Helianthus,

Since you actually admitted misunderstanding something, I will ignore your negativity and clarify other things you have wrong.

You have to interpret language in context; you are making mistakes because I (apologies) am using incomplete phrases with quantitative terms.

When I say "I don't want to pay more so....", that is in the context of Orac's suggestion to increase the number of GPMD. It doesn't mean I want to pay less, which you seem to think.

When I say "specialists will make less", I mean "less than they make now", which in the US is quite high relative to other countries. You appear to interpret that as "less than GPMD make".

Now for the part about numbers and supply and demand, I don't know where you get your ideas. Maybe that part is not my fault but you are just quantitatively confused.

Specialists compete with like specialists-- e.g. cardiologists with cardiologists.

If we eliminate all GPMD slots, then of course more people will stay in school to become cardiologists. So, competition will indeed drive down the compensation; it will be more than GPMD now, but less than cardiologist now.

Then, the question would be "how many cardiologists", which I can't answer just like I can't tell you the color to paint the clinic-- that will be determined as things transition over time. But remember, the cardiologist is much more likely to figure out what is wrong in a 7-minute visit than the GPMD. So you are getting better service, hopefully as I say for not more money overall.

-I said you could educate people who have the combination of intelligence and interpersonal skills that a serious yoga teacher or perhaps a nurse, or other category (EMT? Engineer?) would have to perform the interaction with the patient requested by several people.

Not without sending them to medical school, you couldn't.

I don't know whether it would be realistically possible to make "diagnostician" a specialist category. (Meaning I'm not sure that being an exceptionally good diagnostician is something that can be taught, as opposed to a gift possessed by doctors who happen to have the right turn of mind for it.)

But it would be nice if it could be.

Which sounds like Orac’s (non-)solution; please see #172.

Which was stated where, again?

But remember, the cardiologist is much more likely to figure out what is wrong in a 7-minute visit than the GPMD [sic].

Never seen a cardiologist either, eh?

@ Delphine #194 --

zipping through the days at lightning speed

I can't tell you how many times I replayed that verse while trying to decipher the words to the line immediately after that one as a teenager, back in the pre-internet, pre-G--gle day.

I'm not actually sure that they're truly knowable beyond a best-guess level of certainty. I mean, just because one can safely assume that Mick and Keith knew what they were once doesn't mean they do now.

/off-topic.

I thought this report on relative efficiencies of health care systems on OECD countries was interesting. Despite coming last in terms of efficiency the US did quite well in terms of quality of care. It was 'just' access, efficiency, equity, healthy lives and costs that it fell down on.

That suggests to me that the US medical system itself isn't broken, it's the political system around funding and access that is the main problem.

Krebiozen,

Good info but I wouldn't call ranking fifth out of 11 "doing quite well".

What's up with those Scandinavians?

Krebiozen,

Thank you for the article. I have seen quality healthcare in practice and what it taught me is that it depends on the individual practitioner. The system they work under can either make their lives easier or make them a living hell and push out the element necessary to provide good care.

Zebra,

I didn't know sadmar was a specialist but the merits of his argument should be able to stand on their own no matter who he is and I hope he affords me the same even though i am a nobody.

I am not biting your lure for me to explain how to double the number of MDs. That isn't even what I was thinking. You're the one with the novel idea; you explain it, and while you're at you should thank sadmar for picking up a lot of the slack in yours [I am serious; no snarc intended]

I asked for details for three reasons:
1. To get a more coherent point of view out of you. You throw out a lot to see what sticks and you always leave a opening that you were misunderstood. It is easy to be misunderstood if you are always moving goal posts.
2. Once get as close as we can in #1, to vet if what you are saying has already been tried.
3. For your own benefit so that you can think your idea through, but also, so that you are not deceived by phony implementation plans using statements similar to a beauty queen saying she wants to solve world hunger by getting rid of GMOs. Or more on point, this from sadmar:

Of course TPTB are likely to falsely appropriate the idea(s), and “further erode quality in healthcare” should they consider them at all.

I really don't care what you call the intake worker of the future or if you divorce them from treatment and make them master diagnosticians to include triaging to emotional care. What I am aiming for is a medically trained & experienced person to the level of an MD to be this person because once they are in charge of restricting access on who you see next it matters a great deal how good they are at their jobs. Which is why I don't see why current GP/PCPs would not fit the bill if they are given more time to interact with patients and some active listening training since that makes them better diagnosticians.

And, what would make your IS worker a better diagnostician if they have more time to speak to a patient? Training and experience. So now that we are in this circle-jerk, I don't know why it isn't expedient to utilize the GP/PCPs we have now in better ways than to chuck them entirely into retraining programs so they can be specialists, and to train the new ones to be better diagnosticians/listeners. The only reason is because no one has the will to do this. There is an active attack on physicians going on that I don't quite understand (with the exception of business people trying to extract the last pound of flesh from them while seeming comfortable with their millions of dollars of salary). I hope you don't let your anger at medical professionals blind you to this.

sadmar, I went back and read some of your earlier posts and I think you have one thing backwards. The happy, peppy, next-to-worthless young that don't know what they don't know, you're seeing as GP/PCPs are the young today. I worked closely with about 20 young people (mid 20s to early 30s) in business and they are exactly that. So rather than the "ignorantly positive" self selecting to be primary care physicians, I think it is the few logical, rational thinkers selecting to be specialists, and theirs is certainly the rational choice given the environment GP/PCPs work under.

zebra,

Good info but I wouldn’t call ranking fifth out of 11 “doing quite well”.

What part of

Despite coming last in terms of efficiency the US did quite well in terms of quality

of care.
did you not understand? The US came 3rd in terms of quality of care, and 5th in quality overall. It was on access, efficiency, equity and 'healthy lives' that the US fell down. To clarify the terms:

Access: "people in the U.S. go without needed health care because of cost more often than people do in the other countries"

Efficiency: "The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing."

Equity: "Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs."

Healthy Lives: "The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60."

What’s up with those Scandinavians?

I think you may have misread the chart. Sweden came 3rd overall, but Norway doesn't particularly stand out to me, and both did poorly in terms of quality of care. I'm surprised the UK did so well, having worked and used the NHS and having seen the cracks in the system and the inefficiencies inherent in the system first hand.

Sorry, should read " The US came 3rd in terms of effective care".

So rather than the “ignorantly positive” self selecting to be primary care physicians, I think it is the few logical, rational thinkers selecting to be specialists, and theirs is certainly the rational choice given the environment GP/PCPs work under.

*shrug*

People have different goals and interests, and there are only so many residencies to go around.

Krebiozen 219

Yes, that's what I thought-- effective is a sub-category of quality.

But I was wondering why Sweden and Norway would be at the bottom in quality of care. Perhaps it is the nature of the distribution.

Not A Troll 217,

Two points:

I don't think you really understood what I said about sadmar, and your comments about my presentation are self-contradictory.

Sadmar understood what I was saying just fine. So maybe we need to accept that, just as with health care workers and everyone else in the world, some people are better at some things than others-- in this case, reading comprehension.

Sadmar is a professional wordsmith, so he is able to comprehend and then produce his own version in the hopes of better communicating to a specific audience. I certainly appreciate that, and have said so.

Second point-- yes, you have now again said you want GPMD to spend more time with patients. But whether it is twice as many or 1.5x, this still requires more GPMD. So my question remains-- how do you pay for that?

But I was wondering why Sweden and Norway would be at the bottom in quality of care. Perhaps it is the nature of the distribution.

You could always click on the words "full report" (PDF).

People have different goals and interests, and there are only so many residencies to go around.

True on both counts, and as we have found out on the residences.

IDK. I just haven't see evidence from reading medical student's writings that those who go into primary care (or psychiatry on the bottom of the heap of specialties) are any less idealistic about patient interactions or any more positive than their age group. At least from what I read from med students writing about why they choose those fields. None of them are writing about the joys of seeing a patient for only five minutes. It is more like they think they can make the field better. But I concede that the ones who think they can pull that off may be the only ones writing blog articles.

But whether it is twice as many or 1.5x, this still requires more GPMD. So my question remains– how do you pay for that?

How do you pay for more specialists and subspecialists, who require additional training?

None of them are writing about the joys of seeing a patient for only five minutes.

Strangely, I've never had anything even remotely resembling this experience.

^ And, really, WTF is this supposed to "mean"?

Perhaps it is the nature of the distribution.

zebra,

I think sadmar took your fledgling anti-MD rant with an ideal state as end-point and ran with it to make a coherent, thoughtful idea out of it but one I not convinced is not already being tried. But with my reading comprehension issues I probably have that all wrong.

How will I pay for quality in primary care? You can go first.

Narad @226. I've come close to having only 5 minutes w/PCP but not lately as I am now Complexity Level 4.

It was an exaggeration of the "The Taylorized quick-turnover system" which I don't know how many minutes are assigned to see patients in. I took a WAG.

There is triple hilarity in this one:

Sadmar is a professional wordsmith, so he is able to comprehend and then produce his own version in the hopes of better communicating to a specific audience.

No, you've not just taken it into you head that Sadmar is a desperately needed ally, but you've gone the extra mile and anointed him as some sort of weird lieutenant.

If he had spent as much verbiage crapping all over you, you'd be back to the "filibustering" routine and this:

Blah blah blah… maybe the problem is that some people work hard to use fewer words, and some people don’t work hard to understand, and use lots of words to hide that they don’t understand?

But this is to overlook a detail:

better communicating to a specific audience

Surely, your razor-sharp mind can wrap itself around the usual convention that the word "specific" demands some actual freaking specificity. So, what specifically is the "specific audience" to which you refer?

It's OK if this reduces to "Z. say yum" and "Z. say ick," I promise. Maybe somebody will flesh it out for you some day.

None of them are writing about the joys of seeing a patient for only five minutes.

Strangely, I’ve never had anything even remotely resembling this experience.

I actually did have a psychiatrist once who I used to see for maybe 5-10 minutes at a time; this was kind of annoying, since at the joint I was going to at the time, the psychiatrist could only be seen at a specific location which required me to bum a ride, take a taxi, or bus part of the way and then walk for about 40 minutes. I think it may have been some feeling on his part that he didn't want to waste my time or something, though, since the place wasn't exactly packed and I was seeing an "actual" therapist (who I didn't find very helpful.)

We did spend over an hour together at the intake appointment, though. He was actually one of the more perceptive mental health professionals I have seen in general; I remember several moments in that appointment when he saw through or at least recognized my BS in ways that nobody else had.

He moved on to private practice pretty quickly, in part because he wanted to do therapy and not just have medication appointments. I considered seeing him, but it would have required dealing with the insurance on my own.

^ There was another lady I saw for a while after him who was also pretty good, and also moved on to something else a few months after I started seeing her. It was incredibly frustrating, because the whole reason I had decided to go to a townie place at the time was so I could see somebody besides rotating-door interns.

I think that's actually when I gave up on the enterprise, which was probably a bad idea. Well, 20/20 hindsight.

I think we can conclude that not one of the minions is willing to explain how to pay for Orac's proposal that GPMD spend more time with patients.

I think we can also conclude that, despite the dismal information about the US system provided by Krebiozen, the consensus among the minions seems to be:

"Keep that Socialist Government's hands off my Medicare and tax-subsidized health care."

Or, "I've got mine, and I want even more."

Those who actually read the posts can conclude that, although there are many things about the US system that need to be fixed, your proposal would only make things worse.

Narad,

None of them are writing about the joys of seeing a patient for only five minutes.

Strangely, I’ve never had anything even remotely resembling this experience.

I have, many times, when seeing a GP or a hospital consultant in the UK, which came first in that league table. I note the UK came 10th in terms of "healthy lives"* . I have often said, only partly joking, that the NHS delivers lousy health care to all. It does depend on where you live (the so-called postcode lottery): when I lived in a well-off area in Cambridgeshire, the health care I got was excellent. Since moving to one of the poorest parts of London I have experienced less than excellent care, though it has improved (which was one of the reasons I moved here originally).

That said, a five minute consultation is often all I want. I usually know what I want from my doctor, whether it is for him to take a look at something that's bothering me, or to give me a prescription, a blood test or a referral. I don't usually want to hang around for a chat, especially when I know there's someone who needs a longer consultation in the waiting room. Preventive stuff like checking weight, glucose, cholesterol and asthma reviews and vaccinations are all carried out by a nurse.

Thanks for the link to that PDF, which I somehow missed - I wasn't firing on all cylinders yesterday (or today to be honest). I found it amusing that the US did very well on these criteria, coming first in both:

Doctor or other clinical staff talked with patient about a healthy diet and healthy eating
Doctor or other clinical staff talked about exercise or physical activity

Aren't these the very things that we frequently see sCAMsters bitterly complaining about in regard to US doctors? I see the US came first in terms of nosomial infections too, another thing sCAMsters often complain about.

* I'm a little bemused by this as 'healthy lives', as I mentioned above, includes "mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60", yet scoring first overall, which doesn't see a great consolation somehow. I'll have to drill down deeper into the data.

^Nosocomial - I should have just written 'hospital acquired'.

Being a 'professional' doesn't necessarily make you better than an 'amateur', or mean you exercise all your skills away from work. I was a 'professional wordsmith', having collected paychecks as an advertising copywriter and movie reviewer, and receiving royalties on essays in 'scholarly' books. I was also a professional 'word-skills analyst' having been paid to teach writing and public speaking, grade assignments on both the mechanics of usage and strength of argument...

Which is not to say I bring anything but small random subsets of that expertise to the table when I sit down to whack out a comment on a web-forum. There ARE certain topics on which my expertise ought to figure more than it does here in granting merit to my comments — I mean there's no room for developing sophisticated arguments that stand on their own on the web, and I get bashed for the tl:dr when I make a half-arsed effort. But medicine isn't one of them.

@ Not a Troll
"aiming for trained & experienced to the level of an MD"
So we fire all the PAs and NPs? More to the point, MDs have to know a LOT more than diagnostics. How about I say 'trained and experienced in diagnostics to or beyond the level of a GP-MD? Besides, MDs aren't the gatekeepers now anyway. The folks at the front desk do a lot of filtering, directing and redirecting despite having little or no medical training, or you have to talk to an 'advice nurse' first...

"I don’t see why current GP/PCPs would not fit the bill if they are given more time to interact with patients and some active listening training..."
Because they're not necessarily good at the interpersonal skill stuff, and the psych/interactional skills go way beyond "some active listening training."

'Why not better utilize the PCPs we have now than retrain them to be specialists?'
False dichotomy. PCPs already ARE specialists — 'internal medicine' i.e. the physiogics of a certain class of maladies. MY version of an IS-type proposal doesn't retrain them, and does make better use of them by turning over the handholding and information gathering to someone else, and letting the MDs focus on the formal training and expertise they already have.

"The happy, peppy, next-to-worthless young..."
My peppy young PCPs were hardly 'worthless'. I'd say they were quite good at certain things, including prescribing the right treatments for the maladies they encountered most often, and didn't present complex diagnostic problems as they had clear indicators from basic physical exam procedures and typically ordered tests — especially bloodwork. Nor are the youth of today uniformly “ignorantly positive”. The young uns you worked with were in business, a field that rewards quick decision-making, boosterism, and arrogant overconfidence (did you ever watch The Apprentice before it went to all-celeb contestants?) The work of junior execs and 'mangement trainees' is becoming Taylorized in its own way... And unless you haven't noticed, primary care IS a business in the U.S.

"I think it is the few logical, rational thinkers selecting to be specialists..."
Well, not in my obviously limited anecdotal experience. My guess is that human compassion is still a major factor leading the young towards primary care, but also a key driver leading them to jump ship when they begin to experience how the system works. This was the story of my first PCP in CT circa 2000, fresh out of med school, a little rough around the edges, but he did listen, think, try to relate at a human level. I think he'd have made a great GP. He bailed after about 9 months, and went back to school to learn a more specialized specialty. He didn't come right out and say he was burned out, or dispirited/disaffected by the routine, but it was clear from his facial expressions and vocal tone he was not a happy camper. Thus I got transfered to Dr. Peppy Inandout. As congenial as could be, but I don't recall EVER leaving his office without frustration borne of feeling cut-short before our 'business' had properly concluded. I put those blues on myself mostly — thinking I must be a bit of a malcontent with unreasonable expectations — he's a Dr. for the most 'legit' medical group in town, he must know what he's doing... It was until the unaddressed coughing and laryngitis became unbearable, that I got pushed over the edge of mistrust. Which, once I got the facts of the situation, led me to some serious contemplation of what the hell had gone wrong... Into which entered some other personal tragedy I'll skip going into for now. The point being life circumstances — including having had to move around the country a lot for work, and thus experiencing a lot of different medical institutions — have more to do with any validity my perspective may have vs. the way J. Doe Public might see things, rather than it being the product of any special genius on my part.

You DO understand, NaT, that the "active attack on physicians" comes first and foremost from profiteers "trying to extract the last pound of flesh from them" while rolling luxuriantly in obscene riches as compensation. And this seems to have made you, well, a bit paranoid and subject to a hefty confirmation bias. "Everybody has it in for the GPs!" I'm guessing you feel YOU are facing a firing squad, and just gob-smacked that any 'regular folks' seem to be going along with the doc-dissing, due to your own personal emotional investment. You seem unable to take a 'rational logic' position on zebra's proposal: which would bracket his chippy 'tude, break down the components, separate the wheat from the chaff, and consider that some part of what he's talking about might actually be used to address your concerns and be helpful to your plight. He made that crack about "eliminating" GPMDs (which could just be a matter of differing defintition) so he's The Enemy, and everything he says ought to be rebuked. [Just a guess, here on your subconscious, mind you.:-) ]

But let's put zebra's proposals to the side for a bit, and consider the larger apparently growing animus against doctors among some smallish-but-still-significant sector of the public. It's not that hard to understand. They have been 'trained' by the mythology of medicine to think of MDs as controlling authorities, and by the ideologies of Individualism NOT to perceive the workings of the corporate machine. They don't see that GPs have been thoroughly proletarianized. They think of a medical appointment as "seeing the doctor", not "getting processed by the medicine factory" which is what it is. The bosses act in ways that hide their role, and actively deflect blame to the people they're screwing over. The patients get queasy about the doctors; the doctors get queasy about the patients who complain. Win-win for them. Lose-lose for us. It's all projection rooted in that extraction of the last pound of flesh from EVERYBODY.

When you feel the heat from regular folks not trying to get fatter off the sick, but just worried about their own health, I suggest you cut their complaints enough slack to look behind the surface, connect the dots to who's actually in power, and try to make common cause with the other shmucks on the short end of the stick, by directing their attention to who's actually holding the big end.

That's exactly what the company wants - to keep you on their line. They'll do anything to keep you on their line. They pit the lifers against the new boys, the old against the young, the black against the white - EVERYBODY - to keep us in our place.
Smokey in Blue Collar, written and directed by Paul Schrader, 1978

sadmar,

"How about I say ‘trained and experienced in diagnostics to or beyond the level of a GP-MD?" I'm fine with it but that is far from saying a yogi instructor could do it which is where we started with all this. Outside of surgical skills, I would say diagnostics is the most complex skill in medicine and a large part of what they do.

"Besides, MDs aren’t the gatekeepers now anyway." No, they are not. And MDs are close enough there to dig these gatekeepers out of a hole when they err.

"Because they’re not necessarily good at the interpersonal skill stuff, and the psych/interactional skills go way beyond 'some active listening training'." I'd believe this if I hadn't known MDs, including surgeons, who were good at interpersonal interviewing.The emotional support stuff can come after you are diagnosed. I think this was mentioned before.

...by turning over the handholding and information gathering to someone else, and letting the MDs focus on the formal training and expertise they already have. I'm confused. You say your idea hasn't been tried yet but nurses in doctors' offices have been doing a piece of this for at least 20 years. Or do you mean to say there hasn't been a hand-holder/information gatherer to the level of a GP-MD yet? Also, what is the formal training and expertise GP-MDs now have? It would really help for me to know your definition of it.

"My peppy young PCPs were hardly ‘worthless’." I thought that is what you were implying.

"The young uns you worked with were in business, a field that rewards quick decision-making, boosterism, and arrogant overconfidence..." followed by this "And unless you haven’t noticed, primary care IS a business in the U.S." Yes, that is exactly what I am saying. We don't want boosterism, arrogant overconfidence or bullsh_t positivity in medicine. Not at all.

"My guess is that human compassion is still a major factor leading the young towards primary care,.." I think so too. Maybe you didn't get that from my earlier comment.

He didn’t come right out and say he was burned out, or dispirited/disaffected by the routine... So what is going to change in the MDs routine in your proposal?

"...a bit paranoid and subject to a hefty confirmation bias." I freely admit my visceral reaction to generalized attacks and to solutions presented like "skittles & unicorns" but that doesn't mean I didn't logically parse the idea you distilled from what Zebra wrote. Have you been reading what I write?

I confess I have been hard on him at times in reaction to what I perceived as his naïveté and his lashing out. As you must have noticed the culture on this board is not for the faint of heart and that is no secret. While I have no intention of policing anyone's behavior, I do try to check my own.

"They have been ‘trained’ by the mythology of medicine to think of MDs as controlling authorities.." Agreed, but there is also this: I read quite a bit at the blog Mad in America. Not that it matters but I'm not a mental health patient; I was a psychology major and the subject still interests me. I am a highly sensitive person and the stories I read there, and your own, I find heartbreaking. After the commenters express their rage most of their stories invariably turn to a common theme - they trusted in the doctors, believed them, listened to them but they ended up harmed. Some very badly for whatever reason. [I do not defend incompetent doctors.] And now they hold a hate in their hearts for psychiatrists like you wouldn't believe. It isn't a hate born of evil but one of hurt and betrayal. And, generally, they think the solution is to get rid of the psychiatrists. I don't blame them for their anger, but rather a culture that would teach them blind faith in physicians in the first place. In my personal life, I have tried to counter-act this by mentioning specialists, second opinions and paying attention to your own body first. Most of the time, I got flak in return for having the audacity to question their MDs. The only answer I found to all this is that everyone of us is ultimately responsible for our own health and if the best resources we have at this time are MDs then I will defend them.

"...and try to make common cause with the other shmucks on the short end of the stick, by directing their attention to who’s actually holding the big end." I have been doing this and I am the one that broached the subject of doctors/patients working together. Did my passion hide this? My passion being my warning - everything sounds great in theory but beware what is delivered. For example, I love the idea of EHR - use my patient portal & mobile health apps often - but the electronic health record in the same university hospital system used by my GP and my gastroenterologist failed to let him know I had grade C esphogisits [I know this is not nearly bad as Barretts]. My Gastro didn't let me know the results after scope because he was distracted. When I asked my GP about it at my next visit, he only saw the neg h pylori results. I had to ask again because i recall being told by a nurse my results were nasty (only symptom I had was an intermittent feeling of pulling in my throat). Meanwhile, I had dropped PPI b/c side effects and was not being treated by either physician.My GP had to dig to find the results. At least three in screens into somewhere. Moral of the story: EHRs were rolled out with way too much hype and coercion, and were EXTREMELY poorly implemented. Someday we will get closer to the promise of EHR but it is not here yet and people are being harmed in the meantime.

So, regarding your idea, as I wrote in an earlier comment, I am fine with experimenting with it. Again, I do think it is being tested right now in Patient Centered Homes but please let me know what you think of them. Even with mixed results, PCHs are being touted as the answer to the emotional/time problem in medicine and much money is being funneled into them. At this point business is the driver. I see it as a thinly veiled attempt to marginalize expensive doctors and Zebra's argument dovetails in to this nicely.

You and I are not saying too much different about this subject; it is just that we approach it from different angles. I'm open to your idea enough to support testing it so that it can prove itself better than what we have now. In return, I ask that you be open to my skepticism to your idea, how it should be presented to the public and esp. to its implementation.

^ I apologize. I missed a couple of end tags on the italics b/t sadmar's quotes and my response in the middle of my comment but I hope it is easily figured out.

I think we [sic] can conclude that not one of the minions is [sic] willing to explain how to pay for Orac’s proposal [] that GPMD [sic] spend more time with patients.

I take it that whole bit about the waste generated by the insurance system has been repressed by whatever keeps Z.'s grotesquely distended head together.

I think we [sic] can also conclude [sic] that, despite the dismal information about the US system provided by Krebiozen, the consensus [sic] among the minions [sic] seems to be:

“Keep that Socialist Government’s hands off my Medicare and tax-subsidized health care.”

I'd be fascinated to see a defense of this weird Teaborgan fantasy. I am reminded, though, that Z. never did get back to defending this.

Or, “I’ve got mine, and I want even more.”

All together now:

I just don’t want pay more or spend more time waiting for a doctor because he is playing psychiatrist or sharing recipes with some fat person.

All together now:

I just don’t want pay more or spend more time waiting for a doctor because he is playing psychiatrist or sharing recipes with some fat person.

I saw a doctor today who played psychiatrist; it was great, she even prescribed me some Zoloft and talked to me about all sorts of things for like an hour. I noticed from her business card that she is a mud phud, so I asked her what she got her PhD in, and she said genetics, and told me about tiny worms that when you look at them under a microscope you can see their organs through their skin.

And THEN I got to see a social worker who as all, "Let's find you a therapist who doesn't suck," and she apologized for saying f*ck because it's unprofessional and I apologized (not really) for rubbing off on her.

And then I ALSO got to see a psychiatrist, and he was very serious and concerned, and also sort of unflappable and Vulcan-like, and he was like "No more than ONE drink per day, sport" and I was all "FINE" and he said "and use yr Trazodone for sleeping, silly" and I said "OK" and he said "I want you back here in one week. Do try not to kill yourself between now and then. Here is a phone number you can call and here is my email" and then I MAY HAVE started crying a little bit instead of laughing and making jokes.

And all the ladies at all the desks were SO NICE.

The Zonkey must be incensed.

(It's all through student fees, though, so there. man, UHS is great during the summer. Who knew?)

JP, I am so glad for you. Your story made me smile. NaT.

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