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Is Critical Diagnostic Thinking Dead?


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Is Critical Diagnostic Thinking Dead?
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drewprops
Bastard
 
Join Date: May 2004
Location: Atlanta
 
2021-07-10, 04:59

It took me three useless and expensive visits to a supposed "animal hospital" before I was given a referral to a clinic with real vets and real veterinary specialists.

After my mom was diagnosed with giant cell arteritis I sat in a rheumatologist's office and watched him shush her while he went down a damned checklist, instead of having a conversation with her.

Five years later, that same condition was caused to flare because her young general practitioner put her on a drug for bone density that you are apparently not supposed to go back onto if you've had it in the past.

Some close family friends have the husband in the hospital, finally, after months of various doctors treating him incorrectly for a cough - many Z-packs and butt injections later it turns out he's actually suffering from distention in his abdomen.

We can all give examples of widespread failures in medical AND non-medical diagnostic situations.

My instinct is that critical diagnostic thinking was never as good as I want to believe it to have been.

But it sure feels like it, and so I'm chewing on this one right now.

...

Steve Jobs ate my cat's watermelon.
Captain Drew on Twitter
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pscates2.0
Mr. Katan
 
Join Date: May 2004
 
2021-07-10, 09:07

Sounds all-too familiar. I kinda agree. I’ve got a half-dozen stories on this front that would make you chew a box of nails.

It feels like the hallmark and go-to move of modern medicine/“healthcare” is to throw a bunch of pills at you, don’t dig too deep and get you the hell out of their office ASAP. As a result, you’ll wind up in the hospital soon enough, battling some huge thing that might’ve been avoided/prevented had anyone given a genuine shit months/years earlier.

From where I sit, that’s how it all feels/seems. Enough first-hand experience via friends and family over the years to feel justified in that.

I don’t think it pays - literally - to dig too deep or ask the big, probing questions. Ain’t nobody gots time for that shit! For a couple of decades now everyone’s been trained to just “ask your doctor about…” and that’s often as far as it goes. Pill-throwing and warehousing, with the ghoulish funeral industry shitheads waiting in the wings for their turn.

I have a slightly dim view of the racket, in case it isn’t clear.

Last edited by pscates2.0 : 2021-07-10 at 09:22.
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PB PM
Sneaky Punk
 
Join Date: Oct 2005
Location: Vancouver, BC
Send a message via Skype™ to PB PM 
2021-07-10, 14:54

The trouble for those of us with no medical background is that we don't know what we are telling doctors. We tell them what we feel, the symptoms we notice now, but that isn't always the entire story. Sometimes other symptoms are covered by other aches and pains we are just used to and ignore. Doctors can only make medical diagnoses base on what we tell them and the test results for things they look for based on that. Sure they could do full body MRIs, CAT scans, lumbar punctures, fully blood work studies and such for each person every time they come in, but that would be excessive, expensive, and waste a lot of time in most cases.
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Dr. Bobsky
Senior Member
 
Join Date: Feb 2015
Location: UK's most densely packed city. It's not London...
 
2021-07-11, 06:51

Quote:
Originally Posted by drewprops View Post
It took me three useless and expensive visits to a supposed "animal hospital" before I was given a referral to a clinic with real vets and real veterinary specialists.

After my mom was diagnosed with giant cell arteritis I sat in a rheumatologist's office and watched him shush her while he went down a damned checklist, instead of having a conversation with her.

Five years later, that same condition was caused to flare because her young general practitioner put her on a drug for bone density that you are apparently not supposed to go back onto if you've had it in the past.

Some close family friends have the husband in the hospital, finally, after months of various doctors treating him incorrectly for a cough - many Z-packs and butt injections later it turns out he's actually suffering from distention in his abdomen.

We can all give examples of widespread failures in medical AND non-medical diagnostic situations.

My instinct is that critical diagnostic thinking was never as good as I want to believe it to have been.

But it sure feels like it, and so I'm chewing on this one right now.

...
It's the insurance companies. To reduce costs and errors, everything has been codified to death. This prevents unnecessary procedures and protects physicians from lawsuits if a patient were to die.

Most illnesses do not require critical diagnoses. It took over two months for physicians at the best eye hospital in the UK to order a nerve test when I lost central vision almost a decade ago, and only then did they order an MRI, which was further delayed by 4 months. All diagnostic criteria for what I had suggest an MRI within 4 weeks of initial onset -- at which point I was still being treated like a drug seeker -- to exclude long term illnesses like MS. But I was 1) the wrong age, 2) the wrong gender, and 3) displayed no other symptoms (and perhaps was calmer than I should have been given the loss of binocular vision).

Statistically, I was unlikely to have had MS, and the entire system is predisposed to operate on those statistics. If I had had MS, I would have been flippant (but really unable to do anything); if they had diagnosed the optic neuritis in a timely fashion I could have had a shorter duration of recovery with appropriate treatment, but no end result improvement. In the end, it took over a year for the eyesight to recover almost to 80-90%, which is again atypical (recovery times are typically 4 weeks-4 months, and recovery of sight is lower). It's bizarre watching (literally) your optic nerve repair itself. And I should have been an academic case study because of all of the atypicalness of the presentation -- I suspect I was infected by a cold from a recently pregnant friend, and my immune system went crazy.

All of which is to say: academic interest in your illness is no longer a driving motivation for physicians. You're more likely to see this in paediatrics. It means progress towards medical improvements are moving out of the clinic and into the lab, where a lot of this physicians-as-technicians dumbness will be overcome with cheaper diagnostic tools and more precise medicines. The Drs. won't be needed for the vast, vast majority of things...
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drewprops
Bastard
 
Join Date: May 2004
Location: Atlanta
 
2021-07-11, 07:05

THAT gives me hope.

And fear.

I know that my examples were centered around medicine, but I think that you'll find a similar thing happening in other industries. "Advisory Services" has become a thing in several sectors, as you have grey and white haired seniors making their expertise available, for a price.

When we stop understanding WHY we do a thing and all...


...

...
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drewprops
Bastard
 
Join Date: May 2004
Location: Atlanta
 
2021-07-11, 08:35

Also: while it sounds like you've dealt with your eyesight emergency, I'm sorry that you experienced that.


...
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Ryan
Veteran Member
 
Join Date: May 2004
Location: Promise Land of Trustafarians
 
2021-07-11, 11:10

Went through the same thing with my mother. She was having a variety of issues and doctors just kept writing it off as valley fever.

Eventually we got her in to the Mayo Clinic who figured out it was leukemia. Fortunately it's the "good" kind that moves so slowly most patients have a normal lifespan, and the treatments they have these days are remarkably effective. She takes a daily pill that has virtually no side effects and that's keeping it under control. It's a new kind of "targeted biologic" (I have no idea what that means) and isn't chemo or radiation therapy.

Only problem is the pill runs about $15,000 a month. For the moment we've got the cost down to $10 through her insurance and manufacturer discounts, but we already had one round of her employer trying to drop coverage for the drug. We were able to appeal that decision and get it reinstated. In January she goes on Medicare, so we'll see how that goes.
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pscates2.0
Mr. Katan
 
Join Date: May 2004
 
2021-07-11, 11:15

From $15,000 to $10?! That tells me that one, or both, of those numbers are artificially monkeyed with or tied to “we’ll charge whatever we want, insurance will get it”. There’s no way in hell a regimen of pills - I assume they’re not made from unicorn irises - should be $15K a month.

That’s obscene.

I’m glad she’s doing well, I was just stunned at that price. You didn’t accidentally add a “0” to that $15,000, did you? Because I can almost get/understand $1,500/month.
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PB PM
Sneaky Punk
 
Join Date: Oct 2005
Location: Vancouver, BC
Send a message via Skype™ to PB PM 
2021-07-11, 11:46

Medication costs are simply outlandish, and they can charge whatever they want that’s to the patent system. It’s only when generic drugs hit the market that treatment costs come down. Some drugs are too rare to ever get the generic treatment and the price only goes up.

I recall the case of a five year old girl here in BC who got some rare infection or disease. No problem there is a pill for that. Oh, but it costs $100,000 every 6 months. Thankfully donations from the public and government aid saved the family from that insane fee.
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Ryan
Veteran Member
 
Join Date: May 2004
Location: Promise Land of Trustafarians
 
2021-07-11, 12:52

Quote:
Originally Posted by pscates2.0 View Post
From $15,000 to $10?! That tells me that one, or both, of those numbers are artificially monkeyed with or tied to “we’ll charge whatever we want, insurance will get it”. There’s no way in hell a regimen of pills - I assume they’re not made from unicorn irises - should be $15K a month.

That’s obscene.

I’m glad she’s doing well, I was just stunned at that price. You didn’t accidentally add a “0” to that $15,000, did you? Because I can almost get/understand $1,500/month.
To be fair, it's a drug that has to be custom-tailored to her by sequencing the cancer's DNA or something—I don't know the details—and there are only two pharmacies in the country that can handle it. And for a drug that works this well against cancer with zero side effects? We'd pay just about anything.

It's so effective, all the bloodwork they monitor is in the "normal" range for a person without leukemia.

But yeah the system is absurd. I think the Mayo Clinic also intervened with the insurer and manufacturer to get us another set of discounts. Their staff are fantastic.
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pscates2.0
Mr. Katan
 
Join Date: May 2004
 
2021-07-11, 13:42

That’s good. Every bit helps against that kind of pricing.
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Dr. Bobsky
Senior Member
 
Join Date: Feb 2015
Location: UK's most densely packed city. It's not London...
 
2021-07-12, 06:05

Quote:
Originally Posted by Ryan View Post
It's a new kind of "targeted biologic" (I have no idea what that means) and isn't chemo or radiation therapy.
Hmm. If it is a biologic, I would have expected it to be administered intravenously; as oral biologics show promise but have not been approved for general use as far as I can tell. Targeted chemotherapies can function without side effects, so perhaps this is it -- they would be using a drug that binds to the specific variant protein your mom's cancer displays, hence targeted. I am happy to clarify more if you're interested. One of my projects is on developing a general system for targeting delivery of biologics to specific environments within specific cells, so it's a bit in my wheelhouse.

Quote:
Originally Posted by pscates2.0 View Post
From $15,000 to $10?! That tells me that one, or both, of those numbers are artificially monkeyed with or tied to “we’ll charge whatever we want, insurance will get it”. There’s no way in hell a regimen of pills - I assume they’re not made from unicorn irises - should be $15K a month.
Depending upon the drug, some of these prices are 'reasonable.' They have to produce these drugs specifically for the patient, meaning there isn't a whole lot of spill over to other people being treated for similar disorders, so no economy of scale. These types of drug are difficult to develop, since, once again, they are often targeting a small subset of patients meaning clinical trials must go on longer, and patient trajectories tracked for more time. And if they are biologics, they have to be fermented in a clean lab space, where even a hint of contamination spoils the entirety -- think J&J level vaccine problems for every specific cancer treatment. However, I think the for profit nature of drug companies is to blame for almost all of this -- they have shareholders to pay after all...
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Ryan
Veteran Member
 
Join Date: May 2004
Location: Promise Land of Trustafarians
 
2021-07-12, 09:39

It's quite likely I have some of my terminology wrong, since my knowledge is all second-hand.
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pscates2.0
Mr. Katan
 
Join Date: May 2004
 
2021-07-12, 09:48

It’s just eye-opening to me. I didn’t know medication could be that steep. Getting it from $15,000 a month down to $10 does make it seem like reality must be somewhere in the middle, as is often the case with most things. You can’t base much on the two far-flung extremes, it’ll drive you nuts (or put you in jail).
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pscates2.0
Mr. Katan
 
Join Date: May 2004
 
2021-07-12, 10:11

Quote:
Originally Posted by Dr. Bobsky View Post
However, I think the for profit nature of drug companies is to blame for almost all of this -- they have shareholders to pay after all...
Yeah. I don’t begrudge anybody making a buck, but damn

I just had no idea. I’m the only person I know who isn’t on prescription medication, so this isn’t part of my day-to-day (knock on wood). Like I said…a genuine eye-opener.
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kscherer
The Ban Hammer
 
Join Date: Aug 2004
Location: Boyzeee
 
2021-07-12, 11:08

Quote:
Originally Posted by pscates2.0 View Post
I’m the only person I know who isn’t on prescription medication…
Hey, I'm not on any!
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drewprops
Bastard
 
Join Date: May 2004
Location: Atlanta
 
2021-07-12, 13:30

$15,000 is cheap!

Try Interferon!


...
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Kickaha
Likes his boobies blue.
 
Join Date: May 2004
Location: Hell
 
2021-07-12, 17:02

Quote:
Originally Posted by PB PM View Post
Medication costs are simply outlandish, and they can charge whatever they want that’s to the patent system. It’s only when generic drugs hit the market that treatment costs come down.
BWAHAHAHHAHAHAHAHA

Insulin was never patented.

Have you seen the prices being charged? It's "your money or your life", plain and simple. It's not just price gouging, it's price fixing. The whole fucking industry needs to be converted to non-profit at gunpoint. "Oh, but we have to pay for R&D, and that's why..." *SLAP* No, you fuckers, you are paying shareholders, and spending an order of magnitude more on *advertising* than R&D. Eliminate the profit margins, and the advertising, and get back to where we were pre-1972's HMO Act.

Quote:
Some drugs are too rare to ever get the generic treatment and the price only goes up.
Not in any sane system. Think about it - if the patent expires, and it's a moneypress, who wouldn't dive in and undercut by just a wee bit?

My other brain is hung like a horse too.
#IRC isn't old school.
Old school is being able to say 'finger me' with a straight face.
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PB PM
Sneaky Punk
 
Join Date: Oct 2005
Location: Vancouver, BC
Send a message via Skype™ to PB PM 
2021-07-12, 19:23

I cannot speak to the American system, thankfully I don’t deal with it. Drug makers have very limited advertising rights in Canada, so it’s not a big deal here. The only ones I see regularly are for shingles and hep b&c. I get sick watching American channels, all the stupid drug ads are enough to drive anyone to drink. Thankfully most American ads get covered with Canadian ads, other than some specialty channels.

Some drugs, which is why I said rare, never get generic versions is because too few people take it for the generic makers to bother competing with the name brand stuff.
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Kickaha
Likes his boobies blue.
 
Join Date: May 2004
Location: Hell
 
2021-07-12, 19:24

You lucky bastard.
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Ryan
Veteran Member
 
Join Date: May 2004
Location: Promise Land of Trustafarians
 
2021-07-12, 19:49

I'm fortunate that my only prescription is available as a generic. Even without insurance it's all of four bucks for a 90 day supply.
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Bryson
Rocket Surgeon
 
Join Date: Feb 2005
Location: Whitby
 
2021-07-13, 09:04

I take a drug which will become generic in 2022. Even with insurance paying 80%, it costs me about $75/month. Looking forward to that dropping next year.
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