Page 30 - Binder2

3. They are structurally entrenched.
These strategies are standard practice. They are
built into treatment guidelines, reimbursement
systems, and clinical workflows. They persist not
because they work, but because there is no widely
adopted alternative.

The Illusion of Control

From the outside, these coping strategies—dose escalation,
immunosuppressant add-ons, therapeutic switching—
suggest a system equipped to handle complexity. To the
untrained eye, it looks adaptive: a highly specialized field
responding to biologic variability with individualized
solutions. There are algorithms. Flowcharts. Guidelines. It
all looks very precise.

But from the inside—from the patient’s perspective—it
doesn’t feel like strategy. It feels like trial and error
dressed in a lab coat. A game of pharmacological roulette.
One drug is replaced with another. One mechanism is
swapped for the next. One side effect gives way to another
unknown. All the while, the patient is told this is normal.
Expected. Even optimal.

But it doesn’t feel optimal.

It feels like guesswork. It feels like buying time. It feels
like a system improvising in slow motion, hoping each
new move will stick just long enough to justify the cost.
And if it doesn’t? Try the next one. Add another drug.
Increase the dose. Wait. Repeat.

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