Not a diabetic and I live in one of the richest countries with a social medical system, but the medical industry is an abject failure. My experience with most Doctors who are not surgeons has mostly been that are overpaid for doing essentially nothing and think all their patients are hypochondriacs.
Anything outside the check list leaves them scratching their head. They’re terrible debuggers.
I had early high blood pressure since high school. Four blood pressure medications, one being a diuretic. Signs of edema.
It’s not like my condition required any complicated diagnostics. I met the checklist.
5 cardiologists 2 nephrologists in my lifetime. Nothing but more pills for treatment. Over two decades.
I had to be the one to research and then ask to see an endocrinologist because I thought it might be hyperaldosteronism. They were dismissive when I asked but reluctantly made the referral.
Yes, it was unilateral hyperaldosteronism. Had my left adrenal gland removed because of it.
And now my BP is much more stable. I still take a couple of BP drugs, but in smaller doses. And my BP is much more normal and stable.
No more wild, 3am ER visits where my BP was 200/120. And I lost about 15 lbs of water weight.
If have long lived resistant hypertension, please ask to see an endocrinologist to get screened for hyperaldosteronism.
In reality, there are few things a GP can do better than a nurse or some technician with an LLM, and the sooner that shift happens, the better for society.
What do you think that LLMs can do exactly? Sometimes naive technologists think of AI as some sort of magic solution. But if you look at overall healthcare system costs, very little is being spent in areas that could be easily automated with an LLM.
And for T1D specifically it would be very dangerous to put an LLM in control of something like an insulin pump considering that we don't have any way to do quality assurance to the level required. Simple, deterministic algorithms are preferred for safety critical systems because they're less likely to fail in bizarre or unpredictable ways.
When I was self diagnosing, my Google queries were simplistic.
E.g.
resistant hypertension many medications
Which led me to a couple of research articles about pheochromocytomas and a Washington Post article about someone with high blood pressure on a "bucketload of medications".
In the US, my experience has largely been that it's not healthcare, it's sickcare. Wait until sick, get treated. Annual checkups are a weight check, blood pressure, a few questions, maybe a blood panel if you're lucky, and then a "you look great see you next year", aka, come back when you're sick.
I spent the last few years seeking proactive healthcare and the "system" is very much stacked against you. If you're fortunate enough to have the resources to push through, you can get all sorts of stuff done -- broader blood panels, body scans (eg. Prenuvo), VO2 max, metals tests, mold tests, genetic tests, GI tests, etc etc. But these are luxuries and if you ask most doctors, you'll get back "you look great why would you do that?", aka, come back when you're sick.
A friend of mine in the middle east says you can do all that for almost nothing by walking into any hospital, but it's subsidized by government (oil) dollars.
[edit] Reading more of the comments this seems par for the course in many "wealthy" countries.
None of those things are necessary most of the time, and they’re usually just going to make you paranoid. It’s why doctors don’t generally like to do full-body scans on healthy people: they’re rarely going to find anything clinically significant, but they’re often going to find something that causes a scare and some unnecessary tests. (And if the scan is a CT scan, on average, the radiation may cause more cancers than it catches if you’re scanning healthy people for no reason.)
If you want to have the best shot at preventing disease and living a long, healthy life, it’s not complicated: eat a healthy diet, exercise, get a good night’s sleep, avoid drugs and alcohol, and have fulfilling relationships with other people. Beyond that, you’re spending a lot of money on things that are going to have a negligible or even negative impact on your health and quality of life.
I did a CT scan recently for something unrelated which found some soft tissue lesion in the thymus. Cue doctors trying to tell me that I should just remove the thymus since it's not possible to do a biopsy and anyway the thymus is useless. Read recent research in NJEM that shows that removing the thymus increases risks of getting cancer and that it's anything but benign.
Eventually, I did a PET scan, got second opinions (that think it's most likely hyperplasia), determined that given the result of the PET scan, I don't have carcinoma or anything that is likely to be fast progressing. So, I won't operate, I will do regular MRIs to check the progress and monitor that it's not anything.
All this to say, that yes, having that result mostly caused additional stress for something that is actually likely to have already been there for years and years.
Understanding the results does take education, I agree with that, but having more data over time seems much better than flying blind and then being surprised when something actually does happen.
ya agree there. but most of those things aren't tradeoffs, aside from a bit of time and money (both of which go back to my original point about why I think the system is not working)
> But these are luxuries and if you ask most doctors, you'll get back "you look great why would you do that?", aka, come back when you're sick.
Proactive tests are great! Except for the false positive challenge. If the test has a 99% accuracy and it detects a problem that presents in 0.1% (1 in 1000) of general population, do you have the issue? Should you do something about it?
Well it turns out you only have a 3% (my math is likely imperfect) chance of actually having the thing you tested for unless you also have other symptoms. Now what do you do about it? Unnecessary medical interventions kill people all the time.
Prostate cancer is a great example here. If you’re over 30 and male, you very likely have a little bit of detectable prostate cancer. But you’re fine just leaving it alone for another 30 years and there’s a huge likelihood it’s never going to become a problem at all. Getting it fixed would be way worse for you than leaving it alone. (1 in 8 men eventually gets diagnosed with this meaning way more actually have it)
It's funny that we only apply this "more data = bad" logic to things that aren't readily visible.
If you have a palpable or visible likely-benign condition that isn't causing symptoms, such as a mole, rash, or lump, every doctor will recommend getting that checked out. Most of the time it'll turn out to be completely innocuous, but you'll go to the doctor and they'll decide between it's fine, monitoring, invasive investigation, and urgent treatment.
Obviously if the test itself is invasive (e.g. has a dose of radiation) then that is something that needs to be compared against the potential benefit. I certainly would not have a preventative head CT scan.
However if we're talking about things like an MRI, urine/stool test, or even something like a blood panel that has extremely low risks for most apparently healthy people (I donate blood 6x a year anyway - why not take some of that and test it), then why is it so different to a skin check, besides the cost?
> Obviously if the test itself is invasive (e.g. has a dose of radiation) then that is something that needs to be compared against the potential benefit.
A test isn't always a binary 'you have X ' . Look at PSA screening for prostate cancer starting in your 40s is not recommended for that reason.
I'm aware but also not sure how that changes anything.
Say you're 40 and you get a positive PSA result, maybe that means your risk of having prostate cancer has gone from (for illustrative purposes) 0.1% to 2%. That means the next step is "what do you do to someone who has a 1 in 50 chance of having prostate cancer?", and the answer is almost certainly not a biopsy or anything majorly invasive. The answer might be a finger up the butt, an MRI, monitoring for symptoms, repeat the test in a year, etc.
The problem is that patients aren't used to handling these ambiguous results from tests because we don't do much routine testing, and doctors don't want to face the potential consequences for getting a positive test result and recommending against invasive treatment. However, in many cases, a test would still tell you something useful even if it won't directly be used to escalate to a more invasive test or treatment.
For example, if a routine blood test shows prediabetes (which has happened to a few people I know when having blood tests for unrelated matters), you won't get any treatment for it, but you may be referred to a dietician and have a fire lit up under your ass to make those lifestyle changes you've been putting off.
the test isn't the problem, it's that doctors and patients aren't used to making decisions based on probability (patients demand something must be done, while doctors run on vibes and cover your ass)
(context: spent some time working in a prostate cancer research lab and have doctors in the family)
>Annual checkups are a weight check, blood pressure, a few questions, maybe a blood panel if you're lucky
This isn't my experience. Every time I've gone in for an annual check, the doctor has either suggested that I get or asked if I would like a blood panel. Maybe you should try another doctor.
In my experience, a blood panel doesn't cover everything typically. My A1C, Insulin, and fasting Glucose levels are all within normal range, but actually I have insulin resistance, likely genetic that wouldn't appear in my general panel for at least two or three more decades. This is common in people whose family history includes poverty or subsistence farming. I'm glad I have the resources to address this while I'm still a young professional with no children of my own to manage and full healthcare benefits including out-of-network, but I had to find my own specialists to investigate what was going on with me.
Why would a genetic tendency towards insulin resistance be correlated with a family history of poverty or subsistence farming? Is there any research on that? Which specific genes are involved? Which tests were used to diagnose your insulin resistance?
I don't know the details. This was just something that I was informed after I was speaking to a specialist about a separate issue at a world-class medical campus, who happened to also be studying the effects of insulin on the thing I was actually there to get examined and after some testing and calculations that are more used in research than clinicals.
I don't know why you would expect the healthcare system to do all of that stuff. If you want to know your VO2 Max you can just go to the local running track and execute a Cooper Test for free. But the results aren't really actionable. Regardless of the quantitative result, unless you're already an elite athlete the prescription will always be the same: exercise more.
Enough for what? It's kind of a meaningless question. Unless you're already an elite athlete training 30+ hours per week, you could always benefit from doing more.
Absolutely untrue. There is such a thing as overtraining, having to eat a lot of food to make up for the energy expenditure from exercise, time constraints vs health goals, etc etc etc.
> broader blood panels, body scans (eg. Prenuvo), VO2 max, metals tests, mold tests, genetic tests, GI tests, etc etc.
Do you really need VO2 max test to tell you that you get out breath climbing a set of stairs? What genetic tests are you even talking about( brca ? ).
Is there any actual proof that "catching cancer early" has any long term impact on survival ?
ppl can go waste their money if they really want for entertainment but I don't suggest burdening public healthcare with voodoo science.
> Wait until sick, get treated. Annual checkups are a weight check, blood pressure, a few questions, maybe a blood panel if you're lucky, and then a "you look great see you next year", aka, come back when you're sick.
What do we want them to do. They are not going to come to your my home and switch out your burger and fries with a salad.
I don't get where this notion that you need to go to doctor to keep yourself healthy even comes from. Its not a secret how to be healthy.
Are you asking if early detection of cancer results in better outcomes? Yes, the data unequivocally supports that diagnosing cancer before it spreads leads to lower mortality.
That’s only true if it’s actually a cancer that’s going to spread. Certain things like benign prostate cancer are often not worth treating. Testing everyone for everything leads to overtreatment and anxiety and worse quality of life.
I see the distinction. Thank you for clarifying. I think generally speaking I would prefer to have more data on my health. I don't like the idea that this information might be held back because it would make me "paranoid". That is my decision.
I can see that in the general case, it can lead to increased spending and worse outcomes.
> I don't like the idea that this information might be held back because it would make me "paranoid". That is my decision.
Yea you can get prenuvo or a psa test by paying out of pocket. No one is holding anything back from anyone. I got a PSA test out of pocket for $60 at quest ( family history of PC) .
Yes I put those in quotes because that's how Prenuvo sells their product to the public. If fullbody scans truly improve survival then they wouldn't need kim kardashian to sell their product.
To be fair, most people probably are hypochondriacs. Somehow we have come to expect that all our nagging ailments should be fully treatable by either a pill or a surgery. In reality, human body is pretty good at self-repairing and self-regulating and modern medicine can help it only in certain clear cut cases. Medicine is just not that good and the doctors know it.
I'm certain in the sample of patients most GPs see, hypochondriacs are overrepresented, but that really does not in any way eliminate the problems I experience, so from my point of view it's still a real concern.
Something similar, u just switched to private clinic where i pay 500euros/year for general doctor(even when they work for insurance) and I pay like 100E for specialist. Never happier, fast and good communication.
I also lived in two of the richest countries with a social medical system
My experience is that GPs are over-worked, under paid (given their responsibilities), and can only afford to do shallow diagnostic in the 5-10 minutes they've got per patient. That's explained by a slow but relentless dismantling of any operational margin that existed in the system, whether it's financial, time etc.
I'm talking about the situation in France and the UK, not sure where you are, my point is that I agree about the system failing us, there's a lot to be said about what could be done but that's outside my area of expertise. I'm just being a little nicer to the doctors, as there's only so much they can do given the means they're given.
> My experience is that GPs are over-worked, under paid (given their responsibilities
Their work hours are no longer than anyone else, their pay is way above the average, and their liability is as low as possible.
> and can only afford to do shallow diagnostic in the 5-10 minutes they've got per patient.
My doctor spends it explaining to me how I should just not care that something is wrong and accept that the medical industry is too incompetent to figure out what it is and that there are people who have worse problems, even though he has no idea what is actually wrong.
> Their work hours are no longer than anyone else, their pay is way above the average, and their liability is as low as possible.
YMMV but as a software developer I am certainly not going to start throwing stones in a glass house. :)
Also consider additional time and cost of a doctor completing their education while working up to a max of 80h per week, which would be illegal for any reasonable profession.
> > Their work hours are no longer than anyone else, their pay is way above the average, and their liability is as low as possible.
> YMMV but as a software developer I am certainly not going to start throwing stones in a glass house. :)
I have absolutely no idea of what's involved when working as a GP/consultant, so I probably grossly underestimate their job, but in my interaction with them (involving my health as well as my family's) most of them seem to just put your case into a flowchart and prescribe along, because that's what reduces the liability to 0 and works most of the time. But if that's their job, they'll eventually be replaced by LLMs.
When you don't fall into the typical case, you'll have to go through retelling the whole story to all the flowchart ones (easily 80%) only to find along the way snake oil salesmen (10%), honest "I can't take your case" individuals (5%), and the 1-5% which actually feel like scientists and problem solvers.
(percentages pulled out of my rear but that's roughly my experience)
> Also consider additional time and cost of a doctor completing their education while working up to a max of 80h per week, which would be illegal for any reasonable profession.
I'm not sure why the educational requirements are so extreme for all doctors. Certainly for some, like surgeons, I get it, but for my GP I think it's a total farce. I don't make the rules though, I just can see a broken system when it's right in front of me.
Not sure how it is outside the US, but subscribing nurse-practitioners (requires just 2 additional years after a nursing degree) have been quickly replacing GP docs in the US for this reason. They'll send you to a specialist just like a GP would. It's all the same problems in terms of the underlying model, but the financial and time costs to the system are lower.
I'm not totally sold on what I'm selling though. My spouse has been a nurse practitioner for over 10 years; she had the option of becoming an MD but picked that route because she saw the grueling 80+ hr work weeks of older doctor friends and decided it wasn't for her. Unfortunately, she's still stuck with only 20 minutes for sometimes extremely complex patients that require a great deal of research and follow-through outside of work hours, and the extra slack in the system that is provided by her lower wages has just gone to hiring additional administrative middlemen that are seldom capable of actually filling in the gap, whether for reasons of liability, knowledge, skill, or motivation. These positions exist to try and ease the pressure on docs just like NPs exist to ease the pressure on docs, but it doesn't work because at the end of the day you need someone who can hold the liability (both legal and moral) and the knowledge (the correct diagnosis and the correct plan of action) within the same person.
Just like in software, where throwing more developers at a problem doesn't guarantee your problem gets solved more efficiently, for much the same reason. You need somebody who understands the domain, understands the tools, understands the business framework, and is ready to take responsibility for solving the problem. Each additional person introduces information overhead that makes each one of those tasks more complicated.
Excellent article in Bloomberg on this subject: https://www.bloomberg.com/news/features/2024-07-24/is-the-nu... (non-paywall'd link: https://archive.ph/03f4u) -- not the standard r/noctor drivel, but a well-researched and sources cited article exploring this phenomenon. Not discussed in the article is the phenomenon of more unnecessary testing with less trained providers doing the ordering which has downstream effects of cost and overdiagnosis.
I agree with a lot of the critiques of our healthcare system and as an emergency department doctor share them, but I doubt LLMs or NPs are going to fix our system. I also have a lot of concerns about broader societal trends in looking for pathologies / diagnoses in ourselves to justify or validate not feeling "well", repeatedly asking for more and more tests or self-identifying with a nebulous diagnosis and then incorporating that into identity as one who is perpetually sick. Particularly with younger generation, this is a really big issue and I don't see it getting better.
My wife is a doctor (GP, before internal medicine in biggest hospitals), experience with France and Switzerland. What you say is true - they all start as naive optimists who get treated brutally by whole healthcare system first 7-10 years after school, everybody knows it, often illegal from hospitals but good luck suing your employer. Burned out, 60-70 hour work weeks with weekends is the standard, night shifts, a lot of responsibility with little help/oversight. Always 1 oversight away from harming/killing somebody. Many in Switzerland that are Swiss dropped out, foreigners don't have it so easy.
Then afterwards they are put into position where they have 30 minutes for patients (in France its ridiculous 15 mins, saving money = worse diagnosis/treatment, no way around it). Don't expect miracles if they see 20 folks like you daily, ideally with very vague problems like chest pain which can be anything from sprained muscle due to bad sleeping position last night to heart attack, while having 10 other comorbidities and taking various medication.
Doctors behave as whole system forces them to behave.
Doctors burning-out is probably the worse red-flag you could have for a health system. It's frightening to think the person diagnosing my parents and children might not be in full possession of their capacity or make rash decisions.
I'm seeing the same pattern for many crucial functions having been pushed over the line during the last two decades or so. Whether it's a doctor, a teacher, a nurse, a childminder, the police, etc. All the jobs that are essential for a developed society have crumbled down to the point I'd discourage any young person to pursue a career in that sector.
If that worries you (and it should), never ever go to hospital during night (unless serious emergency of course) or very early morning, or generally just before the end of shifts. You will get potentially worse treatment by definition, depends on many things but probability is against you.
Also, the bigger the hospital usually the better experts they have on critical stuff (and more chance you won't wait long for ie CT or MRI), smaller hospitals and clinics just forward serious patients to big ones.
At the end healthcare is just another branch of market and all woes that apply to rest of us apply to them, no magical immunity due to more noble profession.
