[jrapdx3]

Practicing medicine for decades gives me some "perspective" on the subject. No one in medicine is a "miracle worker", though many of us work hard to the job responsibly.

You are wrong. We do "save lives", and not just in the ED. Every day, if not as dramatically, immediately or even noticeably, our incremental toil helps patients progress bit-by-bit toward better health. Managing chronic, debilitating conditions really does enable patients to live longer and more fully.

You are also wrong regarding income. Doctors in the US are getting paid less and less, while expenses of practice go ever higher. My own income is probably less than most of the people I know in other professions.

The "mess" of the health care system (to the extent it is even systematic) is the result of the constant assault of corporations and governments at all cost to "reduce costs", but the result has been the degradation you and others notice.

The most conspicuous evil has been perpetrated by the insurance industry. For example, amazingly short-sighted insistence on paying for a "generic" medication $3/mo cheaper than the drug already working is an every day challenge. If patients don't get what is really needed, they wind up getting sicker, need more care, the result is more money spent, not saved.

The problem is that the industrialization of medicine makes it increasingly difficult to be helpful. People are not neat little uniform units produced in factories. People are enormously complex organisms that defy all rules we invent to "explain" illness and treatment. People are unique entities that require individual attention and customized approaches if true "health care" is going to be provided.

If doctors are given the resources, time and respect to do their work, I believe almost all will strive to do it right.

[pinkyand]

> The problem is that the industrialization of medicine makes it increasingly difficult to be helpful.

Atul gawande, which is a doctor and a healthcare journalist ,and knows the medical system from inside, thinks that industrialized medicine is exactly what's needed:

http://www.newyorker.com/magazine/2012/08/13/big-med

And in general the positive results from decision support systems seem to agree with him.

[jrapdx3]

Of course, talking about the US health care "system" is hazardous given the enormous diversity of systems within it.

No doubt there are instances whereby particular "industrial" implementations function well. But there are also many that function poorly. "Industrialization" is a term that can be applied to mean numerous and distinctly different things.

I was referring to situations I've observed where doctors are restricted from taking time when necessary to evaluate complex cases. Facing a patient with several serious conditions interacting and combining is far different than dealing with a patient having one condition.

It's impossible to do the job well when "bean-counters" insist on scheduling tightly and emphasis is on "production". This is particularly problematic in primary care settings.

Having been involved in quality assurance activities for many years, I fully understand the value of consistency, adherence to rational protocols, etc. But the ability to deal with "outliers", especially when the exception is the rule, is where "industrialization" is at risk of failing.

[pinkyand]

Yes i agree, sometimes "production" goes too far. In some of those complex case it's even wiser to allocate much more time in advance from doctors and nurses, to prevent future complications - which are much more costly.

But i wonder:

On what sources do you rely when it comes to managing complex cases ? is it only known hard coded medical data in books and databases ? or also some intuition ?

And if it's intuition , how can you form intuition for such complex cases where really each case is pretty unique , as you said ?

[jrapdx3]

The ancient wisdom is the practice of medicine is as much art as science. There is "evidence" supporting many practices. As in every complex endeavor, evidence is not static, but evolving constantly.

Evidence is necessary but by itself insufficient. We must use our own power of observation combined with what we know and what we've learned to decide what to do.

So your question is indeed profound, cuts to the core of the issues. Intuition is one way to phrase it. I once heard a colleague say we're not paid because of what we know, but for the judgement we exercise about advice or treatment to offer.

Each human is indeed unique. Even identical twins are in fact not exactly the same. Rules have limits when no two cases are precisely the same, it always comes down to that very intuition you are intuitively aware of.

After all, we frequently wish to have a second opinion. I do often enough too. I like the saying, get 5 experts in a room, and you're likely to get at least 6 opinions on any subject.

Who said decisions should be easy? I sweat over each and every one.

[pinkyand]

> Who said decisions should be easy? I sweat over each and every one.

True medicine is a really hard job.

So maybe the way decide in medicine should be changed ? maybe they be done remotely but through a recommendation system so that each doctor would get plenty of nearly similar cases - so he could practice and hone it's intuition ?

Or since the complexity is really too great (and as a patient hearing that "this is art not science" isn't that encouraging , even if true) maybe the overarching goal of medicine should be to remove the art, and we finally have the tools to do it(watson, machine learning ,remote diagnosis , etc...) ?

And if we agree that that's a good goal, maybe the current way we try to do it (evidence based medicine) , is a bit clumsy due to both the science and the resistance by doctors , but at least it's going in the right directorion.

[cheald]

> For example, amazingly short-sighted insistence on paying for a "generic" medication $3/mo cheaper than the drug already working is an every day challenge.

Pardon my ignorance, but aren't generics chemically-identical compounds that simply don't carry the brand name? My "generic replacement for Norco" is still acetaminophen and hydrocodone. Indeed, the Wikipedia article on generics notes that "A generic drug must contain the same active ingredients as the original formulation", and that it must be "comparable in dosage form, strength, quality and performance characteristics, and intended use".

What am I missing that makes generics a problem?