Two comments.

First, the doctor who ought to be doing this (making the diagnosis when the diagnosis is not clear) is the general internist. It’s what they spend 3 - 4 years training to do. But once they get out into primary care practice, they find they can spend only 7.5 minutes per patient visit, or else they can’t afford to stay in practice. So - difficult cognitive problems are immediately referred to a specialist. And deciding which specialist (when the diagnosis is not clear) is necessarily a guess. Specialists may end up telling you “Sorry, it’s not my organ that’s causing the problem,” but they’ll only do that after they’ve performed whichever procedure(s) they always perform, on everybody, no matter what.

Second, in my view, the lack of appropriate billing codes for cogitation and communication is a symptom of the problem, not the root of the problem. The root is that doctors (especially primary care doctors) have allowed themselves to be coerced into a position where government bureaucrats and insurance administrators (who each respond to their own byzantine sets of prompts) are able to determine what docs do and how they do it.

I believe, unfortunately, that it has become extremely difficult - approaching impossible - for conscientious internists to practice excellent medicine under what has become the mainstream healthcare system. Alternate forms of medical practice, entirely outside the mainstream system, may be the only viable alternative for these doctors.

DrRich