Real diagnosis in general practice

August 11, 2008 6:41 PM

US doctor question: do general practitioners practice real diagnosis anymore? Every doctor my wife and I have gone to in the past ten years has turned out to be incompetent or disinterested in doing more than the bare minimum.

My son has a fever and some other symptoms, and my wife and I were talking about finding a pediatrician. This led to a discussion about whether it's even worth bothering. We both remember that back in the 1970s, doctors (GPs) here in the US seemed to make serious efforts to diagnose colds, flus, and illnesses. My wife recalls it was normal for them to take throat cultures, do bloodwork to check white blood cell counts, temperature, and so forth. She remembers that sometimes the doctor would decide on a diagnosis after the visit (I would assume to go look in a book and research the symptoms). I recall similar experiences.

Fast forward to the late 1990s and 2000s.... when my wife or I have gone in for minor ailments, we've both had the experience of doctors shotgunning our diagnosis: i.e., half-attentively listen to our problems, do a cursory check of the lungs and ears, not do any more physical checks, then just say that some sort of virus is going around. Typically the doctor would then scratch up some Rx's for something like doxycycline, nasonex, and promethazine and bid us adieu. I'm not talking about one doctor... this is the typical sequence with seven doctors we've had in three different places we've lived in TX and OK.

Does our experience agree with anyone else's? Is our memory flawed or has there been some change in recent decades about how GPs approach diagnosis? Is it possible that new doctors are less technically informed than "old school" doctors used to be? Are we supposed to actually ask for a detailed examination (is there some code word)? Is there a trick to increase our odds at finding a doctor willing to check things out completely, for example using a DO instead of an MD or avoiding a multi-doctor practice? Many will say "word of mouth" but I don't trust it since by the reviews I've seen on Google Maps and ratemd.com, people seem to put emphasis on doctor cheeriness, wait time, and submissiveness about wanted prescriptions.

So as things stand now, we want to bring our kid in but we're hesitant about the idea of getting nothing but 5 minutes of time, an antibiotic, and whatever the pharma rep is pushing.

Somehow I suspect that basically I'm asking about shopping for a doctor. I know. But it's hard to call it shopping when I haven't been able to find a good one, ever, and I suspect there is a systemic problem. Maybe my expectations are too high. Please enlighten me.

posted by crapmatic to health & fitness (28 comments total)

You might find some helpful answers in one of my questions.
posted by unknowncommand at 6:51 PM on August 11, 2008

First, I think you are confusing General Practioner (GP) and Family Practioner. Family Practice is usually just that, they treat most all ages. Back in the 90s I had one, and the whole family went to him. I think he was a dying breed.

Then there is an Internist, they are different than a general practioner.

I would only use a pediatrician for kids, especially for young ones.

I haven't really had a problem with the rest.
posted by 6:1 at 7:00 PM on August 11, 2008

Thanks unknowncommand -- somehow I missed that thread, but my hat is off to you for treading into this subject already. My current game plan is to try several doctors during future visits. One trick I will try is to make sure both my wife and I attend appointments together, so we're alert about the doctor's competency and can compare notes. I can't even figure out where to start, but the free doctor review sites (ratemds.com, etc) seem to be useful for weeding out the bad apples.
posted by crapmatic at 7:05 PM on August 11, 2008

Devil's advocate here: maybe they're *better* at diagnosis and are ruling out all the bad things quickly and efficiently?

Similarly, there's no point is getting diagnoses exactly right when a single solution would fix any possibility. Does it matter whether you have a cold or the flu, if your symptoms are normal and "fluids and rest" is all that can be done?
posted by gjc at 7:05 PM on August 11, 2008

I live in New York, so my recommendation won't help you, but my GP is fantastic. He doesn't push drugs, actually listens to me and throughly explains my ailments to me without talking down to me. He is also personable and doesn't leave me waiting for hours on end. Those things really matter when you are feeling like crap, but have to get back to work in an hour. A pleasant attitude goes a long way (even better if they don't waste your time by shoving the maximum appts into one day)

I came to him after having similar experiences to you with my three previous GPs.

One thing that helped me was letting go of certain requirements that I thought were necessary. The main thing for me was the determination to have a female doctor. Once I let that go I was told to try my current doctor out (by my sister) and I've been with him for the last three years.
posted by Julnyes at 7:08 PM on August 11, 2008

You know, sometimes it really is just a virus going around, and there not much to do for it except ride it out. In fact, with kids' sniffles and fevers, that's what it is most of the time. An antibiotic is not going to touch it, and a good doctor will tell you that.
posted by beagle at 7:09 PM on August 11, 2008

My son has a fever and some other symptoms, and my wife and I were talking about finding a pediatrician. This led to a discussion about whether it's even worth bothering.

I am not a doctor or a parent, but I'd sure want a primary care doctor for my kid if only to have a medical history in case something goes majorly awry. My own medical history is extremely atypical, so I can't accurately comment on your general observations, but I will say that in my recent experience, I haven't even been able to get doctors to rule things OUT, much less give a diagnosis.
posted by desjardins at 7:15 PM on August 11, 2008

Does our experience agree with anyone else's? Is our memory flawed or has there been some change in recent decades about how GPs approach diagnosis?

I recently had a pretty bad experience when I went in to the doctor for Strep throat. I knew I had strep throat - I told her I had strep throat - I don't think she would have even done a throat swab if I hadn't been so adamant. She told me that she was only doing it to humor me - that I had none of the symptoms of strep (I had them all), that it wasn't strep season (it was), and that I most likely had a virus. Yup - I had strep. I think that my experience was due to the fact that I went to Kaiser hospital (which is where I have my insurance), and hospitals have such a low profit margin that they need you to get in and out quickly with a minimum of tests - especially since their insurance is paying for the testing. A few missed calls on their part is well worth the price of doing unnecessary testing in their eyes.
posted by The Light Fantastic at 7:15 PM on August 11, 2008

There are actually ways of getting better care without necessarily spending more money. One way is to go to university hospitals when possible. There really is a difference. Not only are the university physicians more likely to be more dedicated to their craft--most of them have voluntarily taken a lower paycheck to teach, and the positions are quite competitive--but university facilities are almost always state of the art.

Unfortunately, this isn't an option for many people, as there are only about 145 medical schools in the country, so your local city hospital is mostly not one of these.

Note: I am not talking about university health clinics of the type that students go to. Those places are a complete racket. I'm talking about the hospitals attached to medical schools.

Part of your problem may be, I'm afraid to say it, the part of the country where you live. Texas and Oklahoma aren't exactly known for attracting the country's best and brightest medical talent, most of which didn't come from that part of the country, as the population is rather low. Furthermore, most of them went to school on one of the coasts and stayed there. Of the top 50 most prestigious medical schools in the country, you're within 500 miles of no more than 3, and they're in Dallas, Houston, and St. Louis. If you were in, say, Philadelphia, you'd have one right in town and be within two hours' drive of 9. So not only are you more likely to be able to go to one of those hospitals on a regular basis, but the graduates of those schools may well wind up settling in the general area. Finding good care in smaller cities, especially in the "flyover states," can be quite a challenge, and you have my sympathies.
posted by valkyryn at 7:16 PM on August 11, 2008

Valkyryn--I couldn't disagree with you more! Oklahoma has great medical schools. (I lived there for 10+ yrs. and went to nursing school there!)

Our physicians (when living in OK) were excellent, and most were from the area.
posted by 6:1 at 7:21 PM on August 11, 2008

Typically the doctor would then scratch up some Rx's for something like doxycycline, nasonex, and promethazine and bid us adieu

Did these measures effectively treat your ailments? If so, the doctors sound competent.

I'm curious where you live. The few times I have seen doctors in rural areas I have been far less satisfied with their care (obviously a small sample size, but I'm curious nonetheless).
posted by reeddavid at 7:23 PM on August 11, 2008

We've had great luck with our docs, a practice of three family practitioners. They delivered my kids and know us pretty well. I often think of Maud Lebowski when I visit my main doctor, "very thorough" comes to mind. They know the specialists to refer us to, and will take the time to make phone calls on our behalf.
Our doctor has kids the same ages as my kids, in some of the same schools so she is acutely aware of what is going around. She also knows I am fairly laid back, so if I am worried it's serious.
I would ask around, people you know in the neighborhood thru your son; school groups, daycare, baby sitting co-ops. Every neighborhood has some well regarded professionals in all walks of life and it takes word of mouth to find them.
posted by readery at 7:28 PM on August 11, 2008

One thing in my experience, having dealt with a large number of primary care physicians in recent years, is that care in the US has changed a great deal, driven largely changes in private insurance and Medicare. Several doctors have told me similar stories when I asked about this. With sprialing health care costs in the late-80s/early 90s, insurance companies became much more methodical and precise in the procedures they would cover and working to drive down the costs and resources laid out for those. Thus, the business of running a medical practice has become much more a matter of tailoring your care to a specific set of procedures for which you'll be paid by insurance companies. (Out-of-pocket costs for patients can be charged, but they'll have to be chased after and a fair percentage just won't pay them. Hence, diminishing returns for what's not covered by insurance.)

One result of this is that you are likely to be directed to a specialist quickly if your ailment both appears serious and doesn't appear on their regular menu. But it also means that someone like a GP serving as your primary care physician who doesn't do expensive procedures needs to work in volume, since their likely insurance payout isn't that great for a regular diagnostic appointment. The effect is to turn what you would think of as your family doctor in years past into a kind of broker for specialists and a dispenser of presecriptions and a small set of limited remedies. If you aren't someone they can work with in those ways, the business is pushing them to push you elsewhere. You may be seeing a change because you are now well and truly immersed in a generation of doctors who have only worked in that system. The older model of a doctor who did all (or most) of your care and followed the case from start to finish in a methodical and unhurried manner is very uncommon and working against the constraints of the system where he or she exists at all these days. So gjc probably has a point that they took one look at your child, realized it was something in the cold/flu neighborhood, knew that any more work on a diagnosis wasn't going to change what they recommend or lead to a procedure that they'd get reimbursed for, and wrapped things up unceremoniously. (I guess that wouldn't really be an improvement in diagnosis skill though, since crapmatic is describing being offered even less of a diagnosis.) That's not to paint doctors as evil, indifferent moneygrubbers more callous than past generations; it's to suggest that institutional pressures have a powerful effect on the shape of their practice.

So I don't think you're likely to get a better diagnosis for an everyday ailment than you're getting anymore, and I don't think it's a random quirk of your doctor or the doctors in your area. I think we're all just working in a different health care system than the one that existed here 40, 30 or even 20 years ago.
posted by el_lupino at 7:40 PM on August 11, 2008 [6 favorites has favorites]

My kids and I see a family doctor, and she's great. She's done research and talked to specialists after the appointment and then called me (or had one of her assistants call me) the next day to talk about treatment.

She's always made time for us when it's something urgent, but I do sometimes feel like I'm being rushed out of there.

My understanding is that Medicare and private insurance only pay a certain amount per visit, and don't pay anything for the time spent doing research, looking over the patient's charts, etc. Unless your doctor is a specialist, he or she is probably making a lot less money than you think -- and needs to see more patients per hour than is desirable. That's probably changed since your childhood.

(Note: I do not know what I'm talking about.)
posted by The corpse in the library at 7:44 PM on August 11, 2008

seconding desjardins. your child should have a pediatrician.
posted by buka at 8:06 PM on August 11, 2008

We found my son's pediatrician when we took him into the emergency room about six years ago. I wouldn't recommend this for everyone, but it worked great for us.

A method a friend used is to simply drive around your local area and have a look. Go during the middle part of the day, usually right after lunch, and on a day when doctors are usually slow (Wednesday or Thursday seems to be the slower periods in my neighborhood). Pop in and see if a doctor or CNP is available to chat for a couple minutes, or when a good time might be. Pick up literature, and the new patient packet. This worked great for when I needed an ENT doctor, so it might have some merit.

I am in favor of your suggestion to find a single doctor practice. If you have good insurance (usually not an HMO or any sort of public-subsidized plan, as these tend to pay less to providers) a single doc will likely welcome you into his or her fold, especially if you are starting out "small" (routine check-up, shots, etc). This gives you a chance to "interview" the doc while getting something done that your child has hopefully had before, providing a point of reference.

Of course, you could always choose the method I used for finding my dentist: the listed phone number for his office looked cool.
posted by fireoyster at 8:16 PM on August 11, 2008

We go to our local urgent care doctor for GP type things. He doesn't take insurance, just cash up front, and we deal with the reimbursement afterwards ourselves. This is the financial model from 40 years ago, and it makes him the boss, not the insurance company.

Whomever you choose, take some effort to establish a relationship. Just as you want a doctor you can trust, doctors want a patient they can trust. Build up your bona fides - maintain meticulous records, follow instructions with medication, come back for rechecks as specified, etc.

If she asks how often Junior has been coughing, be ready with "no more than once a day, usually 5 to 10 times in a row, usually after he wakes up, a total of 4 days this week, it started June 5th after we installed a new floor", not "oh, off and on for a while."

If you really don't like the 15 minute appointments, ask up front what the allotment of time is. And always be the first patient of the morning.
posted by ebellicosa at 8:18 PM on August 11, 2008

when my wife or I have gone in for minor ailments, we've both had the experience of doctors shotgunning our diagnosis: i.e., half-attentively listen to our problems, do a cursory check of the lungs and ears, not do any more physical checks, then just say that some sort of virus is going around.

I think you just answered your own question. A good doctor will swallow their incredulity at you being in their office with a minor ailment and try to fabricate some sort of chin-scratching fascination with your symptoms, though. Does that make you feel any better?

In modern-day medicine we are truly swamped with serious chronic illness management and an aging and increasingly unhealthy population. I am, still to this day, utterly baffled when someone from an upper echelon of socioeconomic strata brings their self or their child (over 5, say) in for cold symptoms of less than a week's duration. I just always figured most people with busy lives grew up with some sort of basic grasp of health and hygeine. As for the examination, your expectations, again, may simply be anachronistic. Many diagnoses are made largely based on patient history. A detailed multisystem examination is not necessarily going to add anything other than more delays for the other thirty people in the waiting room.
posted by docpops at 8:51 PM on August 11, 2008 [10 favorites has favorites]

As a personal datapoint, I have heard someone at my workplace describe his visit to his doctor something like this:

"I went in and told him it was bacterial. I KNOW it is bacterial-- I can just tell. I told him I am a busy person, I don't have time to be sick, and I don't have time to wait around for a throat culture when I am SURE that it is bacterial. Can I just have some antibiotics already?"

By the way, this is from a scientist with a PhD, who I am sure is familiar with multi-drug resistant strains of bacteria and so forth. Between the insurance companies and the "clientele", our heath system is so screwed.
posted by Maxwell_Smart at 9:33 PM on August 11, 2008 [1 favorite has favorites]

My impression is that the advent of evidence based medicine has in many cases reduced the emphasis on making a diagnosis, when the precise diagnosis makes no difference to the actual outcome.

When you have a cold, and your GP can see you have a cold, they could jump through hoops swabbing you, taking blood "just in case", making you say "aaahhh", etc etc....but they save time and money by skipping that, and telling you to go to bed with some paracetamol and a good book. You may not feel you are getting such thorough care, but you do just as well.
posted by roofus at 12:54 AM on August 12, 2008

Addressing Valkyryn's advice: If you are in Houston, we are not a wasteland that does not attract skilled doctors. In fact, the Texas Medical Center is the largest in the world, and world-renowned for leading care and hospitals attached to medical schools and research facilities.

I've had the same concerns though, with perfunctory check-ups and then immediate prescriptions. So, what I've done with success is to make my first visit with the doctor before anything was wrong -- just a general check-up. During that visit, I explain to the doctor that I am looking to establish a long-term relationship with a general physician, and that I specifically am looking for one with the same philosophy that I have -- that is, no rush to prescribe antibiotics without knowing if a problem can be fixed with them, etc. On the other hand, I am not looking to be the kind of patient who rushes to the doctor with a list of demands based solely on a drug advertisement I saw -- I trust a doctor who graduated from medical school has more medical knowledge than I do, and I want him to apply that knowledge. I then asked if he could offer me that kind of care. He could! And he does! So, this worked for me.
posted by Houstonian at 4:15 AM on August 12, 2008

I recently switched doctors because my family practitioner (physician) mis-diagnosed me (and yes, it was a minor ailment) so ridiculously. I ended up going to see a specialist who literally laughed when I told him when my FP had diagnosed. To me, if she couldn't take a minor ailment seriously, and spend 5 minutes doing a little damn research, what would she do if I had a serious problem?

I do think it's a fairly common problem. Doctors don't do research. They pick something off the top of their heads and prescribe some drug that may or may not work.

My new doctor seems a little more thoughtful, so far. But we'll see.
posted by miss tea at 4:31 AM on August 12, 2008

Many will say "word of mouth" but I don't trust it since by the reviews I've seen on Google Maps and ratemd.com,

"Word of mouth" is from people you know and trust, not random strangers on the internet. Does your son go to school/day care? Do you talk to the other parents there? What doctors do the other parents take their kids to? What doctors do they go to themselves? Do they like their doctors?
posted by DevilsAdvocate at 6:57 AM on August 12, 2008

One of my doctors is a DO and he takes much more time with me than any doctor I've had. He actually listens to my questions, answers them non-patronizingly, and keeps an eye on the larger picture. So I don't know if he's typical of DOs, but he's one anecdotal case.
posted by PatoPata at 7:25 AM on August 12, 2008

The way HCFA has set up medical billing is pretty simple: the less time a doc spends with each individual patient, the more money the doc makes.

Now I don't know about primary care docs, but I find that if I don't spend enough time, my ability to diagnose is not very good. It's probably the same in the primary docs' office; they have to be able to diagnose all the problems in my specialty and every other specialty, and HCFA thinks they should only take half the time to do it. Also, by various means, the supply of primary care docs has been artificially inflated, allowing major price cutting by payors. The result: in order to keep the lights on in the office, more patients must be seen in less time.

Also, costs for docs have gone up. You need full time coding and billing support - the Byzantine maze of medical billing really looks like something devised for inmates of Dante's Inferno, quite punitive - and every year record requirements (completeness, justification for services provided, backup, privacy/HIPPA compliance) get more onerous. The average doc requires three FTEs plus a billing service to support his practice. Add in rent, equipment and transcription costs and you start to get an idea of what docs have to do just to make their operating nut.

Doesn't make much sense. No one gets to practice the way they want to any more except some surgical specialists.
posted by ikkyu2 at 8:35 AM on August 12, 2008

In my geographic area, the good doctors are busy. Getting in to see one of them when you have a medical problem is almost impossible if you haven't already established a relationship. So I'd say that visiting a few doctors is probably a good idea -- but do it when the three of you are well.

I agree that back in the day, doctors spent more time. And they would often give advice on what to do if the first solution wasn't effective. Now it does seem to me that they'll assume the patient has the most likely ailment and treat that. If it turns out not to be the case, the patient needs to come in again. I'm guessing this is all happening because a doctor now needs to see a lot more people in a day in order to make a living.
posted by wryly at 8:47 AM on August 12, 2008

My understanding is that Medicare and private insurance only pay a certain amount per visit, and don't pay anything for the time spent doing research, looking over the patient's charts, etc. Unless your doctor is a specialist, he or she is probably making a lot less money than you think -- and needs to see more patients per hour than is desirable. That's probably changed since your childhood.
(Note: I do not know what I'm talking about.)
posted by The corpse in the library

Actually, corpse, you have hit the nail on the head. Reimbursements to primary care providers for office visits are laughable, and the documentation requirements are onerous.

In addition, health care organizations have all sorts of rules about stuff providers have to do. Where I work, we have 75 things that are supposed to be done annually for each patient, such as screening for colon cancer, depression, and tobacco use. Your provider is probably doing a lot more work at your visit than you realize, and much of it is unrelated to why you think you're there.
posted by neuron at 10:57 AM on August 12, 2008

My experience jibes with yours.

In the last two years, since we moved to Westchester county, I have visited one GP, one psychiatrist, and two dermatologists, none of whom listened to, were interested in, or addressed my any of my medical issues.

It was amazingly hard to find a psychiatrist who would even return a call seeking an appointment. I called more than 20, of whom ZERO called back; one had a receptionist who answered the phone.

I am amazed that any of the apathetic doctors I saw ever have repeat business. It was very depressing to wait months for an appointment, and then get no help.
posted by Lizzle at 2:39 PM on August 13, 2008