Longterm holistic approach on health(care) without reliance on social security

[jacob]

How does the American medical business/system prevent such a doctor-patient conversation based on human-to-human connection taking place? Awhile back I was speaking with a physician in a casual acquaintance setting. The person said that working for a healthcare corporation, when working with a patient, there was a computer screen that pop up and dictate conversations/diagnosis/treatment/medication. Going off script was not an option. The person no longer works in healthcare and said prior work dealing with insurance was similarly familiar.

In practice, the magic words for a patient-driven/bottom-up approach is to learn and have the confidence to ask the magic question: "Is this [procedure/test/specialist] really necessary?" (Answer: Often it isn't) and variations thereof. If the doctor/system is not allowed to break the script, the patient has to take the initiative. FWIW, I don't have a whole lot of experience with US healthcare. However, when I see someone new, I usually lead with a story about how I got railroaded into a bunch of unnecessary dental treatments during my first contact with the US health system and how I don't want to experience that again. That sets the tone.

[jennypenny]

Random thoughts ...

We can do all we can to be healthy, but shit happens. You might inherit an issue. You might grow up somewhere with environmental hazards. Some drunk might t-bone you. Etc Etc ... so much we can't even anticipate like the potential effects of PFAS and other stuff.

Some of you do activities that most people would consider risky. How does everyone account for that? I'd argue that if you ride a bike in traffic every day, you don't have as much control over your health span as you think given how many people are injured on bikes every year.

If you've led an ERE life and have a nice stash for emergencies, it's easy to see rationalizing spending that stash on medical treatments since -- if you die -- the stash is pointless. I mean really ... if the stash is for your well-being and you don't use it to try to remain alive and healthy, then why have the stash? I'm not arguing that people should opt for expensive treatments when they have stage 4 brain cancer that bankrupt their family. OTOH, we're talking about Zone 0 here -- isn't that the whole point of securing ERE resources in the first place?


Side note ... oftentimes a person will opt for treatment for the sake of their family. Even if the treatment doesn't work, it gives family members time to come to terms with the impending death. In that light, it's a kind gesture even if it's a medically pointless one in the end.

[7Wannabe5]

@Frita:

As I'm sure you know, teachers in both public and charter settings are very often compelled to work off a strict script these days also. One of the reasons I prefer working in either chaotic/very-low-income and/or highly-affluent-educated environments is that sticking to the script is less enforceable/enforced. I wonder if this holds true for extreme lower end/upper end medical environments?

Some study I read indicated that the health of even the most affluent residents of realms with high income/wealth disparity is negatively influenced. One of my affluent, very green smoothie level health conscious, grouchy old partners stopped to visit me on his way back from northern vacation site last year. Very suddenly he experienced extreme abdominal pain and yelled for me to call 911. The ambulance arrived fairly promptly but took him to the nearest hospital which was located in the heart of the 'hood. When it became abundantly obvious to him that he wasn't going to receive the level of medical service to which he was accustomed in the affluent suburbs, he called me to come pick him up and drive him through a blizzard to a "decent" hospital, where it was determined that what could have been a heart attack was just a kidney stone. (This, in part, is why I have carte blanche to order whatever I want (but don't want)for Xmas on his bill-lol.)

My point here being that, for better or worse, the neo-liberal economic policy of the last 4 decades has sent out suckers of third-world life-expectation and medical services into first world environments, so this is also something to bear in mind when making calculations and planning practices.

[Ego]

Awhile back I was speaking with a physician in a casual acquaintance setting. The person said that working for a healthcare corporation, when working with a patient, there was a computer screen that pop up and dictate conversations/diagnosis/treatment/medication. Going off script was not an option. The person no longer works in healthcare and said prior work dealing with insurance was similarly familiar.

John Campbell interviewed the research pathologist Dr. Clare Craig yesterday. They talked about how systems are reducing physician decision-making to algorithms and how this is leading to what is very rapidly becoming medicine by artificial intelligence.

AI manipulation will become an increasingly important skill in the future. I have a story about this that I am working on for my journal.

[delay]

One of the bigger mistakes I made during accumulation, was minimizing medical appointments. I didn't want to go or pay for it. Now I'm playing catch-up. Coming from behind at 40 sucks.

Interesting. As I learned in university, the average outcome of a medical intervention is negative. That's despite a depressive number of data washing techniques pushing in the other direction. So if I lived my youth again, I'd make fewer medical appointments instead of more.

Decision-making could be greatly assisted if doctors were willing to make the same decisions for their patients as they/some do for themselves instead of "offering additional options" with increasingly lower ROI to their patients to abide a philosophy of "healthcare as a consumer product".

Yeah, in my experience doctors choose differently for themselves and their family. Like you say they seem to avoid low chance options, high risk options, and options against diseases with low impact.

The person said that working for a healthcare corporation, when working with a patient, there was a computer screen that pop up and dictate conversations/diagnosis/treatment/medication.

Yeah, that's exactly what I experienced in The Netherlands. When I last visited my GP she looked at the screen all of the time and followed its instructions. She ended up with a variety of medicine I could choose from. When I declined she decided to prescribe one anyway, and told me not to pick it up if I didn't want it.

At the time I didn't think the scripting was bad. After all, if you ask ten doctors to diagnose the same patient, they come up with ten answers. Using the knowledge of a central computer system might do better. I wonder who writes those scripts?

[jacob]

I wonder who writes those scripts?

These "expert-systems" were one of the first useful applications of---I don't want to say AI, because it's basically a white box decision tree based on probabilities. They're statistically better at diagnosing than doctors. I suppose the doctor just acts as an "informed interface" between the patient and the computer.

The internet has made a lot of this public and insofar one understands baserate probabilities, it's possible to make fairly accurate diagnostics. That's been my experience on the rare occasion I've shown up over the past 20 years. "Hi, I have an issue. I think it's XYZ but I just wanted to verify." "Let me take a look... You're right. That'll be $150."

[delay]

These "expert-systems" were one of the first useful applications of---I don't want to say AI, because it's basically a white box decision tree based on probabilities. They're statistically better at diagnosing than doctors. I suppose the doctor just acts as an "informed interface" between the patient and the computer.

Yeah, exactly. Expert systems should allow doctors to harness historical knowledge more efficiently. What options are there for these symptoms and how well did they work out in the past? Yet the success rate of medical interventions seem to be in decline.

[7Wannabe5]

Might have something to do with the crisis of irreproducible results in medical research. IOW, AI can handle statistics better than your median MD, but the field of applied statistics itself is in crisis mode.

[Scott 2]

The average outcome of a medical intervention is negative. That's despite a depressive number of data washing techniques pushing in the other direction. So if I lived my youth again, I'd make fewer medical appointments instead of more.

How much of the negative outcome is due to:

1. Lifestyle factors patients will not change
2. People avoiding doctors until there is a severe problem
3. Inability to afford prescribed care
4. Non-compliance with treatment - missing meds, not following surgical aftercare, skipping the physio's home exercise program, etc.
5. A rational choice that the intervention is not worth the effort, given the patient's other obligations

Navigating the modern medical system is a complex skill. I think it's important to learn before a health crisis arrives. Hopefully the process heads off looming problems early. But we ultimately do not have control. Aging is hazardous to one's health. It is a hard problem. We are not buying a cure. We are attempting to delay the eventual cascade of health issues, that ultimately lowers quality of life and culminates in death.

I believe it is common for people, even those pursuing ERE, to work so hard to achieve freedom that they do irreversible physical, social and/or psychological harm in the process.

I agree.

The short list of stuff I'd have taken more seriously - orthodontia, dental cleanings, migraines, eye exams, foot pain, blood sugar, stress, sleep quality. It's easy to ignore specifics and say to yourself "sometimes life hurts". But there's a lot more that can be done. The earlier you start, the more effective it is.

This brings me back to the original post - systemic considerations of medical resourcing.

Since dental care is not socialized, it's a good example. I opted out of orthodontia at 20. I spent my entire career with poverty teeth. Every first impression carried an immediate class signal, which surely impacted my earning potential. One job offer $10k higher, or an extra % point on a couple raises, and the financial return on that care would have been 10x. Additionally, I would have experienced the health benefits of straight teeth - less tartar build up, more even wear, fewer cavities, more varied diet, etc.

The input of 10k at age 20, might have output 100-200k in value. Whether that was of net benefit to society? Up to me. But getting care would have been a sound strategic choice. Even at 40, with a surgery tacked on to the braces, I expect significant return on investment.


TLDR - Think in systems.

[chenda]

Imho routine medicals are a waste of time and money for otherwise healthy people living healthy lifestyles. Aside from dental checkups, eye and smear tests.

[jacob]

It is perhaps a useful perspective to split "healthcare" into two, namely "health" and "care". Oftentimes, a strong focus on one excludes attention to and concern for the other.

[Frita]

@Frita:
As I'm sure you know, teachers in both public and charter settings are very often compelled to work off a strict script these days also. One of the reasons I prefer working in either chaotic/very-low-income and/or highly-affluent-educated environments is that sticking to the script is less enforceable/enforced. I wonder if this holds true for extreme lower end/upper end medical environments?

Both American education and medical systems certainly leave something to be desired from my experiences. Scripted-education seems to be for the middle with the primary focus on moving partially proficient students to the proficient category. When the K-12 school is elite, the scripts also disappear but for different reasons than inner city.

Interesting question, I suspect that lower- and upper-end medical care follows a similar pattern. Specifically, elder care with assisted living and long-term insurance for the middle function as reported recently in the Times:
• https://www.nytimes.com/2023/11/19/heal ... Position=2
• https://www.nytimes.com/2023/11/22/heal ... 32f0bef97b

[Ego]

Physicians have to ability to go off script. The trick is to find a way to encourage them to do so.

[DutchGirl]

It is perhaps a useful perspective to split "healthcare" into two, namely "health" and "care". Oftentimes, a strong focus on one excludes attention to and concern for the other.

There's also the option to split the healthcare system in care, and cure.

Cure meaning there's something to repair, fix or replace. The hope is that afterwards you'll be good as new. (Doesn't always work that way).
Care meaning helping you live your life as best as is possible with the chronic health problems and/or disabilities that you have.

Both can be expensive, in particular in the USA.

Some people who have indeed taken really really good care of themselves during their lives can be really surprised when at age 60, or 65, or 75, they "suddenly" experience a health problem. I wish they weren't as surprised. "My body never did that before!". Well, yeah, but you never had this age before, either.

Anyway, I would urge people here to:

1. Take really good care of your health. Plus don't do really risky stupid things, to reduce the chance of needing healthcare.
2. Think about how you'll pay for healthcare bills, because it's likely you'll have some at some point in your life. Don't be unprepared.

[Seppia]

The internet has made a lot of this public and insofar one understands baserate probabilities, it's possible to make fairly accurate diagnostics. That's been my experience on the rare occasion I've shown up over the past 20 years. "Hi, I have an issue. I think it's XYZ but I just wanted to verify." "Let me take a look... You're right. That'll be $150."

My dad is a doctor. He gets so many “I have read this on the internet” that it has become one of his pet peeves.
He’s always been grumpy, but especially so now that he’s 72, and now his standard answer is “great go get you diagnose from Google” and usually sends people packing.

I’m sure you do this cautiously and with lots of grains of salt, but what you describe above isn’t (in terms of process) dissimilar to the Google scientists that will try tell you how astrophysics work after 5 mins of YouTube videos

[7Wannabe5]

Scripted-education seems to be for the middle with the primary focus on moving partially proficient students to the proficient category. When the K-12 school is elite, the scripts also disappear but for different reasons than inner city.

Interesting question, I suspect that lower- and upper-end medical care follows a similar pattern.

Yes, the article on assisted living which you linked is very reflective of the difficulties my sisters and I have had helping our mother who has a middle-class pension income (over $40,000/year) and no assets (due to bi-polar disease) with her varying disabilities at age 83, mainly due to having 2 hips replaced. Assisted living is wildly expensive, unaffordable even on middle-class pension income. So, she lives in "active" senior apartment complex, has varying levels of private-pay help with housework (also more needful due to bipolar disease making her 10x more messy than median senior)/personal care coming in depending on her current condition, and also fairly frequently lands in a short-term insurance-paid nursing facility for a few weeks until she is once again rehabilitated to "can independently hobble to bathroom" level. If I strictly prioritized "saving resources for the planet" over "my own personal sanity and good cheer", I would/could live with her and help out. I did manage to live with her for a number of months by spending every long weekend with one of my partners, who is too grouchy/supervisorial for me to live with full-time either. Kind of like 4 days in the cuckoo-bananas hamster cage followed by 3 days in the military barracks balanced out to tolerable and even a little bit fun

I currently receive my primary care out of basically an inner-city clinic, but receive my specialty care out of a major research hospital in affluent setting, and I do think the off-script analogy is much like what I observed teaching in inner city vs. teaching in most-educated city in U.S. In schools where all the kids get free government lunchs and a couple sacks of groceries to take home for the weekend, simply maintaining order takes a lot of energy and then you have to deal with the huge deficits the kids have otherwise, so the chaos lends itself to creativity/anarchy. In the schools where the children of affluent academics are clustered, nobody has to worry about crossing the median bar, so the kids get a full hour of recess, yoga class, robotics class, choice of nutritious lunch they order online, free reading and project time, and a parent volunteering to teach a third foreign language or science topic, so the leisure and abundant resources lend themselves to creativity/anarchy.

I actually believe that my multi-millionaire friend might have been better able to get the very best care/treatment for his cancer during the lockdown if he was better able to speak the language of the most educated. He did basically bribe his oncologist by donating to a cause of her choosing, but his grouchy old entitled man behavior was so terrible, nobody at the hospital or associated with the hospice really wanted to care for him. So, he ended up with just me holding his hand at the end.

[jacob]

My dad is a doctor. He gets so many “I have read this on the internet” that it has become one of his pet peeves.
He’s always been grumpy, but especially so now that he’s 72, and now his standard answer is “great go get you diagnose from Google” and usually sends people packing.

I’m sure you do this cautiously and with lots of grains of salt, but what you describe above isn’t (in terms of process) dissimilar to the Google scientists that will try tell you how astrophysics work after 5 mins of YouTube videos

Yes, drawing Venn diagrams between the "I did my [5 minutes of] research on the google and I have all the symptoms" and "I understand Bayesian statistics" and "I read physiology books for fun", the various bubbles are sized very differently and the overlaps are small in the general population.

However! ... I posit that it's possible [and the point of this thread in terms of actionable agency] to get into one of those overlaps and likely have a better idea of what's going on/what the issue is compared to just showing up at the office and saying that "it hurts where I'm pointing in a way I can't quite describe".

[chenda]

I cured my skin conditions by myself, using online research and self experimenting. GPs and dermatologists were mostly useless.

Though the old joke about dermatologists is that they never kill their patients nor cure them.

[delay]

I cured my skin conditions by myself, using online research and self experimenting. GPs and dermatologists were mostly useless.

Though the old joke about dermatologists is that they never kill their patients nor cure them.

Yeah, I went to three different GPs and a dermatologist with my skin problem. They all came up with a different diagnosis, each with various options for medicines.

When I starting experimenting myself it turned out my skin got better when I didn't use soap. That must be the commonest of common skin problems. Yet no doctor mentioned any solution other than medicine.

[Frita]

I actually believe that my multi-millionaire friend might have been better able to get the very best care/treatment for his cancer during the lockdown if he was . He did basically bribe his oncologist by donating to a cause of her choosing, but his grouchy old entitled man behavior was so terrible, nobody at the hospital or associated with the hospice really wanted to care for him. So, he ended up with just me holding his hand at the end.

Your mother’s situation demonstrates how pay-for-care options are eclipsing many Americans. Clearly, caring for her is not a viable option. Good for you choosing yourself.
If the need arose, where do you see yourself as an elder in need of more support?

My mother has been paying astronomical long-term health insurance fees for the past 30+ years to protect the inheritance. At the time, I thought it sounded like a ripoff, a marketed product benefiting the insurance company. Why not just save the money and pay out of pocket? She is still at home in her mid-80s and does not want to move ever. Oh, the irony!

I hear you on the school contrasts. When I worked innercity, I remember a student (who was sent to my office for a disciplinary infraction) asked, “Does your son go to school here too?” Hell, no, he was attending a lovely bourgeois school like you mentioned in a different part of the city. The best part of my work was in the morning doing paperwork before the crazy started. Some of my frequent flyers would come in and do work too, voluntarily, or hangout. I used to think how different things would be if switched at birth with my son. It’s really messed up.

What do you mean by, “better able to speak the language of the most educated” in regards to your high net worth friend receiving better medical care? I don’t think that being consistently grouchy facilitates good relationships of any kind. Was there even more to the issue?