There Was No ‘Reply’ Button

A few moments ago, this was written in high dungeon, I received a message from the woman who considers herself my primary health care provider, entirely responsible for my health decisions  We differ primarily in me thinking I am, no doubt will discover other ways as we go along.  That seems to annoy her.

But that isn’t what has annoyed me so much, disagreeing with people in authority is a constant in my life.  However, the fact that the medical system has assumed an authority over me is an issue for me. The message was a ‘request’ for me to have tests and schedule a visit.  There were instructions and links to be used to fullfill each of those ‘requests’.

But no way to reply directly to the ‘request’.  Which, in my pedantic and easily irritated mind, takes it out of the request category. And additionally, I did have good reasons for the delay, which I would have been happy to explain, had she wanted a reply.

It seems to me very easy to notice that these days our wonderful internet and web have been used to extend advisory roles and solidify them into roles of control of your life, rather than to make more personal interactions and give the individual more control.

Yes, it would require my ‘care team’, as MD, PA and nurses are called who handle that mail, to a) be cognizant of what was obviously a computer-created message and b) at least assimilate the returning info, or copy it into the medical record.  I send my care team info I want in my medical record, seems sensible, and then I don’t forget it.  That has not been encouraged.

Our miserable institutions and organizations have taken a tool, a capability, a very inexpensive addition to mental and economic assets, and used it to prop up a system that was already failing.  If computers and networks had not developed as they have, all of modern electronics would not exist, and very little of our modern wealth would exist. And also, none of the gargantuan institutions in our lives.

The potential for great improvements has been wasted in the pursuit of great salaries and profits and power.  This is not even in the ballpark of personal medicine, I wouldn’t be sure my MD remembered me first visit to the second if I had not annoyed her so much.

Instead, this is the standard evolution of cartels, so evident in the medical business now, as all others previously, so long in the planning and implementation.  It has been a gradual coalescence of money and finance running medicine, ever-more administrators per medical person, ever-more medical people and kinds of medical people under one ever-more profitable economic entity, a continuous division of responsibilities between people.

I can’t get upset with the people working within it, they are playing the hand they have been dealt just like all of us, but that doesn’t absolve any of them from the changes to them personally in this evolution, nor how they treat me.  I bet my MD was a more pleasant person before she started working for the enormous medical machine she is part of.  Also, of course, before she met me.

This trend to the gargantuan in medicine is supposed to be the price of the great medical care we are getting.  Except we aren’t, and don’t take my disgruntled word for it. I know a lot of people who tell about things that went terribly wrong when they were under medical care, and how suspiciously everything was handled, no good explanations for strangeness. 2 of 3 of my close friends and family after their heart surgeries, in fact. Some of that info, of course, is just non-medical people’s observations, but others not.

None of the people I know are, or have been, omniscient, so don’t take their word for it, read the reports.  I just read articles about the study showing 250K accidental deaths a year in the medical world, and know that the real number is many times that rate, because I read the previous couple of reports, the first of which which started out at 50K, and the definition of ‘accidental death’ in those was so restricted as to be laughable.  They knew it was more, it was medicine’s first study of it’s own error rate.

At the time, I believe I heard ’10x’ more from a rational commentator. And I definitely had an MD tell me that Quality Assurance programs in hospitals devolved into ‘ways for nurses to get even with MDs’, for what that is worth. And I have read many articles about obvious programs for preventing hospital-transmitted infections that the leading researchers, who have proved the efficacy of their programs in their and other hospitals, are ignored, the costs are enormous and there are 75K to 100K deaths a year to infections.

So we didn’t get better medicine through the last part of that institutional and financial consolidation of the health care system.  I am very confident my current physician is the best-trained physician I have ever had, because she was trained more recently, has more current knowledge and was trained in a series of top institutions.  And no question, the state of medical knowledge increases, the medical miracles are constant, and I have appreciated those in all of the many benefits in my life and my family’s life.

But the system she is part of is increasingly large and complex and medicine is increasingly large and complex, complexity makes it easy to not apply that knowledge, or misapply it, and we see that in the rising accidental death rates, or perhaps just acknowledged accidental death rates. The costs, the inability of people to pay, we see in the rising suicide rates.

Medicine, applied science in general, is of irreducible complexity, and I certainly believe computers and electronics and automation must be part of that.  But I certainly don’t believe that crony capitalist consolidation of financial empires is going to improve the problem. Their web interface, the great restrictions on patients providing MDs with info (1000 words, is another example, the clutziest email interface ever a 3rd) would be an embarrassment to a provider that cared about patients, but they likely got industry design awards for it, as those are easily bought.  They are a for profit gargantuan health care provider (FPGHCP), and they intend to give exactly the image that they give, and treat patients just like we are treated, because it has been very carefully designed and managed top to bottom. I have friends who do that kind of work also, the real world doesn’t happen like Obamacare’s web site.

But, without looking, I can guarantee there is open source software for small offices doing everything my GHCPP does, except the cost of the constant back-and-forth with insurance companies, a system which is broken. (My last, now retired, MD wrote that kind of software for his own office, my medical records have impressed everyone since.)  My previous insurance company had the highest initial rejection rate of insurance claims in the industry, they bragged that made them more profitable than other companies. Likely the reason for Obamacare being so protective of insurance companies, as that is key to consolidating the medical industry, institutionalizing a slice of the financial pie for Wall Street supporters, with enough good salaries for administrators and the higher levels of the medical world to keep them quietly part of the 10% supporting the status quo. As well as expanding government power, of course.

Was it planned?  Yes, of course, all right out in the open, policy.  And behind the scenes, the medical manufacturers, drug companies and for profit hospitals, financing the politicians and think tanks who did all that policy, and paid for all advertisements in the major magazines where they purchased their various awards for product design and wonderful new products, and which they used to sell us, the voting public, on the policies.  Along with the indoctrination in schools, colleges, and most other social institutions.

That process is selectively fostering and hindering the memes by which we, the public, made decisions. Again I conclude that modern PR has created more concentrated power and wealth than any other technology, including gunpowder.

That is the way a lot of American lives have been, all other countries the same, but different versions of the slideways reducing us from independent people to just another customer being told how to spend the government’s money, as nobody can afford health care any longer, which the generally-failing economy puts even more in doubt.

Nobody wants any of this in the medical system, they can’t resist any more than I can.  My MD would likely rather be working for a small private practice.  Clients and friends of my wife have a nice life and good income, and if you are in a group you have a bit of control. Small offices, unless you are a top surgeon or other specialist, have been pushed out out by the combination of their liability insurance costs, which we can understand better, given that 250K/year underestimate of the situation, and the costs of dealing with the insurers who pay them.

As usual, I don’t have a solution to what is obviously an enormously complex system problem except to unwind the causes of the problem.  Nobody can do anything about the complexity of medicine, no amount of automation for patient or MD will ever take that away.  However, we can do a lot about the overheads of dealing with insurance and malpractice and FPGHCP’s inherent complexity and the mistakes that causes. Those must be huge, because independent MDs paid in cash commonly charge 20-30% of what FPGHCP charges, me and the insurance company. Not to mention the continuous frauds (errors they say, but I have talked to people in their billing department) that are my FPGHCP’s bills to me and my insurance company.

Wrong questions produce wrong answers.  We should know by this time that ‘consolidation’ is an answer to the wrong question.

Why do that to yourself? This blog has preached the perils of complexity and bad control systems and bureaucratic organization since the beginning. Programmers have to deal with complexity, working through designs and algorithms to accomplish a calculation within a time limit is a big part of our work.  In even ordinary work, every programmer easily finds himself balled up in self-created complexity, and finding the bugs can be a bitch. Failure due to ‘second system syndrome’, having too-high expectations written into the specifications, is a very well known failure mode.

Entire theories of proper programming practice aim at not ever adding anything to a program until it is well-tested working at the slightly previous level, and if a new version on top of that doesn’t work quickly, abandon the changes and try again, because you didn’t understand it well enough in this attempt.

Fixing sick software is a lot easier than a sick person. MDs can’t abandon the sick, we know they have irreducibly-hard problems.

But software engineers have learned how to avoid making things worse at the project level, and many of us have learned about working in large companies. I could never do the quality or quantity of the work I am capable of, what I did in my own projects nights and weekends, when in those environments.  The institutions keep you in meetings and reporting with conflicting requirements to different parts of your work, which itself always the same kinds of conflicts, all those take time to resolve and produce errors.

My MD can’t have it better, she is in that kind of company. I can tell, because there wasn’t any reply button.

Added later : The inevitable link proving how right I am.

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