Doctors Are Creating Too Many Patients

Hugh Pickens writes "H. Gilbert Welch writes in the LA Times that the threshold for diagnosis has fallen too low, with physicians making diagnoses in individuals who wouldn't have been considered sick in the past, raising healthcare costs for everyone. Part of the explanation is technological: diagnostic tests able to detect biochemical and anatomic abnormalities that were undetectable in the past. 'But part of the explanation is behavioral: We look harder for things to be wrong. We test more often, we are more likely to test people who have no symptoms, and we have changed the rules about what degree of abnormality constitutes disease (a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is).' Welch says the problem is that low thresholds have a way of leading to treatments that are worse than the disease. 'We are trained to focus on the few we might be able to help, even if it's only 1 out of 100 (the benefit of lowering cholesterol in those with normal cholesterol but elevated C-reactive protein) or 1 out of 1,000 (the benefit of breast and prostate cancer screening),' writes Welch. 'But it's time for everyone to start caring about what happens to the other 999.'"

Comments

Title

[turkeyfish]

Perhaps the title of the article should read lawyers and doctors create too many patients.

Re:Title

[h4rr4r]

Sounds great, for 18 years I went undiagnosed with a serious medical conditions. The impact to my health is now permanent, the perception many people have of my due to my ADD like symptoms in the past still has not changed 10 years later. 1 blood test found the problem. If I paid for it in cash it would have cost less than $200. Yet for 18 years I heard I was tired, or had too much stress, or was just depressed. No shit I was depressed, that was because of the medical problem. It fucking causes depression.

The minute we do what you are talking about my story will be very common. I would say 90% of doctors I have met could be better replaced with google and the ability for patients to order their own blood tests. They never follow up, they only order test as a last case and do nothing more than suggest the latest drug the pharma rep-whore just showed them. If that drug fails, they just try another. An expert-system on a PC would be better than them.

Symptomatic

[nuggz]

So we should wait till everyone is symptomatic?
Many conditions can be treated more effectively and cheaply if they're detected early.

Some conditions dont' even become symptomatic until significant damage is done.

The question really is how to balance the best treatment with the financial constraints.

Re:Symptomatic

[Dunbal]

And also to treat the patient and not a set of lab results. This happens all too often in my country.

For example my father in law, who has never been symptomatic, was being treated for gout because he had a uric acid score slightly greater than 7. Since I am also a physician I ordered a few tests to rule out other conditions that could result a slightly abnormal uric acid result, took him off the allopurinol and told him to eat all the red meat he wants. He is still not symptomatic, has no kidney trouble, and will be dead in 10 years from his prostate cancer anyway.

Why label him as a "gout" sufferer and even worse, treat him for it, if he doesn't actually manifest the disease? Doctors must remember that the way we determine what "normal" values are is by fitting large samples to a bell curve, chopping off the ends at 1 or 2 standard deviations, and calling the middle "normal". There are perfectly healthy people on either end of the curve, however. We need to use our clinical skills to figure out who needs treatment and who doesn't, otherwise you might as well not have doctors at all and leave medicine to some giant, complex algorithm.

Re:Symptomatic

[MoonBuggy]

Why label him as a "gout" sufferer and even worse, treat him for it, if he doesn't actually manifest the disease? Doctors must remember that the way we determine what "normal" values are is by fitting large samples to a bell curve, chopping off the ends at 1 or 2 standard deviations, and calling the middle "normal". There are perfectly healthy people on either end of the curve, however. We need to use our clinical skills to figure out who needs treatment and who doesn't, otherwise you might as well not have doctors at all and leave medicine to some giant, complex algorithm.

Using your discretion necessitates taking responsibility for the diagnosis. The eight people you saved from unnecessary and potentially damaging medication will be better off, as will the ninth who you gave a valid prescription to, but the family of tenth guy who died without being medicated might sue.

If you just followed the guidelines, you might end up unnecessarily medicating six of those ten, and one or more of them may still die, but if it goes to court you just need to compare the numbers on the patient records to those on the guidelines and that's that - you have proof that you "did the best you could".

The whole issue is based on the fear of litigation. That's been said before. The thing I haven't seen any analysis on, though, is whether that fear is founded. We all have some anecdote about an unjust lawsuit that we read about in the news, but I haven't seen any real figures on whether it's the actual risk of litigation that's prohibiting doctors from taking (necessary) risks, or whether it's the unfounded fear of litigation that almost certainly won't actually happen. An interesting Ph.D thesis for someone, perhaps...

Re:Symptomatic

[demonlapin]

the unfounded fear of litigation that almost certainly won't actually happen

Almost is a pretty important word there. Statistics apply to populations; for an individual doctor, either you are sued or you aren't - and if you are, all that the plaintiff's attorney and his expert have to do is convince the jury that the patient would have been better off without you. The fact that you have prevented minor (but not fatal!) harm to dozens of other people by avoiding carrying out tests that turned up normal, prescribing medications that probably weren't necessary, etc., doesn't matter.

Re:Symptomatic

[Dunbal]

A few points: First and lucky for me, I live and practice in a country with very little medical litigation - even for clear cases of medical malpractice (of the "oops we amputated the wrong leg" variety).

Secondly, that is what informed consent is all about. There is absolutely nothing unethical about giving the patient information and letting him make the decision. There's nothing wrong with saying "look, honestly your results are a little abnormal but since you aren't sick I think we should just observe you for a while, re-test you in a few months, and take it from there". Of course you're not going to do this if you suspect something serious, like a lurking cancer. This is where you want to be aggressive - IF the patient agrees (but you have to tell him why). But for the thousands of less serious conditions - why not be more relaxed? Exactly how many patients do you think actually comply with all those pills and strict dietary recommendations anyway? The medical literature says not too many.

Informed consent for some people is getting the patients to sign a form. For me it's taking the time to explain, in detail, what I suspect, why I suspect it, and what the consequences are with and without treatment. And really you can't win a law suit against that. But it should never be about the legal aspect anyway. "Defensive medicine" is not good medicine.

Re:Symptomatic

[Dunbal]

I remember reading somewhere that 85% of all illnesses cure themselves spontaneously. This is why snake oil salesmen, acupuncture, homeopathy, and whatever else you care to name has such a tremendous "success" rate. People swear by it. Why? Because it's true - it "works". 85% of the time, anyway.

We doctors are there for the other 15%, which will lead to loss of life or limb if left untreated. Now because I believe in freedom, I think you are perfectly free to decide for yourself which of the above categories your illness lies in: the 85 or the 15. However it will take you about 10,000 hours of study to be able to tell the difference with any degree of certainty. Or you could pay a doctor $50 or whatever it is he charges, and have an answer in 10 minutes. It's called "specialization", the key to any civilized society.

I used to think that medicine was just about learning lists. Lists of symptoms, and matching those with lists of diseases, and then picking medications from a list of medication to treat that disease. That's not how it works at all. The untutored person is incapable of making a correct diagnosis because 1) he doesn't know what to look for and 2) he has not seen enough sick people. Medicine is not learned from a textbook. It's learned at the patient's bedside. And I have seen thousands upon thousands of patients, from perfectly healthy people who think they are sick, to the dying, and even the dead being brought back to life. That's what lets me tell, usually within 10 seconds of someone walking into my office, exactly what is wrong with them. All my questions and all my tests are just there to confirm my diagnosis. The best an algorithm will be able to do is give you a list of possible causes. Then you would be stuck with floundering around ordering tests to pick something from that list. That may be how it works in TV shows, but that's not how it works in real life. Those tests cost money and time, and sometimes the patient has neither.

Re:Symptomatic

[Kilrah_il]

Of course not, first line treatment for Diabetes is lifestyle changes: Proper diet, weight-loss and regular exercise. Only after failure of these measures do you recommend drug treatment (usually oral drugs, and only later Insulin and other drugs given by injection). The benefit of classifying the patient as having Diabetes, is that there is a better chance of her conforming to the lifestyle recommendations.
If you tell some one that he may have a disease, he will not necessarily listen to your recommendations. However, if you tell him that he has Diabetes and that if he doesn't lose weight he will have to start taking drugs or risk a heart attack, there is a greater chance that he will do something about his weight and diet. Just look at all the people who stopped smoking after having their first heart attack. Nothing like a nice slap in the face (metaphorically speaking) to make someone wake up and smell the coffee.

Doctors Are Creating Too Many Patients

[tverbeek]

You'd expect doctors to know how to use contraceptives to prevent this.

WOOOOOOOOSH

[RedK]

That's the sound the point of this story made when it flew past your head. Maybe you missed the part about "diagnosing people with no symptoms".

Anyway, we're all sorry for you and we'll all cry ourselves tonight hugging our loved ones thanks to your heartfelt tale, but it has nothing to do with what is being discussed here. Maybe you should submit this to your doctors : Reading Comprehension fail might be another symptom.

Re:WOOOOOOOOSH

[WorBlux]

Empathy is irrelevant here. The article is about new techniques being abused to get people to pursue treatment where it is not needed or where it may even be harmful, not that new techniques should not be used, or that new techniques are perfect. Pointing out that someone is offtopic or missing the point is not and excercise of cruelty. No matter when in this post this person with the chinese mystery illness was he would have been considered sick. This is not the case with the original topic And original topic which was not misdiagnoses, but a specific type of misdiagnoses. Diagnosing something as a problem when it is not actually a problem.

Cut of the PC crap where you can't do anything that might offend anyone who is less privileged or worse off than you are. You are doing sick people everywhere a disservice by acting as if they are so fragile that they can't handle some public criticism . While doctors individually are generally well-meaning that doesn't mean there aren't systematic factor about the health care industry that lead lead to something other than wellness. A treatment may or may not be given, and the patient may or may not require it. For instance a doctor afraid of malpractice may diagnose where there is actually not a problem, because it's much harder for spot an error where treatment was given but not necessary than to spot the error where treatment was necessary but not given. Also if people go to the doctor and don't get anything other than a clean bill of health they feel a bit jipped. You go to a doctor when you are wanting treatment, and doctors though well-meaning by humouring this may doing more damage with the treatment than a minor abnormality could.

Yes, the whoosh post was flippant and a bit of a better-than-though game. However moralising is almost always the same sort of one-one-upmanship. "Look at how caring I am, you uncaring fool." You're message would be better received if you just let the facts frame the main point instead of the judgement.

Testing is addictive

[penguinchris]

You know, when it comes to testing... you have to do more and more to reach that payoff...

Diabetes? Bad example

[MisterBuggie]

Diabetes is something you're never cured from. No matter what such and such a diet might say, it may greatly improve things, but the diabetes is still there. Fasting blood sugar over 126 is a sign that something is up. Starting lifestyle changes and/or beginning treatment early on helps slow down the progression, and avoids later complications. In this case it actually reduces the number of patients with severe complications... It's not a case of declaring people diabetic who aren't really. It's a case of getting it under control before it progresses too much. Because if you hit 130, without at least diet changes, the diabetes is most definitely going to get worse.

This is just stupid

[rsilvergun]

Study after study shows people with access to more health care live longer. I'll point out John McCain and Earvin "Magic" Johnson as too people that'd be dead w/o the extensive and highly personalized healthcare they receive. This sounds like another conservative shill trying to convince the poor they don't need to see doctors like their rich people do, but than again the author could be another one of those Homeopath loons/Charlestons...

Re:This is just stupid

[Christoph]

I agree.

My late brother's doctor told him his swollen lymph nodes were nothing -- he had no symptoms, and a routine white count showed no infection.

That's how lymphoma presents. The next year he was in the ER due to wheezing, and was diagnosed with stage 3 Hodgkin's lymphoma, which eventually killed him (photos of his last years). He had a bone marrow and stem cell transplant...not looking for lymphoma in someone asymptomatic turned out to be pretty expensive as well as fatal for the patient.

This story is not rare, either. After speaking to a handful of other Hodgkin's patients, they all had similar experiences. And those were the survivors.

Re:This is just stupid

[metacell]

Study after study shows people with access to more health care live longer.

The key word being "access".

"Access" means you can get health care if you need it. It doesn't mean you get healthier the more health care you receive. If you try to treat more and more of a patient's symptoms, no matter how insignificant they are, you'll eventually reach a point where the side effects are worse than the symptoms you're trying to cure.

Kind of agree...

[Anonymous Coward]

As I understand the current situation:

1) If they don't do the tests and catch a problem, the doctor and hospital will be sued.

1a) The results of a trial may put licenses at risk, depending upon the State Board's agressiveness.

2) If they due the tests either tax subsidized insurance or a Medicare type program will pay for the tests and treatment.

Conclusion: How could the situation any different.......

Re:Kind of agree...

[0100010001010011]

My girlfriend, a doctor, agrees. I just texted her the article and her response:

"We make more patients bc we practice defensive medicine. No one wants to be sued".

Re:Kind of agree...

[hedwards]

This.

It's more common in some areas of medicine than in others. But I know that in psychiatry if they don't make a diagnosis then the insurance company definitely won't pay. Whereas if they do suddenly the patient gets crap treatment and most of their medical complaints blamed on mental illness.

What's worse is that the area of psychiatry is hardly one where diagnoses are clearly separable from other options, and doctors usually get the difference between insomnia and depression wrong leading to patients being prescribed antidepressants when bed rest would do more good. Antidepressants usually interfere with sleep leading to often times even worse sleep.

Re:Kind of agree...

[nomadic]

No offense to your girlfriend, but do you really think she's going to say "oh, yeah, we definitely are to blame"?

The Medical Malpractice Myth.:

What do we know?

First, we know from the California study, as confirmed by more recent, better publicized studies, that the real problem is too much medical malpractice, not too much litigation. Most people do not sue, which means that victims—not doctors, hospitals, or liability insurance companies—bear the lion’s share of the costs of medical malpractice.

Second, because of those same studies, we know that the real costs of medical malpractice have little to do with litigation. The real costs of medical malpractice are the lost lives, extra medical expenses, time out of work, and pain and suffering of tens of thousands of people every year, the vast majority of whom do not sue. There is lots of talk about the heavy burden that “defensive medicine” imposes on health costs, but the research shows this is not true.

Third, we know that medical malpractice insurance premiums are cyclical, and that it is not frivolous litigation or runaway juries that drive that cycle. The sharp spikes in malpractice premiums in the 1970s, the 1980s, and the early 2000s are the result of financial trends and competitive behavior in the insurance industry, not sudden changes in the litigation environment.

Fourth, we know that “undeserving” people sometimes bring medical malpractice claims because they do not know that the claims lack merit and because they cannot find out what happened to them (or their loved ones) without making a claim. Most undeserving claims disappear before trial; most trials end in a verdict for the doctor; doctors almost never pay claims out of their own pockets; and hospitals and insurance companies refuse to pay claims unless there is good evidence of malpractice. If a hospital or insurance company does settle a questionable claim to avoid a huge risk, there is a very large discount. This means that big payments to undeserving claimants are the very rare exception, not the rule.

Finally, we know that there is one sure thing—and only one thing—that the proposed remedies can be counted on to do. They can be counted on to distract attention long enough for the inevitable turn in the insurance cycle to take the edge off the doctors’ pain. That way, people can keep ignoring the real, public health problem. Injured patients and their lawyers are the messengers here, not the cause of the medical malpractice problem.

Re:Kind of agree...

[JamesP]

A good job of a lawyer trying to put the blame somewhere else...

The fear of litigation alone is sufficient to make doctors order all kinds of tests

Of course doctors are to blame, they put themselves on the "all knowing" spot.

One way out would be to limit the (financial) responsibility of a doctor in case of malpractice.

Re:Kind of agree...

[h4rr4r]

Then there would be even more malpractice. Tons of that already. How about this simple in between step, one used in many fields, if your solution does not fix the problem you do not get paid.

If I take my car to the mechanic and he can't fix it, I don't pay him. If I buy a ladder to paint the roof and it does not work or breaks the first time I get my money back. Doctors are about the only field who expect to be paid even when they are totally useless. Then they have the gall to tell me I need a yearly checkup.

Re:Kind of agree...

[jedidiah]

You are ranting and raving as if a multi-million dollar judgement is not infact proof that a doctor has made a dire mistake. You are really whining about doctors being held responsible for their mistakes. This is not a remarkable thing for any sort of professional or any proper adult really. Doctors need to be held accountable for their screwups and in some cases just plain greed and disregard. The same goes for incompetent nurses.

If there are too many malpractice suits, then it's time to consider cleaning up the profession in question.

Ignoring the problem will just ensure that quality of care degrades the the medical versions of Crassus never gets his due.

Re:Kind of agree...

[cetialphav]

The reason you get this kind of treatment from the Vet is because you are shelling money out of your own wallet for the cat. You have the option of doing nothing and letting nature take its course. Doctors who are doing voluntary procedures (e.g. Lasik, breast enhancement, etc) will give you the same treatment. When I got Lasik, my doctor gave me a fixed price that covered everything and it was all well explained.

The problem with the current medical system is that the money flows through intermediaries and not directly from the patient to the doctor. There are doctors who are trying to change this (http://thestory.org/archive/the_story_209_Cash_Doctor.mp3/view), but they are the minority. Insurance should really protect against big financial burdens, not for the treatment of a cold. By having all the money flow through insurance companies, we just add inefficiencies into the system.

Re:There's still a lot to do in medicine

[Moryath]

You were demonstrably sick.

Here's what generally happens in the US of ADD. Someone comes in to the doctor's office overtired. They have a cold because they overworked themselves and shot their immune system to hell through fatigue.

The doctor then proceeds to order up bloodwork, EKG, MRI... a thousand useless tests. Even worse is the "full body scan" crap advertised on Right Wing Wacko Radio lately. Spend thousands of dollars getting scanned, followed by thousands of dollars fixing the 3-4 "abnormalities" it finds in every human that are of no danger to your life whatsoever.

Y'know what would have worked equally well? Send them home with a doctor's note, have them get some fucking rest, and while we are at it, reinstitute actual worker protections so that they weren't burning the candle at 5 ends at their job taking home 50+ hours of work home each week on top of the 60 they already spend in the office including "working through lunch" out of fear that thanks to the the Retardicans fucking up the economy they're going to get downsized or replaced or their job sent to India.

Prescription Correlates + to # of Prescribers

[retroworks]

This is very worrisome, glad to see it being discussed. According to the USA Bureau of Labor Statistics, health care employment accounts for (by far) most of the growth in jobs in the USA http://www.bls.gov/oco/cg/cgs035.htm. What happens when a new sport surgeon opens an office in your county? What happens when a urologist opens an office in a town of 10,000 residents? The free market says that when people take employment providing a "service" which they themselves are empowered to prescribe, that prescription rates increase proportionately to the wages.

I realized this when I broke my arm in almost precisely the same place, in almost exactly the same way. The first time it was a reset, an X-ray, and a cast. The second time, a new Osteopath building had been opened in town, with two new very smart and very nice doctors. Good people. Outcome was surgery, metal plates, screws, therapy, etc. My insurance paid for both treatments, but I got to see the bills. The second broken arm was over $10,000 more expensive than the first time. And when I read about the dangers of putting people under anesthesia, I really wonder how the risk was weighed against the benefit of making payments on the new doctor's office. I'm not grossly cynical about the health industry, but whenever a field of the economy becomes too respected (think Catholic Church), people begin to assume the best, and that's a recipe for problems.

By the way, there is a new Urologist in my town of 10,000, with a lovely office. He just told my wife that both our sons need teen circumcision, under anethesia. What is really worrisome is that the USA's aging population makes for an almost infinite number of diagnostic tests, etc., for these people to fill. If the government paid for car repairs, we'd have lots of mechanics and lots of repairs.

Re:Prescription Correlates + to # of Prescribers

[Anonymous Cowar]

If the government paid for car repairs, we'd have lots of mechanics and lots of repairs.

That's a really long way to go for a car analogy.

Re:Prescription Correlates + to # of Prescribers

[DrgnDancer]

The second broken arm was $10,000 more than the first, but the first "treatment" resulted in your arm breaking in exactly the same way a second time. Don't get me wrong, there are a ton of factors involved in the location and severity of a bone break, and it may well have been inevitable that your arm would break the same way when you injured yourself in a similar manner; *but* it's also arguable that the less elaborate and complete first treatment resulted in the bone healing weaker and more likely to rebreak.

Regardless of whether the first break contributed to the second, it's also not inconsiderable that getting such a similar injury in nearly the same place caused the doctors to have to take much more care in the second treatment. Having two healed breaks, practically on top of each other, is almost certain to weaken the bone; the addition of some titanium plated for support of such a weakened bone might have been prudent caution.

You also mention therapy, which is certainly a not inconsiderable expense but can significantly increase the pace of recovery. It may not make you any stronger or healthier in the end, but the "end" might be 8 weeks instead of 12.

I'm not a doctor of course, and I don't know the details of your case, but in my mind your having had two such similar breaks is an excellent argument for the second being more expensive. Now the urologist thing does seem a bit suspect, but again, it's hard to say. Is your son experiencing some sort of symptoms that such an operation might alleviate?

Re:Prescription Correlates + to # of Prescribers

[tkprit]

I've seen the phenomenon when a local specialist merely upgrades his office with new diagnostic testing equipment. Suddenly everyone needs a bone scan, or a 'routine' endoscopy, &c silly ass tests that have nothing to do with why the hell you went in to the specialist. (Of course the specialist says it's a "service" for his/her patients, so we don't have to drive 20 mts away to have a 'beneficial' test done. But I bet you the specialists recommend the testing a lot more after they install the new equipment in their offices.)

Actually, I've seen the same phenomenon in veterinarians offices as well. "We do routine BONE SCANS on our PATIENTS" [to catch and prevent the possible spread of cancer, arthritis, or I suppose make sure they're getting enough CALCIUM SUPPLEMENT].

(Yes, I got SUCKERED into getting my middle-aged chihuahua a freaking bone scan because he had a funny bump that I expressed concern about. I thought it was an x-ray until I saw the bill. They recommended I get pet health insurance. The funny bump turned out to be a benign growth; ie, a funny bump.)

I stay the hell away from doctors, vets, dentists, and car mechanics as much as possible. And I try to select the ones with the LEAST in-office equipment possible.

Re:Prescription Correlates + to # of Prescribers

[MoonBuggy]

This is why the public/private hybrid system in the US confuses me. Public systems are prone to bloat and wastefulness because there's an essentially unlimited budget, and because there's no real competition or risk of failure. Private systems tend to be (but are by no means always) more efficient because of the market pressure, but are also much more willing to screw over or ignore patients because their goal is profit, not good service.

Most people won't accept leaving poor people to die in the streets, so the government steps in. Suddenly the private system has many of the factors that lead to inefficiency in the public system, and they still need to syphon money off the top to make a profit. I honestly fail to see how that would ever be expected to work out for the best.

Re:Prescription Correlates + to # of Prescribers

[retroworks]

All good points, DrgnDancer. It may well be that the second broken arm procedure was necessarily more expensive, it may well be that I have two sons requiring teen circumcision. It is also a valid point that in a litigious society that doctors have a very good reason (or excuse) to err on the side of more diagnostic tests and more expensive procedures. I'm unhappy with the complications and skeptical of the justification for the surgery, but it's just a single anecdote.

I found this 2009 NPR story on how a spike in the number of hysterectomies performed in Lewiston, Maine, led to a search for environmental causes http://www.npr.org/templates/story/story.php?storyId=113571111. After looking at a number of potential toxins or environmental factors, the number of hysterectomies required suddenly fell dramatically. Then the spike resurfaced in another community. The correlation? The doctor prescribing the hysterectomies had moved his practice to the second location.

The moral of the story is not that "doctors are bad" or "lawyers are bad", but that human behaviors tend to be influenced by economics, and that no field should be considered immune from self-interest.

Re:Prescription Correlates + to # of Prescribers

[DrgnDancer]

Indeed, I was not trying to say that "Doctors are always right" either. Like anything else, you have to evaluate the facts and make a decision. Those facts include the expert opinion of your doctors; but like everyone else they are human and they err. In my mind the treatment on your arm is a bad example. There are a number of factors that could have led to a very similar seeming injury requiring very different treatment, or for a specialist to recommend a more elaborate treatment than a generalist (that is, after all, part of the reason we go to specialists). I actually missed the plural on "sons" in your post on my first read through, the Urologist's opinion seems even more suspect now than it did. Of course one fairly nice option that our system does allow for is second opinions... in this case I'd certainly seek one.

Absolutely

[sunilhari]

Doctors have a much lower threshold for diagnosis of "sick people" because if they miss anything, they can get sued for malpractice (founded lawsuit or not). Even if the lawsuit is completely without merit, most lawyers will settle instead of clearing the doctor with a full trial due to cost. So when the threat of lawsuit is over a doc's head, good medicine goes out the window and lawsuit-preventing medicine goes into full effect.

I realize not every doctor is actually good, and that they can make egregious errors and need to be corrected. Enact tort reform, cap damages, and actually encourage preventative medicine instead of paying lip service to it and you'll get lower costs and better yield for the non-sick 999.

I don't expect a doctor to start caring about the other 999 until that 1 possibly sick person can't sue him and take everything he owns.

Lawyers

[Anonymous Coward]

In a court of law the question to be asked "Was there a test to determine the problem with my client's husband that would have saved his life if you had done it?" That single question is the reason for all of this, because if the answer is "yes", which is always is even if there were no legitimate reason to run said test, then the doctor is guilty of malpractice. He does that three times, he is no longer a doctor.

Stop blaming the people trying to help you, who have to protect themselves from the lawyers. Blame the root cause.

So where's the evidence?

[EdwinFreed]

TFA makes a lot of assertions about unnecessary treatment and increased costs with no associated benefits, but doesn't present or link to a single piece of actual peer-reviewed data. In the specific case of changing the cutoff of blood glucose levels from 140 to 130, the appropriate question to ask is whether or not treating the many side effects of diabetes sooner saves more than it costs.

The reason is financial

[Chemisor]

The reason is neither technological nor behavioural. It is purely financial. Pharmaceutical companies and hospitals need to make money. To make money they must offer drugs and services, the more expensive, the better. Since people really are healthy most of the time, they can avoid paying for health care at all, which naturally is unacceptable. Hence doctors try very hard to create more sick people to create more income. Whether it is by selling hypertension drugs to people with 140/90 (which was considered perfectly normal 50 years ago), cholesterol drugs to everybody, unnecessary vascular stents (which, according to studies, temporarily relieve pain but have no effect on longevity), unnecessary screenings, unnecessary surgery, unnecessary psychoactive drugs, and heck, heaps of drugs of all kinds. The average american is from birth convinced that he is sick all the time and that without health care he will die. What better incentive to buy medical services?

Mental health too; perhaps even moree.

[ron_ivi]

Seems every personality trait (inability to pay attention to boring teachers; enjoying math more than people; shyness; risk-taking extroverts; etc) are being labeled with some mental condition that shrinks like to charge a lot for.

Re:Not news for news. Doesn't matter.

[hawguy]

This is not news for nerds. This is aging population concerned with health problems magazine selling bullshit.

Closest thing to nerdiness is the fraction 1 out of 100, which is also bullshit.

Slashdot's early adopters (and its editors) are starting to move into that aging population demographic...

From a doctor

[deuist]

I'm an ER doctor. I can't create patients as they come to me with symptoms. I will say that people come to me with minimal symptoms such as cough and fever and then demand blood work, X-rays, and antibiotics, even though the majority of the time their symptoms are caused by a virus and will get better all on their own. Somehow, our society has become so weak that every cough, scraped knee, or hangnail requires a visit to the hospital. And somehow we think that physicians can't diagnose anything without a thousand dollars worth of painful tests. Whenever I try to explain to someone, "You have a cold. You're going to be fine," that's not a good enough explanation. I've even had a few people demanding admission to the hospital---which, if you didn't have a life-threatening disease before, you can certainly pick one up during a hospital stay. This problem is societal in nature and has been made worse with television shows such as House and ER where lay think that every problem requires specialists and lots and lots of tests. Don't blame me; I'm just a cog in the wheel.

Re:From a doctor

[guanxi]

Here's a perspective from the other side of the relationship: If you want an honest, intelligent assessment from a doctor, good luck. Most doctors I interact with treat everyone like ignorant hypochondriacs, insist I waste my time on pointless visits, and don't seem to understand basic risk management.

A good decision should be based on the cost/benefit analyses of the distributions of outcomes. If I ignore this symptom, what is the distribution of outcomes? Is there a 50% chance of serious harm? 5%? 0.05%? I'm not asking for scientific precision; even an order of magnitude would be nice but most doctors won't answer that question at all and just keep asking me what I want them to do, insisting I make a decision based on no expertise or information. It's an absurd situation I've come to expect.

Also, no matter how I present it, most treat patients like hypochondriacs. Again, I just want a rational assessment. Finally, one doctor told me, 'if a patient brings me something, they must be scared about it so I'm going to treat it'. No you idiot! I'm starting to suspect that the medical community has a contemptuous view of its customers.

Finally, I can now email a quick question to everyone in the universe -- my lawyer, my accountant, my technical support, probably even my God -- except one class of people who haven't yet mastered integrating the telephone into their business process, much less email. For those special people, I have to set aside hours of time (and more, because they are incapable of being punctual like every other professional) for even the simplest question. Nobody else treats their customers so disrespectfully. /end of rant

That might be in the US....

[Windwraith]

Because where I live, I suffered from a crippling disease for 5 years that almost ended up fatally, and going week after week after week to the medic, treated like a liar or an attention whore, coming back home every day without results.
Until, finally, after years of calamity, they found what it was. About f*cking time if you ask me, it ended up being a serious intestinal disease combined with a esophagus and a circulatory thing and lots of inconvenient little things.

Please take note of the time. 5 years of my life lost without being able to go out of home and unable to work, socialize or well, just about anything that wasn't being yellowish in color.
Because of medics, who could have detected this much earlier, I lost the best years of my life, the ones between young adulthood and proper adulthood. I am like a hermit who just came out of a cave. All because medics didn't want to do a bit of work and do science stuff.

Here, where free healthcare exists, medics are only concerned about getting their taxpayer-founded salary every month, and don't give a crap if the patient dies or not.
After seeing medic after medic and having to hear "it must be psychosomatic" for years, I have very little respect for the medical guys.

A medic like the ones described in the article would have saved me 5 years of my life. That's not something trivial.

Re:That might be in the US....

[Windwraith]

I want my time back, yeah, but I don't really want anyone else to have to live through that in exchange, if that's what you mean. It was painful, it was discouraging, and it was unfair.

What I would ask for, instead, is for at least a little support. I have been healthy for only 4 weeks now, and I don't even know what to do with my life. 5 years of being called liar makes funny things to your head.

Re:Well

[blackpaw]

No its for the percentage who get painful damaging life altering treatment for the false positives that prostrate screening generates. Or the women get cancer from excessive breats scans that have minimal increases in detection rates.

Or the immense amount of resources it consumes for diminishing returns, when said resources could be way more effectively applied elsewhere, saving more peoples lives.

My wife is a doctor...

[Richard_at_work]

in the UK for the NHS, and her position on this has always been that patients want you to diagnose them with something, and if you do not then they will re-present either to another doctor at your practice very quickly, or at the local accident and emergency room. And last month she was provided with the best example of this ever...

Ever since I met her, she has complained to me (in a friendly way) that people present to the A&E (she was working A&E minors at the time) with conditions that 30 years ago would have been treated at home, but because the home remedy and care experience isn't being passed down these days, current generations of parents do not know how to care for minor conditions any more and are quick to panic.

One example of this is D&V (diarrhea and vomiting - generally any tummy bug that causes you to crap loads and throw up loads) - patients, or the parents of young patients, will regularly show up to A&E with D&V and expect the doctors to do something. If they were to be admitted, it would remove a bed from use for other more serious reasons, and the only thing they would get would be intravenous saline, and thats not even guaranteed. Seriously, would you rather be crapping and throwing up at home in privacy, or in a hospital in public? Do it at home folks.

Anyhow, on with the example - in this case, she was working as a GP at a practice and a mother presented her 3 year old child with D&V, my wife kindly explained that everything was fine, the kid was not in undue distress, they don't tend to worry that the kids not eating or drinking for at least 5 days, and it was just a case of waiting it out. After a lengthy consultation, the mother and child left.

Four hours later, my wife switched to do a locum shift at the local A&E department - and who was her second patient...? The mother and child. The child hadn't presented any more serious symptoms and had not declined in condition, the mother just wanted someone to do something. So my wife, who had suffered the embarresment of calling the patient in and realising why they were here (the parents faces went bright red when they realised who the doctor was that was calling them apparently), had the job of telling them exactly the same thing again.

To put their minds at ease, she called her senior in who explained the same thing. And then just to top it off, had a paediatrics doctor come down to again reassure them that the only things they could do was to allow the D&V to run its course. After a six hour period in A&E, the parents and child left with no treatment, no medication and essentially nothing gained.

And then my wife finds out, a day later, that the parents had driven the twenty miles to the next major hospitals A&E department and done the same thing there - to be told the same thing and sent home in exactly the same manner.

No names and no identifiable information because I don't know any - my wife is very good at venting but retaining the pertinent private details so even I can't identify the patients.

Long story short, the patients are more of an issue these days than the medical carers - patients thing the doctor is there to treat them and damn them if they don't.

Plus, of course, its easier to overtreat for a minor condition than it is to defend the non-treatment in court for the one case in a million that goes from "minor, non-worrying condition" to "death or loss of limb". One of the things my wife is frightened about is the one in a million case where a reoccuring headache is actually the brain tumour that everyone suspects - but she cannot refer all thirty patients a week who come in with that complaint to the specialist simply because the money isn't there.

Re:My wife is a doctor...

[stewbacca]

Clearly some people go to the ... ER even when there's clearly no need to...

Yeah, we call them the "uninsured". Give me a public option so we can have our emergency rooms back for, you know, emergencies.

Re:My wife is a doctor...

[mesterha]

nothing is going to stop doctors from providing it and profiting on it.

You can stop the doctor from profiting on it by giving them a fixed salary and removing their ability to be financially vested in the testing companies. Kind of like how it is done in England (the location of the anecdote) and almost all of the first world.

Really?

[MaWeiTao]

I find it rather interesting that this claim is being made when I've found it to be quite the opposite to my experiences overseas, especially in Asia.

In the US, someone gets the cold or even the flu and they just deal it. There's a massive selection of over-the-counter drugs to help deal with so many basic illnesses.

In Taiwan, as an example, feel a bit off and people start insisting you visit the doctor. And why wouldn't they when, thanks to their social healthcare system, it only costs a few dollars for a visit? So people go in constantly for things like simply colds and then get prescribed a ton of medication that aggressively deals with all the symptoms. Of course, the flip side is that their equivalent to our pharmacies are lacking in any real medication.

So doctors end up being overburdened and are underpaid when practicing for the state. Visit those clinics and the routine consists of describing your symptoms, the doctor makes a few assumptions about what you've got and prescribes something for it. I've had visits where they don't even bother measuring heart rate. The expectation is that if you've got something serious it will be apparent when your condition doesn't improve or even worsens. Many doctors open private practices where they can charge whatever they want. It's more expensive but for people willing to spend the money they can get the care they want right from the start.

And it isn't something unique to Taiwan, I've observed similar things in Japan and some parts of Europe. Who the hell isn't going to take advantage of something if it's cheap? In my experience the US is the opposite. Unless you're well-off or have a low co-pay you're going to put a visit off until you really need it.

On the other hand, I have found American doctors to be excessively cautious. But then, I've always attributed that to a fear of lawsuits. They don't want to risk overlooking something that a patient will then come back and blame them for. As always, this is a complicated issue which isn't being properly addressed.

at the root are regular people

[fermion]

Doctors are just technicians who work on people. They get paid a lot because they work on people and the risks are higher than say if they worked on cars or computers. However the ordinary person seems to think doctors are geniuses that can keep a perfectly healthy and that a perfectly healthy person actually is possible. Doctors are screwed because if they tell the truth they can't charge enough to pay off medical school loans.

Likewise, people have been convinced that expensive drugs are the cure all for everything. This leads to, for example, in the US the creation of medicare part D whose purpose is support the drug companies ability to charge higher than market values for drugs. The drug companies has the help of people like this who laugh at the medicine that has kept the human race healthy for thousands of years, and doesn't seem to understand that difference between marginal statistical efficacy and safety. We may choose to take a drug because it is necessary for our own health or the health of the community, but that in no way means the drug is safe, or the community should not ask for drugs with fewer potential side effects. At the root of this is the idea the inductive reasoning will conclusion that then become necessary conditions of life, rather than things that are probably good for you. This fallacy is promoted because it is useful, and most regular people don't know it is a fallacy.

If we have too many patients, the doctor is only partly to blame. We have an epidemic of cleanliness, kids using hand sanitizer and not getting sick to build up resistance to common bugs. We have people who never eat a real meal of fresh food, rather everything on thier paper plate is processed or synthetic. No one has a Aloe plant around. People are prescribed expensive drugs when, if the laws were tilted to the pharmcos, they could grow what the needed in a pot.

Which is not to say the many people are not genuinely out of kilter. I think the diabetes example might be silly because as we know more, we reset thresholds. Complaining about a new threshold is saying that inductive logic is infallible. In fact, all thresholds are guesses and needs to be reset with new data. In general saying people who were sick in that past are sick now is equally silly. Just because ALS was not written about until the late 19th century and was not widely known in the US until well into the 20th century means we should call these people sick and try to help them? To me this thing is not that doctors have too many patients, but that people do not seem to have a choice to become a patient or not. If you do not subject yourself to the leeches of modern medicine, you somehow are not a respectable person.

What about ADD and other ABC soup?

[metalmaster]

Im in my 20's so i guess it started with my generation, but it seems like anyone I went to school with who wasnt interested in the subject matter or had too much pent up energy was put on Ritlin or one of its many alternatives. Instead of letting those kids expend their energy by running around it was just easier to cram a pill down their throat 3 times a day.

'Do no harm'

[Duncan J Murray]

It might not be common knowledge that blood test 'normal ranges' (i.e. the range in which the quantity measured is said to be normal) were determined by taking thousands of healthy volunteers and performing the test - but creating the range based on the middle 95% of normal values. Therefore, even before we started testing people, we deemed 1 in 20 healthy people to be 'abnormal'.

Counting on my fingers, we do a minimum of 22 blood tests on patients admitted to our hospital. Statistically, even if you are well (though that is unlikely given you presented to the hospital, and were assessed and deemed unwell enough to be admitted) at least 1 of these blood results should be abnormal. And I haven't even started on your ECG, radiograph, blood pressure, pulse, oxygen saturations, respiratory rate, temperature etc etc etc. And if just one CT scan were performed, that looks at so many metrics, that several are bound to be abnormal to some degree (so called 'benign incidentalomas').

Part of being a good physician is knowing what abnormal results are significant, and what are red herrings. Ignoring a result is a difficult thing to do in medicine (the article has some good reasons why) and takes a good knowledge of the context, as well as plenty of experience, to be confidently able to say 'that is a red-herring'.

I disagree with the writer suggesting that thresholds should simply be raised. This is a stupid and dangerous way of dealing with this problem! The problem isn't how _far_ above threshold the value is, but whether it is or it isn't. Raising the threshold does not eliminate false-positive results, but will undoubtedly result in false-negative results. Tests in medicine are assessed to measure their 'positive predictive value' (see wikipedia), which, simply put, is about choosing a threshold that will find a balance between limiting false-positives, and limiting false-negatives. Instead of blanket raising of thresholds, doctors should be basing their decisions on the _evidence base_ - i.e. research done looking at how patients with these values fare with and without treatment. Only then will we know whether what we are doing is helpful or not.

The writer is writing in a public journal, and I think it is dangerous of him to suggest that some people don't really need treatment for diabetes - a condition that is hard enough to demonstrate to patients the dangerous long-term consequences. I wonder how many people reading this article have decided 'I don't really have diabetes - this person says so! And I thought I felt well, too!' and chucked their meds out the window. And yet, there is very strong research and evidence that shows that people diagnosed with diabetes (whatever their blood sugar) do much better if their blood pressure and glucose levels are kept below certain levels. And by 'doing much better' I mean, have less heart attacks, less strokes, go blind less, have less kidney failure, have less neuropathy and die less. All these things are real-world problems which damage peoples health. We are not just treating a number! (but we only know this from the evidence).

The other side to this argument is social. Here in the U.K. we are proud of having a largely non-private system. With all the cost and time pressures on the NHS, it means that we don't investigate or treat unless we feel it would benefit the patient. If an NHS doctor in the U.K. says you have a health problem, it's something you should probably listen up to, because he is not paid to do that. Of course some would argue that the flip-side is that patients may not get investigated or treated enough, which may be balanced somewhat by the law courts. I'm not saying it's good that doctors say 'well because this person has come in with a,b and c, and even though I don't think it is 'x', we can't justify in a law court not doing investigation 'y', but it does provide a counter balance.

Doctors should try to good, be very careful not to do harm, and base their decisions on rational arguments backed up by evidence.
(the article's suggestion of simply raising the thresholds is idiotic)

Re:'Do no harm'

[Overzeetop]

Part of being a good physician

And that's the rub. Physicians are smart folks, but there's still a whole range from valedictorian to barely passed the tests. George Carlin (I think) said, "Somewhere in the world is the world's worst doctor. And somebody has an appointment to see him tomorrow."

It's hard to come to grips with the fact that there are practitioners out there who really aren't that good. And there are a lot of them - 80% will not even be in the top fifth of their specialty (see what I did there?). I see it in nearly every field. I wish it weren't so, but it is. Sometimes it's easier to go through a checklist that see the whole picture. I think, on the whole, doctors are better than most professionals at that, but pressures can skew decisions either way.

Patients just make the problem worse - expecting a solution for every out-of-balance condition they feel. You've seen what we eat and the routine stress we subject ourselves to - it's amazing we're as well as we are. I feel lucky to be blessed with a physician who listens well, and allows me to be an active part of my diagnosis and treatment.

I am a doctor and I agree

[Invicta{HOG}]

He makes a lot of good points in his article. Obviously the length of the article limits how much detail he can go into and how much of data he can reference, but there is definitely a lot of tests and procedures which are likely causing more harm than good. He makes note of one good example (prostate cancer screening) that we know causes more harm than good in certain populations. In older men, detection of prostate cancer is far more common but the chances of symptoms from the prostate cancer is low. We actually know that in these men we cause more harm than good due to morbidity from biopsies and from unnecessary surgeries/procedures.

It is unfortunate that he mentions the lower cut-off for diabetes - even if he thinks that 130 is too low, we actually know that even people with fasting sugars of 100 are at increased risk for diabetes and, thus, for death. If the intervention is more intensive couseling of lifestyle changes, then there's not a lot of downside to increasing the diagnosis of diabetes and prediabetes.

But his central point still stands - if the US is going to tame its healthcare costs then it needs to look at overdiagnosis and its causes. In some cases, expert committees and professional societies (with their own biases) are to blame. In other cases, malpractice lawyers, the pharmaceutical industry, greedy doctors, and patients who cannot live with uncertainty are to blame. Luckily, there are entire journals devoted to this aspect of healthcare policy and it has not been ignored by mainstream medicine and those who wish to improve it.

Re:Sounds about right.

[HornWumpus]

You do realize that antivirals are basically useless and your wife's immune system is what cleared the virus?

Both the doctors gave you pills knowing they would do nothing but also knowing they had to do something to get you to leave.

Re:There's still a lot to do in medicine

[h4rr4r]

What happens when you legislate that the "guberment" will back loans of people who clearly will not pay them back (aka subprime loans)?
The housing market collapses.

That was not the driving factor, most sub-prime loans were not government backed. They were far to large to qualify for that.

What happens when you legislate that you cannot tap your own natural resources because of environmental concerns?
Someone else taps those resources and charges you outrageous prices. $4+ per gallon gas and rising.

Do you think US based oil companies would charge you less out of patriotism? Oil and gas prices are set by international markets for these products.

What happens when you fail to secure the borders?
You get an overwhelming flood of non-taxpaying welfare recipients who destroy your healthcare system, overload your criminal justice system, and undermine your educational system.

Most illegals are young men, between the ages of 18-35. They work here then go back home. They are not a burden but a resource of cheap labor. Also the USA-Mexico Border cannot be secured. It is too large and no fence is going to keep out anyone with a fence.

Either you are sadly misinformed or tragically stupid.

Re:There's still a lot to do in medicine

[emj]

What happens when you legislate that you cannot tap your own natural resources because of environmental concerns?

Do you think US based oil companies would charge you less out of patriotism?

Well the Venezuelan government does sell its oil cheaper at home, so clearly it can be done.

Re:There's still a lot to do in medicine

[stewbacca]

How would you like to work in an industry where you are told here is what you get paid by the government?

Doesn't seem to be a problem in England, Germany, Belgium, France, Norway, etc. etc. etc.

Capitalism is great an all, but some things (like the health of citizens) are more important than profit.

Re:There's still a lot to do in medicine

[TapeCutter]

Someone comes in to the doctor's office overtired...

Yep, that was the only symptom my brother-in-law had, they gave him a general check up and found a large tumour on his prostrate. Luckily they cut it all out but it was a couple of months not knowing whether it had spread or not. His older brother didn't bother going to the doctor and is now terminal with prostrate cancer that has spread thru his body.

What you describe sounds like a money making scam as opposed to preventive medicine. They don't advertise "full body scans" here in Oz, but the UHC system does advertise to get people to go for prostrate checks and other types of simple* screenings, they also send doctors to give free check ups at the workplace because early diagnosis is both cheaper for the health system and less painfull for the patient.

*simple - because a finger up the bum isn't what I would call a "high tech" test.

Early diagnosis can save money and lives

[justanothermathnerd]

If you can identify a population of patients who are very likely to progress to a diagnosis without intervention and if there are useful treatments for these patients that can prevent suffering and large medical costs down the road, then it clearly will be worthwhile to diagnose and treat the condition early, even before there are visible symptoms.

The example of criteria for diabetes diagnosis is a good one. Type 2 diabetes is a progressive condition that often starts to develop long before a patient has obvious symptoms or uncontrolled blood sugar. Patients diagnosed wih "pre-diabetes" can often avoid becoming full-blown type 2 diabetics.

The trick is to use diagnostic tests intelligently and balance the risks and benefits. Advocating "don't introduce new tests" without explictly evaluating the costs and benefits of the new tests would be a horrible mistake. On the other hand, letting the vendors push the introduction of new tests without thorough evaluation would be equally bad.

Re:Disconnect Between Patients and Payments

[osgeek]

You didn't at all understand what I said. High deductibles don't get you any kind of transparent pricing from a doctor. They don't get you any kind of leverage in the situation. That's all determined by private pricing between doctors and insurance companies. You are a minor percentage of your doctor's business and he has no need to cater to your needs because he's protected by insurance companies and the laws that they've helped write to force most people to go to their employers for the one size fits all plans that make insurance companies the most money.

I recently was researching getting a vasectomy. The doctors that I went to each had done thousands of them, yet their offices could NOT tell me what the procedure would cost. No clue. How was I supposed to make an informed decision to even fund my FSA without being able to get a price on a procedure that's routine? What, the doctor's office couldn't look at the last dozen bills they sent out and give me a range? You think the doctor and insurance company weren't excruciatingly aware of the costs and charges for the doctor's most commonly performed procedure? If you went in to a auto shop and they couldn't tell you what it cost to get your brake pads replaced, you'd turn around and walk back out.

I honestly don't think we'll get a level playing field between patients and insurance companies without legislation that forces doctors to treat walk-in patients with the same level of negotiating leverage and transparency as the insurance companies.

You even mentioned that most doctors won't even take your plan. That alone shows that you didn't get it. If a doctor doesn't even have to accept your high deductible personal health plan then something in the system is broken. There's institutional collusion between doctors and insurance companies that current health care legislation supports in every way. It needs to be torn down and replaced with something that allows transparency, accountability, choice, efficiency, and effectiveness for each citizen.

Re:It s simple they are in defensive medicine mode

[jedidiah]

I have witnessed multiple occurences of mis-prescribing penicillin to patients that are allergic to it. In some cases, this could have been FATAL if not for patient oversight. None of these situations led to a lawsuit. Although the perpetrators certainly needed to be disciplined in some way. Undoubtedly each of these people committed malpractice more than just the one time.

This is a pretty basic and simple sort of thing. It's not terribly complicated. It's not something like OB/GYN that's inherently problematic. It's dead simple and people are screwing it up on a regular basis.

We have a medical profession where ditch diggers need to buy a copy of the PDR to keep from getting killed by sloppy nurses and doctors that don't keep up.

Re:You mean

[jedidiah]

Some times, there is no suffering what so ever going on. You would not know by looking at a person that they are supposed to be sick. Yet they are prescribed medications which sometimes have a cascade of interacting side effects. So not only are you wasting money on the original non-condition but you waste money dealing with all the side. Quite often it makes much more sense to just take the "Dr. McCoy" approach of adjusting your own habits.

Isn't that an interesting view on medicine in the future: You can do more for yourself than I can just by taking care of yourself.

My doctor does e-mails

[Sycraft-fu]

Well not regular e-mails. By law they can't because of HIPAA and all that they can't use e-mail because it isn't encrypted. However they contract with a HIPAA approved messaging service you can sign up for. More or less you pay $15/year for a login to a HTTPS site that does messaging which satisfies the requirements. Via that I can e-mail my doctor and get a response. Now that doesn't mean everything gets solved through e-mail, but I can get simple questions answered.

Likewise my insurance offers a 24 hour nurse line. I can call any time and speak to a registered nurse and have questions answered. The questions they can answer are less than a doctor, of course, nurses are the "level 1 tech support" of medicine but they can be helpful for many things.

To me it seems like their support works a lot like the computer support I do professionally does: You can contact via e-mail or phone for simple questions, however if something more serious is wrong, I'm going to make you bring your computer down (and they make me bring myself i) so I can have a look at it personally and render a more informed diagnosis.

If your doctors don't do that, then perhaps it is time to shop for new doctors.