The Enshittification of Lymphedema Treatment

John Fuller Beckwith6/27/2026

‘Enshittification.’ It’s a rough word. Some might consider it off-putting, perhaps it feels vulgar. It’s a newly coined term, a neologism that is now in the dictionary. Importantly, this word accurately captures what has happened to lymphedema therapy in the United States.

‘Enshittification’ was coined by Canadian journalist Cory Doctorow to describe specifically the degradation of online platforms and services. Doctorow posits that a valuable service is developed to promote use and build a good reputation, then, having captured that reputation, the service is deliberately degraded over time in order to extract maximum financial value. The value and quality of the service is eroded while the owners make more and more money. But because there are no other options we, the users, find ourselves stuck with it. Think Google, Amazon, Twitter and Facebook. We could apply this to heathcare generally but we see it in sharp focus in lymphedema treatment.

I am not on facebook. Never have been. I am a dedicated and passionate lymphedema specialist however I don’t wade into the static in therapist support groups. But a colleague of mine has connected to a facebook group for therapists. She shared a thread that was quite disconcerting. A caring CLT was asking for support and perspective because her clinic management is looking to cut lymphedema treatment times from 60 minutes to 30 minutes. (Before we delve into rationales against this idea, let me go into a soundproof room and just scream - Outrageous! Obscene! WTF! Okay, had to vent for a moment.) Of course this is ridiculous, but what is concerning is that it is actually happening.

While most commentators in the group agreed this can’t and shouldn’t be done, the thread drifted toward accommodation, with a number of contributors offering advice on how to make 45-minute treatments work. If you have read my other essays, you will see I consider 60 minutes too much of a compromise and a disservice to our lymphedema patients. I schedule my clinic for 90-minute appointments and daily treatments is the default frequency option.

If you pay attention you can see this trend has been building over the years and decades, even if you are new to the lymphedema field. When CDT came to the US from Germany, patients were treated for 2-hour sessions and seen twice per day, which is how the original structure was designed to achieve optimal results. Over time both session length and frequency have been curtailed: two-hour sessions became 60 minutes, then 45 minutes. Twice daily treatments dropped to once daily and eventually to once or twice per week.

And in all of this the first phase of CDT, the intensive phase, has been in many places erased entirely. Patients are thrust straight into phase two of CDT: self-management. No real skilled intervention by the trained CLT, just instruction in self-care and pushed into garments.

To put it nicely, this is a disservice to people with lymphedema. More bluntly and accurately, it is the enshittification of lymphedema therapy. Well-meaning therapists are stuck now in a system that is promoting a mere facsimile of the CDT that came from Germany, squeezing out the quality and forcing the burden onto the patients.

Look, a good portion of caring therapists and patients who read this may feel this label on the current state of lymphedema therapy is over the top and perhaps even unnecessarily vulgar. I understand wishing not to raise the temperature of debate and avoid offending some of our colleagues. But I think it is more important to speak plainly and call a spade a spade.

Enshittification feels like too strong a word but to frame lymphedema treatment as enshittification is, sadly, not hyperbole. We have an obligation to speak truthfully. We cannot address a problem that we can’t name and frame accurately. The sad truth is that much of lymphedema therapy in the US has degraded to the point it no longer resembles the gold standard. And, sadly, it no longer provides patients with the treatment they need and deserve.

In summary, managers and therapists primarily focused on maximizing revenue have deliberately, over time, degraded the quality of lymphedema therapy by shortening treatment times, reducing treatment frequency and pushing patients prematurely into self-treatment. In lymphedema care, platform decay looks like this: treatment quality eroding to the point where a 30-minute session is seriously proposed and defended. This is the enshittification of lymphedema therapy.