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We think of doctors as healers because that’s the traditional role they grew out of. But with the institutionalization of medicine in the 20th century, they bec

We think of doctors as healers because that’s the traditional role they grew out of. But with the institutionalization of medicine in the 20th century, they became accessory bureaucrats. Their job is to approve or deny access to institutional services, per institutional policy, and they go through many years of learning how to do that. Their pay is scaled with the cost of the institutional services they safeguard, those costs in some markets being obscene and arguably corrupt. But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc

AussieWog93 3y ago
[flagged]
- swatcoder 3y ago
  Sorry, would it help if I rewrote that as "Doctors decide if you get a $10,000 MRI and a $42,000 course of medicine, that their education and pay is based on being trusted to make these decisions according to AMA and government guidelines, and that this is a dramatically different job than checking out Timmy's swollen ankle and Jamie's sore throat. So nurses and pharmacists are being enabled to do more of the ankle and throat stuff that doctors are too expensive to provide" Because it's the same thing in different words, and pretty grounded in the reality we all see.
anoxor 3y ago
[flagged]
sf_rob 3y ago
From my experience as both a patient and a spouse to a general practitioner the opposite is generally true. Doctors are grossly unaware of both costs to patients and insurance eligibility of procedures. They push for the solution that they believe will resolve the issue with the best health outcomes while minimizing their own risks of lawsuits without considering other factors. Next, a faceless bureaucracy on both the medical and medical insurance side of things (few of whom are medical doctors) will slowly spin into motion to maximize profit and minimize costs, all while you have very little recourse/leverage/knowledge to fight the outcome. I will grant you that in some specialties and smaller private practices what you describing is probably true.
- swatcoder 3y ago
  Of course doctors are often committed to the wellness of their patients, but I'd argue that the point of their extensive training is to help them align "best health outcomes while minimizing their own risks" with very specific institutional understandings of what that looks like. And that's what their pay is ultimately based on. They need to make the correct decisions, per the AMA/government/etc, about very expensive things and with minimal supervision. And it needs to authentically feel like it's for a good reason. But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
- waffle_ss 3y ago
  It's really an indictment of how far HN has fallen to Redditification* that you see this kind of low-brow ignorance so prevalently and so often. Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients. Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing"). I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path. * Yeah I know it's against site rules to say but I don't care it's true
  - swatcoder 3y ago
    I don't get the vitriol or where you assume I see doctors as "greedy" or determined to "screw over their patients". I assume you've read a lot of stuff here that gets under your skin, and that my post somehow reminds you of those. But you read a lot of things into it that I didn't write and wouldn't write. Doctors are brilliant individuals and often deeply invested in patient care. Many if not most of them pursued the career because they wanted to be healers. But as you beautifully describe, a lot of their actual job is now committed to navigating endless bureaucracy because they are the only people who have been institutionally blessed to do so. Given that many of them do care so much about patients on a personal level, and pursued the field for that reason, it's tragic that paperwork takes so much away from their opportunity to do so. My perspective even goes so far as to argue that their pay isn't a product of greed at all, but simply a necessary outcome of institutionally mediated medical goods, of which they've been tasked as front-line guardian, being grossly expensive. Reduce the cost of what they control access to, as we see in non-US health care markets, and their pay naturally reduces. In lieu of that, the US solution is to cleave out the responsibilities that don't require 8+ years of education and residency to get right and allow them to be dispensed by others. There's no indictment of doctors here, friend. None at all. It's all just mechanisms in a system much much bigger than them, and these mechanisms (as you describe!) frustrate them at least as much as anyone else.
andrewmutz 3y ago
This is not at all true. There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines). But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat". Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.

AussieWog93 3y ago

[flagged]

swatcoder 3y ago
Sorry, would it help if I rewrote that as "Doctors decide if you get a $10,000 MRI and a $42,000 course of medicine, that their education and pay is based on being trusted to make these decisions according to AMA and government guidelines, and that this is a dramatically different job than checking out Timmy's swollen ankle and Jamie's sore throat. So nurses and pharmacists are being enabled to do more of the ankle and throat stuff that doctors are too expensive to provide" Because it's the same thing in different words, and pretty grounded in the reality we all see.

anoxor 3y ago

[flagged]

sf_rob 3y ago

From my experience as both a patient and a spouse to a general practitioner the opposite is generally true. Doctors are grossly unaware of both costs to patients and insurance eligibility of procedures. They push for the solution that they believe will resolve the issue with the best health outcomes while minimizing their own risks of lawsuits without considering other factors. Next, a faceless bureaucracy on both the medical and medical insurance side of things (few of whom are medical doctors) will slowly spin into motion to maximize profit and minimize costs, all while you have very little recourse/leverage/knowledge to fight the outcome. I will grant you that in some specialties and smaller private practices what you describing is probably true.

swatcoder 3y ago
Of course doctors are often committed to the wellness of their patients, but I'd argue that the point of their extensive training is to help them align "best health outcomes while minimizing their own risks" with very specific institutional understandings of what that looks like. And that's what their pay is ultimately based on. They need to make the correct decisions, per the AMA/government/etc, about very expensive things and with minimal supervision. And it needs to authentically feel like it's for a good reason. But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
waffle_ss 3y ago
It's really an indictment of how far HN has fallen to Redditification* that you see this kind of low-brow ignorance so prevalently and so often. Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients. Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing"). I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path. * Yeah I know it's against site rules to say but I don't care it's true
- swatcoder 3y ago
  I don't get the vitriol or where you assume I see doctors as "greedy" or determined to "screw over their patients". I assume you've read a lot of stuff here that gets under your skin, and that my post somehow reminds you of those. But you read a lot of things into it that I didn't write and wouldn't write. Doctors are brilliant individuals and often deeply invested in patient care. Many if not most of them pursued the career because they wanted to be healers. But as you beautifully describe, a lot of their actual job is now committed to navigating endless bureaucracy because they are the only people who have been institutionally blessed to do so. Given that many of them do care so much about patients on a personal level, and pursued the field for that reason, it's tragic that paperwork takes so much away from their opportunity to do so. My perspective even goes so far as to argue that their pay isn't a product of greed at all, but simply a necessary outcome of institutionally mediated medical goods, of which they've been tasked as front-line guardian, being grossly expensive. Reduce the cost of what they control access to, as we see in non-US health care markets, and their pay naturally reduces. In lieu of that, the US solution is to cleave out the responsibilities that don't require 8+ years of education and residency to get right and allow them to be dispensed by others. There's no indictment of doctors here, friend. None at all. It's all just mechanisms in a system much much bigger than them, and these mechanisms (as you describe!) frustrate them at least as much as anyone else.

andrewmutz 3y ago

This is not at all true. There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines). But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat". Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.