Tales From the American Medical System

post by Zvi · 2019-05-10T00:40:00.768Z · score: 56 (30 votes) · LW · GW · 47 comments

Epistemic Status: Overheard in New York

I am walking and talking with my friend, a Type I Diabetic, when he receives a phone call from his doctor’s office.

As a Type I Diabetic, my friend needs insulin. The effects of not having insulin are very bad, and include death.

He has run out of refills on his prescription, and will run out of insulin on Saturday. He called about a week ago to attempt to remedy this situation and get refills.

That’s for background. This isn’t about the order of magnitude higher my friend’s copay is in America, compared to the entire retail price in Canada.

This is about my friend’s attempt to get legal permission to continue buying life-saving medication for a lifelong condition with no known cure.

Because for some reason, in America you need legal permission to buy it, and you need to renew that periodically, despite there being chance of the need for said life-saving medicine going away.

I overheard the phone call from my friend’s end. The rest is filled in based on a combination of talking to him after, and extrapolation. He has reviewed this for accuracy.

The nurse tells my friend he needs to go see his doctor, because it has been seven months, and the doctor feels he should see his doctor every three.

My friend replies that he agrees he should see his doctor, and he has made an appointment in a few weeks when he has the time to do that.

The nurse says that he can’t get his prescription refilled until he sees the doctor.

My friend explains that he does not have the time to drop what he is doing and see the doctor the next day. That he is happy to see the doctor in a few weeks. But that until then, he requires insulin to live.

The nurse says that he can’t get his prescription refilled until he sees the doctor. That if he wants it earlier he can find another doctor.

My friend explains again that he does not have the time to see any doctor the next day, nor can one find a doctor on one day’s notice in reasonable fashion. And that he has already made an appointment, and needs insulin to live. And would like to speak with the doctor.

The nurse refuses to get the prescription filled. The nurse does not offer to let him speak to the doctor, and says that he can either wait, make an appointment for the next day, or find a new doctor.

My friend points out that without insulin, he will die. He asks if the nurse wants him to die. Or what the nurse suggests he do instead, rather than die.

This seems not to get through to the nurse, because my friend asks these questions several times. The nurse does not offer to refill the prescription, or let my friend talk to the doctor.

My friend says that if the doctor does not give him access to life saving medicine and instead leaves him to die, he will post about it on social media.

The nurse now decides, for the first time in the conversation, that my friend should perhaps talk to his doctor.

The doctor calls a few minutes later. The doctor is quite upset about this threat to post on social media about being denied access to purchase life saving medicine.

The doctor accuses my friend of having a gun to his head. My friend points out this is a rather interesting choice of metaphor. One could say that the doctor has a gun to his head, in the form of denying him access to life saving medicine. And that the two do not seem remotely comparable.

This seemed right to me, as I had used exactly the words ‘gun to your head’ when discussing the situation with my friend between the two phone calls.

I was not referring to the possibility of posts appearing on social media.

The doctor goes over details of my friend’s care. He wants my friend to come in.

My friend agrees. Points out he already made an appointment. That he needs insulin to live.

The doctor asks, what if your sugars are high?

My friend points out that if this were the case, he would still need insulin to live.

The doctor keeps asking my friend to come see him. My friend keeps pointing out he has already agreed to do this.

The doctor continues to admonish my friend for his blameworthy behavior of only doing all the things he’d been asked seven months ago to do, of only seeing several other specialists for tests, rather than also seeing this doctor every three months as a good obedient patient properly concerned for his own health would have done.

My friend points out that regardless of all that, he would still need insulin to live.

The doctor then admonishes my friend for his terribly blameworthy behavior of not being aware he had run out of refills. Clearly, my friend should have tracked that. My friend points out that he doesn’t keep the prescription boxes, he keeps the vials. That few patients know, no matter what they in theory ‘should’ know, how many refills they have left on a reliable basis. And that he had realized all this a week ago and called his doctor, but was only now hearing that the refill wasn’t going to be forthcoming. Also, to paraphrase a bit, he asked the doctor: Why the hell is it going to run out at all, anyway? Are we expecting a cure real soon now? This need for insulin to live isn’t going to go away.

Having properly pointed out all the ways my friend was bad and should feel bad, the doctor now claims that the nurse was never told that the doctor wasn’t going to refill the prescription without my friend coming in first.

My friend points out that the nurse did in fact say exactly those words. That the prescription would not be refilled without a visit first.

What the doctor then claimed he said to the nurse was rather that the doctor did not want to refill the prescription. That the doctor would prefer that my friend come in.

This is standard implicit command deniability. Pure gaslighting. It’s the same as when a mafia boss says it would be great if a certain someone wasn’t seen round these parts some time soon. Or when the CEO remarks that people seem to be using too many vacation days. The nurse’s job depends on enforcing the implied order given by the doctor.

The doctor asks why my friend is being so unreasonable. My friend points out that he started with an entirely and unquestionably reasonable position of agreeing to come in at his next available time in exchange for continued access to life changing medicine. 

That he’d only changed to what the doctor was characterizing as the unreasonable position of ‘if you deny me life saving medicine I might tell people that you did that’ when it was clear that until he threatened that, he was going to be denied life saving medicine.

If anything, the original position seems to me like it points out that the system has given someone the power to threaten to withhold life saving medicine, that they agree the person needs, in order to coerce the behavior they want from the other person. Which seems bad. But hey.

After a number of minutes of such admonishments, my friend having been sufficiently interrogated and admonished for his dastardly non-submissive, non-compliant role, and his unwillingness to drop everything in his life on a dime for no reason, the doctor offered to renew the prescription for long enough to make it to the appointment. Thus allowing my friend, for the low low co-pay price of ten times what it costs in Canada, to legally purchase the life-saving medicine he will need periodically for the rest of his life.

In some ways this was the good scenario. In the end, access to life saving medicine was in fact renewed. And this was what happened when my friend had, he insists, an unusually conscientious doctor, who is using his powers of coercion, via the threat of withholding lifesaving medicine, entirely to ensure the health of his patients, and who was in the office and capable of responding promptly.

Ladies and gentleman, the American medical system.

 

47 comments

Comments sorted by top scores.

comment by Dave Lindbergh (dave-lindbergh) · 2019-05-10T02:40:44.219Z · score: 25 (10 votes) · LW · GW

I've been thru this same thing with doctors.

One, after being pressed with "why?" repeatedly, fessed up.

They get paid for each office visit. The way they make money is to force patients to visit the office periodically, on pain of having necessary prescriptions cut off.

I'm not talking about narcotics or controlled substances here. (For those, the DEA really does force the MDs to see the patient in person for each prescription.)

You have a greedy doctor. He thinks he's only cheating the insurance company (cheating by demanding needless office visits) but of course everybody pays for that. And your time is worth something, surely.

My advice: Get another doctor.

comment by Scott Alexander (Yvain) · 2019-05-10T16:46:07.157Z · score: 49 (21 votes) · LW · GW

I don’t think it’s necessarily greed.

Your doctor may be on a system where they are responsible for doing work for you (e.g. refilling your prescriptions, doing whatever insurance paperwork it takes to make your prescriptions go through, keeping track of when you need to get certain tests, etc) without receiving any compensation except when you come in for office visits. One patient like this isn’t so bad. Half your caseload like this means potentially hours of unpaid labor every day. Even if an individual doctor is willing to do this, high-level decision-makers like clinics and hospitals will realize this is a bad deal, make policies to avoid it, and pressure individual doctors to conform to the policies.

Also, your doctor remains very legally liable for anything bad that happens to you while you’re technically under their care, even if you never see them. If you’re very confused and injecting your insulin into your toenails every day, and then you get hyperglycemic, and your doctor never catches this because you never come into the office, you could sue them. So first of all, that means they’re carrying a legal risk for a patient they’re not getting any money from. And second of all, at the trial, your lawyer will ask “How often did you see so-and-so?” and the doctor will say “I haven’t seen them in years, I just kept refilling their prescription without asking any questions because they sent me an email saying I should”. And then they will lose, because being seen every three months is standard of care. Again, even if an individual doctor is overly altruistic and willing to accept this risk, high-level savvier entities like clinics and hospitals will institute and enforce policies against it. The clinic I work at automatically closes your chart and sends you a letter saying you are no longer our patient if you haven't seen us in X months (I can't remember what X is off the top of my head). This sounds harsh, but if we didn't do it, then if you ever got sick after having seen us even once, it would legally be our fault. Every lawyer in the world agrees you should do this, it's not some particular doctor being a jerk.

Also, a lot of people really do need scheduled appointments. You would be shocked how many people get much worse, are on death’s door, and I only see them when their scheduled three-monthly appointment rolls around, and I ask them “Why didn’t you come in earlier?!” and they just say something like they didn’t want to bother me, or didn’t realize it was so bad, or some other excuse I can’t possibly fathom (to be fair, many of these people are depressed or psychotic). This real medical necessity meshes with (more cynically provides a fig leaf for, but it's not a fake fig leaf) the financial and legal necessity.

I’m not trying to justify what your doctor did to you. If it were me, I would have refilled your insulin, then sent you a message saying in the future I needed to see you every three months. But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!” If my receptionist tries to call, they’ll hang up. At some point I start feeling like I’m being held hostage. I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.

I do think there are problems with the system, but they’re more like:

- A legal system that keeps all doctors perpetually afraid of malpractice if they’re not doing this (but what is the alternative?)

- An insurance system that doesn’t let doctors get money except through appointments. If the doctor just charged you a flat fee per year for being their patient, that would remove the financial aspect of the problem. Some concierge doctors do this, but insurances don’t work that way (but insurances are pretty savvy, are they afraid doctors would cheat?)

- The whole idea that you can’t access life-saving medication until an official gives you permission (but what would be the effects of making potentially dangerous medications freely available?)

comment by jimrandomh · 2019-05-10T20:35:19.607Z · score: 13 (4 votes) · LW · GW
(but what would be the effects of making potentially dangerous medications freely available?)

It's already OTC in Canada, and nothing bad has happened as a result.

comment by jimrandomh · 2019-05-10T21:25:33.869Z · score: 11 (3 votes) · LW · GW
But I’ve seen patients try to get out of this. They’ll wait until the last possible moment, then send an email saying “I am out of my life-saving medication, you must refill now!” If I send a message saying we should have an appointment on the books before I fill it, they’ll pretend they didn’t see that and just resend “I need my life-saving medication now!”

Insulin is different from the sorts of drugs you prescribe. Most medications, if someone run out, they start suffering health consequences, it's very unpleasant and it incurs a bit of lasting harm, but they don't die. Being without access to insulin is about as serious as being without access to water. If you send a message saying there should be an appointment on the books before renewing the prescription, then there's a real risk that the delay causes them an emergency room visit, or kills them.

comment by Ikaxas · 2019-05-10T22:39:13.298Z · score: 9 (2 votes) · LW · GW

"no refill until appointment is on the books"

But Zvi's friend had an appointment on the books? It was just that it was a couple weeks away.

Otherwise, thanks very much for commenting on this, good to get a doctor's perspective.

comment by Benquo · 2019-05-10T17:04:20.662Z · score: 4 (2 votes) · LW · GW
I really only have one patient who is definitely doing this, but it’s enough that I can understand why some doctors don’t want to have to have this fight and institute a stricter “no refill until appointment is on the books” policy.

Why not just dump that one patient?

comment by adamzerner · 2019-05-10T17:44:51.735Z · score: 2 (1 votes) · LW · GW

Thanks for chiming in. I was hoping to hear from a practicing doctor.

That all does make sense. A doctor requiring appointments for refills seems understandable now. The system that forces them to do so doesn't, but that's a separate issue.

comment by clone of saturn · 2019-05-10T18:51:00.865Z · score: 1 (1 votes) · LW · GW

(but what would be the effects of making potentially dangerous medications freely available?)

Well, you can already walk into any hardware store and buy all sorts of deadly poisons, no questions asked. So my guess would be not much, except they'd be a lot cheaper.

comment by Jiro · 2019-05-10T19:41:08.014Z · score: 4 (2 votes) · LW · GW

The conceptual gap between a standard use of a poison from a hardware store and a deadly use is much larger than the gap between a standard use and a deadly use of a medication, so I would expect far more tragedies to come from the medication than from the hardware store poison.

Nobody's going to self-diagnose and inject themselves with poison from a hardware store.

comment by adamzerner · 2019-05-10T02:50:06.623Z · score: 18 (5 votes) · LW · GW

Grrrrrrrrrrrrr!!!!!!!!!!!

I thought that was a possibility but I didn't think it was too likely.

Don't they have enough money already? I've always been confused about people who are already extremely wealthy acting so greedily. Eg. CEOs. You already have a ton of money, the extra money can't mean that much to you because of diminishing marginal utility stuff, why hurt other people in pursuit of more? Is it that they compare themselves to others around them and want to have more than their friends? Is the pursuit of more just a habit?

comment by Alexei · 2019-05-10T04:13:32.720Z · score: 3 (2 votes) · LW · GW

There’s a good number of people for whom utility is almost linear in amount of money they have.

comment by adamzerner · 2019-05-10T04:32:03.746Z · score: 3 (2 votes) · LW · GW

Why is it that they are like that?

comment by Benquo · 2019-05-10T14:23:57.459Z · score: 8 (1 votes) · LW · GW

In some cases (this is the most nearby alternative hypothesis to Davidmanheim's), the spending required to maintain their class privilege (unless they're really unusually clever) scales slightly ahead of their income.

In other cases, they get addicted to the game, and become obsessed with scoring points.

comment by Davidmanheim · 2019-05-10T07:14:27.219Z · score: 8 (3 votes) · LW · GW

Because their desire to spend money is a constant multiple of the amount they have, and that constant multiple is usually slightly above one.

See: Hedonic Treadmill.

comment by Gurkenglas · 2019-05-18T13:42:11.549Z · score: 2 (2 votes) · LW · GW

At the very top end, if Bill Gates has twice the money he can save ~twice the African lives.

comment by Benquo · 2019-05-28T11:23:32.590Z · score: 8 (1 votes) · LW · GW

Why do you think that?

comment by Gurkenglas · 2019-05-28T14:42:02.819Z · score: 1 (1 votes) · LW · GW

I haven't looked into it like GiveWell has or even read up on it, but my armchair thinking was just that there ought to be diminishing returns because the low-hanging Africans are saved first, and increasing returns because of economies of scale, and those feel like they should about balance out for purposes of saying "can save ~twice the African lives".

comment by Benquo · 2019-05-28T15:53:06.764Z · score: 6 (2 votes) · LW · GW

There just aren't enough excess deaths in Africa for your claim to be true without implying silly things about how easy it is to save foreigners' lives. Most relevant part of the argument:

GBD 2015 estimates that communicable, maternal, neonatal, and nutritional deaths worldwide amount to about 10 million in 2015. And they are declining at a rate of about 20% per decade. If at current cost-effectiveness levels, top charities could scale up to solve that whole problem, then if we assume a cost of $5,000 per life saved, the whole thing would cost $50 billion. That's more than Good Ventures has on hand - but it's not an order of magnitude more. It's not more than Good Ventures and its donors and the Gates foundation ($40 billion) and Warren Buffett's planned gifts to the Gates Foundation add up to - and all of those parties seem to be interested in this program area. Seems unlikely that excess deaths in Africa preventable by the Gates foundation are much higher than global deaths due to communicable, maternal, neonatal, and nutritional causes. (Are they going to stop wars in Africa? End aging, but just for Africans?) If the GiveWell numbers are true, then the "economies of scale balance out diminishing returns" argument implies that the current amount of money available to the Gates Foundation alone is enough to make Africans substantially better off from a mortality perspective than Americans - but surely by the time death rates roughly equalize, we should expect to have exhausted the comparatively cheap interventions like immunizations or diarrhea medication. And if they're false and Gates is spending money slowly for good reasons, then you're already abandoning the premise that extra money would help, since we're already much farther out on the diminishing returns curve than we're pretending to be. I looked up the 2017 numbers to double-check, and it's about 10M deaths per year, of which the majority seems to be infectious disease (such that if you scale up preventing individual cases you eventually get eradication). declining at about 30% per decade.

comment by shminux · 2019-05-10T03:08:30.333Z · score: 23 (8 votes) · LW · GW

The situation is pretty clear: the doctor wants more money, your friend does not want to give him more money for an unnecessary visit, but is also not willing to sacrifice his time or his money or both to knuckle under and get the life-saving medicine that should not even require a prescription renewal in a reasonable healthcare setup.

This was a contest of wills, your friend found some blackmailing ammo (a threat to post on social media), and he won the game of chicken. If the doctor had the nerve and refused, your friend would have somehow found the time to come in the next day, to this doctor or some other, and, depending on his mood that day, made good on his threat or not. We don't know.

One thing is clear though: it was not about life and death, it was about time and money.

comment by Gurkenglas · 2019-05-18T13:49:56.376Z · score: 1 (3 votes) · LW · GW

In a game where some actors are humans, we should expect the highest stakes at play to sometimes be lost. Or do you think that nuclear war is impossible these days?

comment by shminux · 2019-05-18T16:53:09.962Z · score: 2 (1 votes) · LW · GW

Seems like you are making an important point, but I am not sure I get it. Mind clarifying?

comment by Elo · 2019-05-29T17:22:52.751Z · score: 2 (1 votes) · LW · GW

The battle over time and money (patient value for their time) (doc value for money) was more central to the discussion than life and death. Bringing in the subjective life and death claims helps to elevate the stakes of the discussion, but this "signalling game" was all about the time and the money, not the life and death as claimed by the report.

We can pretend it was about life and death but the ticking clock was still very long. I could think of it as a "runway". Yes at the end of the runway if the patient did nothing they could die in a week. On the other hand they have access to money and plenty of options. Lots of start ups run with 6 months of runway and crash, instagram had huge success in a very short time.

The fake runway here has death at the end, before that point includes, "the patient spends exorbitant money" making the runway longer.

comment by Dagon · 2019-05-29T17:06:06.357Z · score: 2 (1 votes) · LW · GW

I believe he's pointing out that yes, this is about time and money, but the limits of the game include life and death. Death will sometimes result from this money-centric behavior.

I don't think that's particularly surprising nor outrageous, but I'm a bit more cynical and semi-malthusian than many seem to be. There are BILLIONS (and growing!) of humans with near-infinite wants. There is a finite (also growing, possibly even faster than population, but still more limited than the wants of humans). Some are going to travel internationally and eat fine meals, and to do so they will find ways to get paid for providing unnecessary "services", like writing a trivially-obvious prescription.

The system is such that a few people will die because they fail to jump through the hoops set up to ensure payment to the power-holders.


comment by romeostevensit · 2019-05-10T01:31:24.117Z · score: 13 (4 votes) · LW · GW

If it were in person the nurse may even have smiled at him.

comment by PeterMcCluskey · 2019-05-10T15:26:34.986Z · score: 12 (4 votes) · LW · GW

This doesn't sound like something that would happen at Kaiser. It's sometimes unclear whether people at Kaiser care about my health, but they seem to have clear incentives to be polite and to not waste my time with unnecessary visits.

comment by adamzerner · 2019-05-10T01:43:05.570Z · score: 9 (6 votes) · LW · GW

I'm trying to steelman and see if there's a way for this situation to make some amount of sense.

  • What happens if you let patients buy refills without a prescription? Would they consume too much of it? Would there be any sort of risk of them selling the excess to others? I wouldn't think so for either of those questions, but I know very little about this domain.
  • Is there a medical reason why the doctor might not prescribe more insulin if he examines the patient and finds something new? I know you're saying that the answer is "no" and that he'll need insulin regardless, but perhaps there is some edge case. The medical system seems pretty obsessed with edge cases and covering their asses. "Have a headache? Ok. Let's just make sure that you don't have a brain tumor or anything first."
  • On that note, I wonder if the doctor is coming from a place of worrying about covering his ass and getting sued if he prescribes more insulin without the exam. Maybe he also knows that he's going to prescribe it regardless, but legally, he needs to say that he examined the patient first in case the patient has a weird reaction or something and ends up suing him.

Of course, this isn't to excuse the behavior. When we're talking about life and death, the system needs to have protocols in place to reallyreallyreallyreallyreally make sure that the death part doesn't happen.

The doctor accuses my friend of having a gun to his head. My friend points out this is a rather interesting choice of metaphor. One could say that the doctor has a gun to his head, in the form of denying him access to life saving medicine. And that the two do not seem remotely comparable.

What an amazing reply.

comment by jimrandomh · 2019-05-10T02:03:50.473Z · score: 18 (7 votes) · LW · GW
What happens if you let patients buy refills without a prescription? Would they consume too much of it?

No. Prescriptions don't specify precise dosages, because those are adjusted much too frequently for direct doctor involvement.

Would there be any sort of risk of them selling the excess to others?

No. There is no secondary market for insulin, because primary-market insulin is easily available at the price of a plane ticket, and improperly stored insulin is unsafe and indistinguishable. Furthermore, no one is trying to restrict access (other than as a way to extract money).

Is there a medical reason why the doctor might not prescribe more insulin if he examines the patient and finds something new?

No. Type 1 diabetics continue to require insulin 100% of the time, no exceptions.

On that note, I wonder if the doctor is coming from a place of worrying about covering his ass and getting sued if he prescribes more insulin without the exam.

In fact, by refusing to prescribe, this doctor created a considerable risk. If the person in the story hadn't managed to get a prescription, and had died, a malpractice lawsuit would probably succeed.

comment by adamzerner · 2019-05-10T02:16:07.565Z · score: 11 (3 votes) · LW · GW

Yeah, that all makes a lot of sense. Thanks for the reply.

So now I'm finding myself very curious as to what possibly could have been this doctors motivation for acting this way. Why would he have such a strong preference to see the patient so soon? And why would he be so reluctant to give the patient insulin in the meantime?

True maliciousness and desire to cause harm seems unlikely, so what could it be?

My first thought is some sort of twisted ego. "You don't say no to me! I'm the doctor! I am the one who knows when I do and don't need to see you!"

That seems somewhat plausible, but also seems to introduce other questions. Why would the doctor want to see the patient in the first place? More revenue? I guess that's possible but doesn't seem likely to me. Maybe the patient has other complications and the doctor cares about the patient and wants to see the patient more frequently to make sure they're alright. That seems to contradict the subsequent "you don't get your lifesaving medicine unless you listen to me" attitude, but I guess it could just be that ego is his stronger drive, or just that he's inconsistent.

Now that I think about it more, the thing that seems most likely to me actually is that the doctor may have come across a good(seeming) reason to have this policy in the past, and just follows it blindly now. Idk though, what would that good reason even be?

comment by Korz · 2019-05-10T11:55:02.208Z · score: 9 (3 votes) · LW · GW

To me too, a mindset of "I am the authority on this topic" from the doctor sounds likely.

I would not be surprised if the doctor adopted a rule of "always discuss treatment in person" as health issues often are very emotional and patients may be ill-informed: Meeting in person is a plus for establishing trust between doctor and patient, which will be essential for handling such situations. This reason doesn't really apply to the case presented by Zvi, but it seems reasonable that at least some motivation for the doctor's behaviour comes from a sloppy application of this rule. It seems to me that the doctor (and nurse) dismissed the possibility that someone could actually have a reason for not visiting right now and then got stuck in their positions.

If the doctor also doesn't reflect on their role as doctor in a consequentialist way, for some situations they might value shown respect ("If your doctor says you should meet them now, you should meet them now") more than the actual improvement in their patient's lives.


I wonder how the doctor would react if Zvi's friend would point out his motivation for keeping his schedule while actively endorsing the importance of his doctor's opinion. This should happen in person, as phone communication is (even) less good at correcting misinterpretations.
If I am right, this could allow the doctor to be assured that their value of shown respect is safe. And possibly this lets the doctor be open to the point of Zvi's friend.

- - -
Apart from this, I am quite distraught by the almost active distrust in their patient's decisions on the side of this doctor and nurse. If this really is typical for the American medical system, there will be massive associated problems ..

comment by Benquo · 2019-05-10T14:26:06.289Z · score: 11 (3 votes) · LW · GW

Doctors valuing their position as an authority, and caring enough about this to threaten to withhold vital care until their authority is affirmed, seems like it would necessarily entail the kind of distrust you're worried about. The paradigm of epistemic authority is one where information can only flow down power gradients - there's no way someone with lower rank would know something that someone with higher rank is ignorant of.

Obviously this is a terrible paradigm for any kind of healing that requires knowing about the patient.

comment by adamzerner · 2019-05-10T17:23:43.908Z · score: 2 (1 votes) · LW · GW
I would not be surprised if the doctor adopted a rule of "always discuss treatment in person" as health issues often are very emotional and patients may be ill-informed

Ah, that does seem plausible. Along with the hypotheses that he sloppily applies this to diabetics who need insulin, and it subsequently became an ego contest.

I wonder how the doctor would react if Zvi's friend would point out his motivation for keeping his schedule while actively endorsing the importance of his doctor's opinion.

I too suspect that the doctor would have responded much better. I've been learning more and more that when you give people an out that lets them maintain their ego, they often are happy to take it. The places where people get really stubborn is when giving in would compromise their ego.

But of course, it's 100% not acceptable for a doctor to let their ego get in the way of life saving medicine, and it is extremely understandable for someone being denied life saving medicine to overlook all of this.

comment by romeostevensit · 2019-05-10T18:29:51.669Z · score: 4 (2 votes) · LW · GW

Keep in mind doctors are optimizing for patients of average ability wrt not acting insanely on their instructions. I found a lot more sympathy for people in positions of authority when I gained experience with the breath taking number of ways people can alter what seem to be very simple instructions.

comment by adamzerner · 2019-05-10T18:32:44.005Z · score: 2 (1 votes) · LW · GW

Gotcha. Maybe it could make sense to apply it to diabetics then.

comment by romeostevensit · 2019-05-10T22:29:46.368Z · score: 4 (2 votes) · LW · GW

Regulatory capture, in practice, means that if you circumvent the existing players they can have you arrested. Many many people are trying to figure out how to supply insulin to diabetics in the US, but no dice so far.

comment by ryan_b · 2019-05-10T14:31:02.248Z · score: 4 (4 votes) · LW · GW

1. I really won't mourn when the machines wipe this profession out.

2. I am pretty sure that a Silk Road for medical care would already be a profitable project. My question is, how easy would it be to get basic symptoms|diagnosis|prescription AI software written up without it being easily traced.

comment by ChristianKl · 2019-05-11T16:47:14.210Z · score: 4 (2 votes) · LW · GW

You probably wouldn't want both the drug delivery and the diagnosis part to happen on the same website. You likely want the diagnostics to be hosted in a jurisdiction like Ecuador or maybe India, that needs cheap diagnostics and doesn't want to shut you down.

comment by ryan_b · 2019-05-11T20:53:40.760Z · score: 2 (1 votes) · LW · GW

I agree. That being said, because this would currently be a criminal undertaking, I feel like the real differentiator is willingness and ability to manage the legal risk. I suspect this weighs against a diverse black market economy springing up that is advanced in multiple sectors simultaneously.

I also think it would be better than the current combination of principal-agent problems and conflicts of interest. At least the website depends on its reputation for success, contra all the players in the legit system.

comment by Pattern · 2019-05-17T23:44:13.883Z · score: 1 (1 votes) · LW · GW
an unusually conscientious doctor, who is using his powers of coercion,
entirely to ensure the health of his patients, and who was in the office and capable of responding promptly.

So do the regular doctors use coercion, while they aren't in the office and capable of responding promptly? Or do they do refills conditional on seeing their patients once every 6 months as opposed to 3 months?

comment by Zyryab · 2019-05-10T01:44:06.740Z · score: -5 (13 votes) · LW · GW

I recommend you show this to a doctor who treats patients with type I diabetes and see if it passes the intellectual Turing test. I don't believe the doctor is being represented accurately here.

Alternative view: Your friend has a deadly disease that requires regular doctor visits and prescriptions. It sucks. It's not fair, but it requires him to take some level of responsibility for his own care. He seems to have failed to do so by not keeping his appointments and letting his prescriptions run out. His doctor needs to see him and check his levels (presumably his A1c) to manage his diabetes. Your friend has unnecessarily escalated the situation by threatening to use the social media mob against the doctor.

Your friend is not evil. He's just young. And like all young patients with a deadly chronic disease, is having a hard time dealing with his mortality. Your friend should keep his appointment with his doctor, but at the same time find a doctor who will be better suited to his schedule and needs.

The doctor is not evil. He just needs to have a clear view of the patient before he goes around prescribing deadly medicine (insulin can kill) to a patient who has shown an inability to manage his disease (keeping appointments, not running out of life-saving medicine).

Regarding the price of medicine in Canada: I believe the fixed low prices in Canada are being subsidized by your friend and all Americans.

Regarding the 3-month figure from the story, from https://annals.org/aim/fullarticle/2653838/treatment-type-1-diabetes-synopsis-2017-american-diabetes-association-standards

"Hemoglobin A1c reflects average glycemia over approximately 3 months and has strong predictive value for diabetes complications (14, 15). Measurement every 3 months in patients with type 1 diabetes determines whether glycemic targets have been reached and maintained. It may also confirm the accuracy of the patient's meter (or their reported CGM or SMBG results) and adequacy of the testing schedule."

comment by jimrandomh · 2019-05-10T01:57:42.916Z · score: 22 (11 votes) · LW · GW
Alternative view: Your friend has a deadly disease that requires regular doctor visits and prescriptions. It sucks. It's not fair, but it requires him to take some level of responsibility for his own care. He seems to have failed to do so by not keeping his appointments and letting his prescriptions run out.

Type 1 diabetic here. Regular doctor visits are actually pretty useless to us, other than refilling the prescriptions. Every six months is customary, but excessive. Every three months is scamming money out of insurers.

Regarding the price of medicine in Canada: I believe the fixed low prices in Canada are being subsidized by your friend and all Americans.

It's cheap literally everywhere except the United States. It's not a matter of subsidized capital costs, because those were all paid off more than a decade ago, and prices were cheaper then.

Measurement every 3 months in patients with type 1 diabetes determines whether glycemic targets have been reached and maintained.

Measuring HbA1c can be done cheaply with an over-the-counter test kit. It does not require a doctor visit. Also, testing HbA1c that frequently isn't important and isn't done by most diabetics.

comment by TheMajor · 2019-05-10T10:26:08.916Z · score: 1 (1 votes) · LW · GW

I think your first remark is exactly the point. If the visits are useless then this is a crappy doctor scamming money and time out of patients and insurance companies, if the visits are important then asking OP's friend to come in (for being over 4 months late on a 3-month checkup) sounds very reasonable to me. I think Zyryab's suggestion of asking a doctor to Turing Test this makes a lot of sense - maybe the checkups are more valuable in certain life stages/demographics/early after diagnosis? Maybe the checkup is something more complicated than recording the HbA1c levels? I'm surprised to hear that without outside medical information the doctor is guilty until proven innocent.

comment by DanielFilan · 2019-05-10T01:54:16.962Z · score: 18 (8 votes) · LW · GW

Your friend has a deadly disease that requires regular doctor visits and prescriptions.

I think that this is a sketchy way to phrase this. Presumably, what a disease requires is a cure (or one of several cures). 'Doctor visits' and 'prescriptions' are one system society can have to assign cures to people, but there could also be other systems, like 'you get to walk to a store and buy insulin if you want some without needing anybody's seal of approval, and you can also see somebody to advise you on how much insulin to take'. Saying that the disease requires regular doctor visits and prescriptions seems to me to rhetorically imply that the costs associated with those are due to the disease, not due to the health care system, without doing the work of checking how well the system works (after all, if the system were about as well as we could manage, the costs really would be due to the disease).

comment by Zvi · 2019-05-10T11:30:01.807Z · score: 8 (5 votes) · LW · GW

I am confused why anyone would believe that this post is attempting to pass an ITT. It isn't.

It's also giving the doctor the benefit of the doubt in important ways that jimrandomh seems confident are unlikely to be accurate - in particular, that the doctor's justification for such frequent and copious appointments is concern for the patient, and has no profit/fraud motive of any kind.

comment by TheMajor · 2019-05-10T10:15:38.823Z · score: 1 (6 votes) · LW · GW

I'm really surprised this is being downvoted so much.

As far as I can tell (and frankly I don't care enough to put serious effort towards finding more information, but I do note nobody in the comments started with "I am a doctor" or "After talking about this with my own doctor, ...") OP's friend was in a life-threatening situation, the solution to which is a renewed insulin prescription. On top of that, the doctor/medical establishment enforces the rule that people (only young people? only people who recently developed diabetes? There could be a good medical reason here, I don't know) with Type I Diabetes have regular checkups.

Now I imagine there are all sorts of reasons for wanting to skip this checkup. Maybe the checkup isn't needed, and is just a money scam (small aside: if my doctor tells me I need a regular checkup, this is not my first thought. But individual situations can vary). Maybe the doctor's schedule is so unreasonable that it's impossible to make an appointment. There could be thousands of valid reasons. The problem as I see it is that, from the point of view of both the doctor and the nurse, they are only negotiating over the checkup. You mention right at the start that the nurse offered a solution ("drop everything and come see your doctor tomorrow") - from that point on the situation was no longer life-threatening! There was no realistic scenario in which this would cost your friend more than the plans they made for the next day! You were just haggling over what is more important, your friend's schedule or the rules set by the medical establishment that you need an active prescription to get insulin and you need a checkup to renew your prescription. Guess which one the nurse is going to find more important.

I understand if it feels like your friend is being blackmailed by the doctor (and in fact it seems like they are), but by refusing to visit the next day you are the ones who escalated the situation. And then escalated even further by threatening with media exposure. I think from the point of view of the nurse your friend is showing rather hostile behaviour. I'll take the liberty of going through the phone call as you posted it, filling in how I expect nurses to act:

The nurse tells my friend he needs to go see his doctor, because it has been seven months, and the doctor feels he should see his doctor every three.

Probably standard procedure. At any rate this decision it out of the nurse's hands, so they are just providing information here.

My friend replies that he agrees he should see his doctor, and he has made an appointment in a few weeks when he has the time to do that.
The nurse says that he can’t get his prescription refilled until he sees the doctor.

Still standard. Nurses don't get to overrule conditions doctors set for medication, if the doctor says a checkup is needed then the nurse has no way of handing over insulin.

My friend explains that he does not have the time to drop what he is doing and see the doctor the next day. That he is happy to see the doctor in a few weeks. But that until then, he requires insulin to live.
The nurse says that he can’t get his prescription refilled until he sees the doctor. That if he wants it earlier he can find another doctor.

Still the same issue. The nurse doesn't have the authority to overrule the conditions set by the doctor. Also I'm missing a sentence here, who introduced talking to the doctor the very next day?

My friend explains again that he does not have the time to see any doctor the next day, nor can one find a doctor on one day’s notice in reasonable fashion. And that he has already made an appointment, and needs insulin to live. And would like to speak with the doctor.
The nurse refuses to get the prescription filled. The nurse does not offer to let him speak to the doctor, and says that he can either wait, make an appointment for the next day, or find a new doctor.

So apparently making an appointment one a one-day notice is very doable on the doctor's side. By this point you are solidly haggling about time, not medicine. I also think the nurse could have let you speak with the doctor here. But I think it's also plausible that they get/did in the past get phone calls from all kinds of entitled weirdos who refuse to show up to appointments, and at this moment it's really not clear your friend is not one of them. Why would their day plans be more important?

My friend points out that without insulin, he will die. He asks if the nurse wants him to die. Or what the nurse suggests he do instead, rather than die.
This seems not to get through to the nurse, because my friend asks these questions several times. The nurse does not offer to refill the prescription, or let my friend talk to the doctor.
My friend says that if the doctor does not give him access to life saving medicine and instead leaves him to die, he will post about it on social media.
The nurse now decides, for the first time in the conversation, that my friend should perhaps talk to his doctor.

Really? Your friend escalates from "I don't want to visit you tomorrow" to "that means you must want me to die", which of course the sensible nurse ignores, and your strategy was to repeat it a few more times? Yeah, you really showed them there. I bet the nurse immediately realised they were wrong the first time, and connected you through with the doctor before you got to the third repetition. From their point of view you've refused a good solution to the problem and are now just bugging them to make your life easier (who likes going to checkups? Nobody. So who haggles about not wanting to show up? Well, not everybody, but more than just your friend I bet). And at that point your strategy is to escalate even more by threatening media exposure, and put even more pressure on that poor nurse? I'm not surprised the doctor claimed you are blackmailing them after this.

What was your goal of the conversation with the nurse in the first place? You need a doctor's prescription for the insulin, so shouldn't you have aimed for talking with the doctor? And if that was your goal, what purpose did it serve to tighten the screws on the nurse? You should have acted like a model patient and calmly requested you speak with the doctor, who can (and did) overrule the normal medical process just to give you life-saving medicine.

I guess that became a far longer monologue than I planned, I'm not going to go through the phone call with the doctor because it's just more of the same. I think OP is in the wrong here, at the very least in their interaction with the nurse. And I do agree that this is a bad medical system, but you really can't throw the co-pay costs, the lack of automatic prescription extensions/sufficiently large prescriptions to last you a long time and your interaction with the nurse and doctor on one heap and pretend this is the fault of "the American medical system". The overall structure sucks, but some of these people are just local actors who cannot make a change and your friend threatened them to not have to change their schedule.

comment by philh · 2019-05-14T15:01:40.885Z · score: 13 (4 votes) · LW · GW

There was no re­al­is­tic sce­nario in which this would cost your friend more than the plans they made for the next day!

Do note that, although they probably weren't in this case, the consequences of dropping your plans for the next day can be almost arbitrarily bad.

For example, it might cause you to lose your job, which in turn causes you to lose your health insurance and your flat.

(In another situation, you might be told "either you work tomorrow or you're fired", and someone could tell you that you're not in danger of losing more than your plans for tomorrow. But in that situation, maybe your plans for tomorrow include "visiting the doctor to get the insulin you need to remain alive".)

comment by ryan_b · 2019-05-10T14:23:55.449Z · score: 2 (4 votes) · LW · GW
What was your goal of the conversation with the nurse in the first place? You need a doctor's prescription for the insulin, so shouldn't you have aimed for talking with the doctor? And if that was your goal, what purpose did it serve to tighten the screws on the nurse? You should have acted like a model patient and calmly requested you speak with the doctor

The part you are looking for is here:

My friend explains again that he does not have the time to see any doctor the next day, nor can one find a doctor on one day’s notice in reasonable fashion. And that he has already made an appointment, and needs insulin to live. And would like to speak with the doctor.

Then after being ignored several times, social media is brought up:

My friend says that if the doctor does not give him access to life saving medicine and instead leaves him to die, he will post about it on social media.
The nurse now decides, for the first time in the conversation, that my friend should perhaps talk to his doctor.

The nurse is not in any sense the victim, until the doctor threw them under the bus. They refused a refill of a prescription, and also refused access to the person with the authority to do so.

comment by Jiro · 2019-05-10T19:54:04.561Z · score: -9 (5 votes) · LW · GW

My friend explains again that he does not have the time to see any doctor the next day

He had the time to see a doctor. He didn't have the time to see a doctor without disrupting his life, which isn't the same thing as actually not having the time to see the doctor. And the fact that seeing a doctor disrupts his life is his own fault for delaying the appointment.

The doctor shouldn't be required to alter his procedure just because doing so would alleviate the consequences of the patient's own decisions.