I appreciate your compliment.

> because no one cares to address systemic issues because no one is incentivized to.

I'm not sure that's true having practiced both in the US and Canada which are both very similar. Speaking to my own specialty (radiology) there are several academics working to build evidence to reduce unnecessary and expensive follow-ups that seem to have low clinical utility.

I'll give you an example, current follow-up regimens for pancreatic cysts are unnecessarily long and expensive with very high probability although all societal guidelines (US and international, with the US version actually the shortest) have very long and expensive follow-up recommendations based on limited evidence from Japan and expert opinions.

When I report a pancreatic MRI although I don't personally want to I still recommend "follow-up in one year per ACR guidelines" as that is currently the standard of care and in the chance that I'm wrong (no compelling evidence on either side at this point but the status quo is to follow-up) the outcome (pancreatic cancer) is devastating.

Simultaneously, several groups (including myself) are looking at long-term evolution of these cysts so we can one day stop doing these probably unnecessary studies with confidence. This is despite the fact that I can bill $130 for a "stable pancreatic cyst" MRI that takes me 2 minutes to report.

Within my own specialty the same thing has been done for breast masses, liver lesions, ovarian masses and renal masses within recent memory and we have dramatically reduced investigations at financial cost to ourselves in the interest of patient care.

> That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.

There's a time and place to fix systems-level issues (which are very hard to objectively evaluate and obtain evidence for fixes), during a specific patient encounter is not one of them.

Inertia in healthcare is real but we also have to remain cognizant that the consequences of mistakes/poor decisions are far more significant than in most other areas of life.

> Another anecdote...

Primary care is broken in the US and Canada (can't speak to elsewhere) due to several issues, the funding model being one of them which greatly limits how much time a GP can spend with a patient while still eating/being able to sustain a practice. Hospital-based specialty care is a lot better on average as we have more resources.

> he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc

For example we do this in oncology where I mostly reside professionally. Treatment decisions are influenced by these factors and every cancer center I've worked in has allied health professionals as part of the team to also help evaluate these factors.

> The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.

The issues you describe are most prominent in private practice environments which are very heterogeneous and there are definitely toxic physician groups that optimize billing, but I wouldn't say the system as a whole does not care. I suggested somewhere that patients try to find academic-affiliated practices (ironically my clinical work is private practice) if they are unhappy with their care as these groups have far less financial considerations and are generically speaking a better choice.

Overall I'd say the system is far from perfect and there are many inefficiencies but the majority of physicians I've worked with do in fact care about patients more than financial incentives. There is no easy fix for these very complex issues.