This is a very concise way to put it. And what's worse is that if you do try to take the narrative into your own hands and bring the whole story into appointments, there's a fair chunk of those doctors that will take offense at you trying to lead the conversation or decide that all that effort is evidence of some sort of malingering disorder. Even with lots of effort and information organization, it's still often a damned if you do, damned if you don't sort of thing.

> My experience suggests that the transactional nature of modern medicine is part of what makes these types of investigations so hard. A doctor will be booked solid all day without time to reflect or investigate and that really only works with one-off problems.

I'd argue that has more to do with the sheer number of variables and our limited understanding of how they interact.

Patient resilience is also a factor. Few have the resources to eliminate all possibilities at their own expense while accepting the risk of having nothing to show for it. The opposite end of the spectrum are people who show up expecting to walk out with Vicodin and SSDI after the initial consultation.

Using chronic migraines as an example, that shit is a response to something-- and it may not even be medical in origin. Worst case: if you're a diabetic homebody living with six cats' dirty litter boxes, have mold in your basement and bats shitting in your attic, drink no water, smoke meth and eat only takeout Chinese food, any single one (or combination) of these could cause chronic migraines, and are far from being the only causes. Stipends and Oxy won't fix any of this.

Doctors are not investigators. They are scientists. Trained investigators are presumed unqualified to "manage that narrative and mine it for insights" because they are not Doctors (credentialism/"you're not a doctor" is literally the response any disability attorney would suggest you raise against skeptics, failing to notice the irony in a non-doctor attorney/client team touting the validity of a self-authored medical narrative).

> chronic migraines as an example, that shit is a response to something

Sort of. I think the _chronic_ aspect of chronic migraine often ends up being a response to something, but migraine itself is considered a primary condition.

In my case, I respond to many stimuli that are out of my control or hard to control all the time — weather, seasonal allergies and stress to name a few. I also have stimuli that I can control, and by controlling those I reduce the impact to those things I can’t control.

FWIW, I’m not shitting on doctors, here. I actually think that there is some evolution of our medical system that takes the narrative into account, perhaps by process or an intermediary that helps a patient manage their “case”.

I’m not sure transactional is the right word. The problem you are identifying is physician bandwidth, or more fundamentally, insufficient physician supply to meet medical demand, which leads to lower quality care.

That doesn't sound quite right to me. There is a lack of physicians, especially family/general, which makes everything harder.

But that doesn't nearly account for everything. It is also true that the system is set up very transactionally, and that this makes it difficult to address many chronic issues as well as they could be.

If you are lucky, you have an involved general practitioner who has a long history with you, good notes, and time to get into difficult analysis. For many people currently this is a pipe dream. Hell, many people are reliant on ER for basic care - a system that is fundamentally incompatible with this sort of baseline and evaluation.

There are problems beyond just supply and demand. The reason in my experience that someone might use the term transactional is that at any given appointment, most doctors will only choose to focus on one or two topics or concerns. And generally, to get any sort of treatment option for those they'll need some sort of code for insurance to reimburse for the visit. This is especially true for specialists, whom if you visit enough doctors you'll realize push procedures or specialized tests very heavily because that's what makes money. In the current system every single aspect of medical care must have a price tag attached, must be composed of transactions and codes, or the doctors won't get paid. When the concept of "what is the diagnosis" implicitly morphs into "what is the billing code", medical care becomes a fractured and transactional experience rather than a holistic assessment. (And for any doctors reading this, I know that "holistic" is one of those quack trigger words, but those quacks are responding to an unmet need even if their treatments and diagnoses are pure bunkum.)

I think you’re absolutely right that that physician bandwidth is the cause, I think you could characterize the transactional medical experience as a side effect of that problem.

When I say transactional, I mean that each interaction has a cause (“what brings you in today?”) and an action (“try this medication”, “see this specialist”); each visit is like a full story arc from start to finish.

Compare that to psychotherapy where each visit is more like a continuation of the previous session — a narrative. IMO, people who suffer from chronic conditions would benefit from a model that draws on the narrative aspect of therapy.