Who Gets Paid to Find Out Why?

There is something about healthcare that has frustrated me for years. A patient can see multiple doctors, have imaging, blood work, medications, injections, therapy and specialist appointments and still not have an answer to the question they actually care about:

Why is this happening to me?

That does not mean the doctors are bad. It does not mean the tests were unnecessary, and it certainly does not mean medication does not have a place. I think the problem is much bigger than that.

Our healthcare system is very good at creating pathways for treating identifiable problems. But when the problem is complicated, longstanding or involves multiple systems, finding the "why" can require an enormous amount of time.

And that raises a question I don't think we talk about enough:

Who gets paid to find out why?

Think about someone who has been struggling with pain or declining health for five or ten years. They may have had several injuries, surgeries, changes in sleep, changes in body weight, abnormal blood work, new medications, increased work stress and a gradual decline in physical activity. Their nutrition may have changed. Their digestive health may have changed. Maybe their symptoms have changed several times along the way.

They see an orthopedist for their knee. A gastroenterologist for digestive issues. A physical therapist for their back. Their primary care physician follows their blood work. Another provider may address sleep or mental health.

Every one of those practitioners may be doing their job appropriately.

But who is responsible for putting the entire story together?

Who sits down with five or ten years of information and asks what changed first? What happened next? What preceded the current problem? Which findings matter and which don't? Could seemingly unrelated problems actually be connected? What treatments have already been tried, and what can we learn from how the person responded?

Doing that properly could take hours.

The Economics Matter

This is where the conversation gets uncomfortable.

Doctors work within a system that demands efficiency. There are patients waiting, notes to complete, insurance requirements, laboratory results to review, messages to answer and referrals to make. Spending several hours investigating one complicated patient simply isn't realistic in most healthcare settings.

A true deep dive might involve reconstructing someone's medical history, reviewing previous injuries and surgeries, comparing years of blood work, understanding medications, nutrition, sleep, stress, activity and lifestyle, reviewing previous treatment responses and then performing a thorough clinical examination.

After collecting all of that information, someone still has to sit down and think about what it means.

Compare that with identifying the primary complaint, ruling out something dangerous, ordering an appropriate test, prescribing a medication when indicated or referring the patient to another specialist.

One fits neatly into the existing system.

The other doesn't.

That isn't necessarily a failure of the doctor. It may be a failure of the incentives surrounding the doctor.

Medication has an economic model. Imaging has an economic model. Laboratory testing has an economic model. Procedures have an economic model. Pharmaceutical companies obviously have a financial interest in medications being used.

Again, that doesn't make any of those things bad. Medication saves lives. Imaging can provide critical information. Surgery can completely change someone's life.

But where is the comparable economic incentive for spending hours trying to understand how ten years of health, injury, lifestyle and physiology fit together?

Who gets paid to review the old ankle injury, the change in blood work three years later, the declining sleep, the change in activity, the nutrition, the stress, the medications and the current pain and ask whether any of it belongs to the same story?

That work is difficult.

More importantly, it takes time.

And time is expensive.

Treating the Symptom Is Easier to Scale

This may be one of the reasons healthcare has become so effective at managing individual problems while sometimes struggling with complicated people.

There are times when symptom management is exactly what someone needs. If someone is in severe pain, reducing that pain matters. If blood pressure is dangerously high, it needs to be controlled. If someone has an infection, treat the infection. If someone needs surgery, they need surgery.

But controlling a symptom and understanding why it developed are different questions.

A medication may successfully change a laboratory value without explaining why that value became abnormal. An anti inflammatory may reduce pain without explaining why a particular tissue keeps becoming irritated. An injection may allow someone to function again without explaining why the same area continues to become overloaded.

The problem isn't treating symptoms.

The problem is when treating the symptom becomes the end of the investigation.

Healthcare Has Silos. The Human Body Doesn't.

Specialization has produced some of the greatest advances in medicine. We absolutely need specialists.

But the body does not know which specialist you were referred to.

Sleep affects recovery. Stress affects physiology. Hormones influence tissue. Nutrition influences metabolism. Pain changes movement. Movement changes loading. Previous injuries can change how someone moves, and those changes can alter how forces are distributed elsewhere.

That does not mean everything is connected to everything. It doesn't mean we should invent relationships just because they sound plausible.

It means someone needs the opportunity to investigate whether a relationship exists.

Sometimes a painful knee really is just a knee problem.

Sometimes it isn't.

And sometimes the most important information isn't where someone hurts today. It is the sequence of events that brought them there.

An injury occurs. Movement changes. The person compensates. Activity changes. Sleep deteriorates. Weight changes. Stress increases. Another area begins hurting. Treatments address each problem as it appears.

Eight years later, someone has to try to reconstruct the story.

That is difficult work.

And once again, we come back to the same question:

Who gets paid to do it?

Maybe This Is the Gap We Need to Fix

I don't think healthcare has a shortage of intelligent people.

I don't think physicians need to be told to care more.

And I don't think the answer is rejecting medication, imaging, surgery or modern medicine.

Maybe we need to look at the structure around them.

If the system financially rewards short encounters, tests, procedures, prescriptions and moving patients efficiently through the system, we should not be surprised when spending hours investigating complicated health histories becomes difficult to provide.

We say we want root cause care.

But root cause investigation requires time.

Time to listen.

Time to examine.

Time to review.

Time to compare.

Time to question.

And time to think.

Someone has to pay for that time.

Until we figure out how to make that kind of investigation viable, I think complicated patients will continue moving between very good practitioners who each understand one piece of the problem without anyone being given enough time to understand the whole.

Maybe that is the question healthcare needs to answer:

Not just who can treat the symptom, but who gets paid to find out why?