6 ms·

The Lawlessness of Medicine

87 points by Petiver 11y ago

drchiu 11y ago
What's worse is that modern day society expects physicians to be able to act with some certainty. And when outcomes don't turn out the way everybody wishes it would have, the target of scapegoating is the physician. If you saw a person falling in front of a car, and you stopped to help him but in the process stepped on the man's glasses, would you believe it to be fair for the person who fell to blame you for the broken glasses?
- harryjo 11y ago
  Yes, if you also got the credit for saving him from the car!
  - crpatino 11y ago
    And in a world where stepping on someone's glasses can bankrupt a well to do family, that pettiness of yours and all that think as you do causes people to die under the tires of a car... because would be helpers do not think they can afford to do what is right.
polskibus 11y ago
I can't scroll down linked article on android 5.1 chrome. Although what I've read on the first page corresponds to my observations regarding medicine.
- godzillabrennus 11y ago
  It's unusable on the latest iOS using an iPhone 6 Plus.
- unixhero 11y ago
  You just have to clever up! I managed to scroll down by invoking the Android text selector and be dragging the selector block downwards. Android-CURRENT on Huawei Nexus 6P here :)
jrapdx3 11y ago
To quote the article: "Mukherjee’s laws of medicine are laws of uncertainty, imprecision, and incompleteness. ...". I don't know if these ideas constitute science "laws", but of course the practice of medicine is bounded by such factors. Then again what discipline of any importance is not also similarly constrained? A common theme on HN is the inevitability of software flaws, the uncertainties and corner cases inherent in programming tools, like compilers, render satisfactory outcomes a matter of probability, not at all unlike medical diagnosis and treatment. Nothing new, medicine has been regarded in the last century or so as an art, with a basis in science to the extent it exists. Truth is that a great many phenomena have received little or no study, yet unstudied problems still show up in the office every day and must somehow be addressed. Good practitioners welcome scientific contribution and eager to employ "evidence-based" procedures. Trouble is there's not much guidance forthcoming, leaving those in the front lines doing what they can with the inadequate tools in the toolbox. It's worth adding that a substantial part of the probabilistic nature of the work is attributable to the limitless variability of human illness. I've long expressed the idea in a terse form: The reality is no two people ever have exactly the same disease. The subtle differences are what make diagnosis and treatment a constant challenge. Put another way, abstraction is at once a powerful benefit and potential source of error. Declaring a patient's condition falls into a particular diagnosis lends a valuable clue. However such categorization may easily blind us to the small, crucially important distinctions among sufferers with the same diagnosis. We can easily be fooled by our own cleverness. Point is that the intuition, the talent, of a fine practitioner will always defy "explanations", and that makes it an art. Edit: punctuation
forgotpwagain 11y ago
I will note that Siddhartha Mukherjee is also the author the _The Emperor of All Maladies_, perhaps the greatest popular science book on cancer that is scientifically and historically accurate and very engaging. I highly recommend it (and will be picking up this book on the basis of Dr. Mukherjee's previous work).
raverbashing 11y ago
Very interest article (yeah, it scrolls for me). And it mirrors some of my concerns with only basing yourself on EBM Most studies are flat. They are concerned with "condition X and drug Y". They go to a finer granularity usually when it's obvious (like treatment A works ok but it is obviously a worse choice if patient has condition B). Getting too deep in conditions is a slow process Added to that the elements of diagnostics, which more often than not is a "Plato's Cave" view of the patient's condition "The first law is that a strong intuition is more powerful than a weak test. By this, he means that common things occur commonly and uncommon things, uncommonly... “If you hear thundering hoofbeats, think horses, not zebras — unless you happen to be in Africa.”" Bayesian thinking!
jepper 11y ago
Very interesting article, his previous book 'The emperor of all maladies' is also highly recommended. A lot of medicine is not level III evidence or better backed. As both a doctor (surgical attending) and programmer medicine feels not just like debugging a very complex non linear machine. Patient psychology is one of the hardest parts of the job. Is the stomach pain caused by a psychical problem or can it be functional? The use of protocols (part of the science) can help in catching non typical presentations of illnesses, especially if the patient is not adequate in presentation (drunk, very young, old, trauma etc). But sometimes medicine comes down to an art, when you have the feeling something does not add up, you have to dig. The same with (older) attendings with very attuned diagnostic skills due to lots of experience that can help solve non-obvious cases.
- Madmallard 11y ago
  Too bad it's all standardized now so the quality of care goes down for everyone. Doctors that actually care about making their patients better need to be able to deviate and research for themselves... and not be overwhelmed.
  - HelloMcFly 11y ago
    What makes you believe that standardization results in lower quality for everyone?
- cantrevealname 11y ago
  > medicine feels not just like debugging a very complex non linear machine One way in which medicine is not like debugging is the hours spent by a physician vs a programmer. I (as a programmer) have sometimes spent 100 hours tracking down a bug whereas I've never seen a physician spend more than a few minutes trying to diagnose an illness. Even with a gravely ill person, my experience has been that an attending physician has never spent more than about 15 minutes on the diagnosis (or to be a bit more generous, let's say several 15-minute re-evaluations as new information came to light, such as blood test results). It's a strange contrast. I considered my bugs to be serious bugs, and it was worth 100 hours to diagnose it correctly. But my bugs are nothing compared to a human life. Why is our medical system OK with quick diagnosis? Does it all come down to money or would more time available to the physician make no difference because [medicine is art not science / some other reason]?
mathattack 11y ago
Interesting. For a while I've felt that Medicine isn't the science it's cracked up to be - or at least our knowledge of the state of the art is never as certain as presented by science. It seems to have many false paths of thought similar to economics. In the spirit of confirmation bias, I recently listened to a great podcast relevant to the topic [0] which discusses why this is. It's more than just lazy statistics. [0] http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.html http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.htm...
moobsen 11y ago
AFAIK, the most important law of medicine is "First, do no harm." The rest is basically the details. https://en.wikipedia.org/wiki/Primum_non_nocere https://en.wikipedia.org/wiki/Primum_non_nocere
- JoeAltmaier 11y ago
  Yet doctors routinely do harm - chemotherapy, amputations etc. Its part of many therapies to make a patient hurt. So that's a noble goal, but modern medicine left it behind a century ago.
  - nisa 11y ago
    These things are not taken lightly and are done to reduce more harm or to avoid death. What's the alternative?
    - JoeAltmaier 11y ago
      The point is, "Do no harm" is sophomoric. Harm is, sometimes, the way to do a greater good. Save a life. Restore function. Remove cancer.
jerryhuang100 11y ago
technically i think it's called stochastic systems biology

87 points by Petiver 11y ago

What's worse is that modern day society expects physicians to be able to act with some certainty. And when outcomes don't turn out the way everybody wishes it would have, the target of scapegoating is the physician. If you saw a person falling in front of a car, and you stopped to help him but in the process stepped on the man's glasses, would you believe it to be fair for the person who fell to blame you for the broken glasses?

harryjo 11y ago
Yes, if you also got the credit for saving him from the car!
- crpatino 11y ago
  And in a world where stepping on someone's glasses can bankrupt a well to do family, that pettiness of yours and all that think as you do causes people to die under the tires of a car... because would be helpers do not think they can afford to do what is right.

polskibus 11y ago

I can't scroll down linked article on android 5.1 chrome. Although what I've read on the first page corresponds to my observations regarding medicine.

godzillabrennus 11y ago
It's unusable on the latest iOS using an iPhone 6 Plus.
unixhero 11y ago
You just have to clever up! I managed to scroll down by invoking the Android text selector and be dragging the selector block downwards. Android-CURRENT on Huawei Nexus 6P here :)

jrapdx3 11y ago

To quote the article: "Mukherjee’s laws of medicine are laws of uncertainty, imprecision, and incompleteness. ...". I don't know if these ideas constitute science "laws", but of course the practice of medicine is bounded by such factors. Then again what discipline of any importance is not also similarly constrained? A common theme on HN is the inevitability of software flaws, the uncertainties and corner cases inherent in programming tools, like compilers, render satisfactory outcomes a matter of probability, not at all unlike medical diagnosis and treatment. Nothing new, medicine has been regarded in the last century or so as an art, with a basis in science to the extent it exists. Truth is that a great many phenomena have received little or no study, yet unstudied problems still show up in the office every day and must somehow be addressed. Good practitioners welcome scientific contribution and eager to employ "evidence-based" procedures. Trouble is there's not much guidance forthcoming, leaving those in the front lines doing what they can with the inadequate tools in the toolbox. It's worth adding that a substantial part of the probabilistic nature of the work is attributable to the limitless variability of human illness. I've long expressed the idea in a terse form: The reality is no two people ever have exactly the same disease. The subtle differences are what make diagnosis and treatment a constant challenge. Put another way, abstraction is at once a powerful benefit and potential source of error. Declaring a patient's condition falls into a particular diagnosis lends a valuable clue. However such categorization may easily blind us to the small, crucially important distinctions among sufferers with the same diagnosis. We can easily be fooled by our own cleverness. Point is that the intuition, the talent, of a fine practitioner will always defy "explanations", and that makes it an art. Edit: punctuation

forgotpwagain 11y ago

I will note that Siddhartha Mukherjee is also the author the _The Emperor of All Maladies_, perhaps the greatest popular science book on cancer that is scientifically and historically accurate and very engaging. I highly recommend it (and will be picking up this book on the basis of Dr. Mukherjee's previous work).

raverbashing 11y ago

Very interest article (yeah, it scrolls for me). And it mirrors some of my concerns with only basing yourself on EBM Most studies are flat. They are concerned with "condition X and drug Y". They go to a finer granularity usually when it's obvious (like treatment A works ok but it is obviously a worse choice if patient has condition B). Getting too deep in conditions is a slow process Added to that the elements of diagnostics, which more often than not is a "Plato's Cave" view of the patient's condition "The first law is that a strong intuition is more powerful than a weak test. By this, he means that common things occur commonly and uncommon things, uncommonly... “If you hear thundering hoofbeats, think horses, not zebras — unless you happen to be in Africa.”" Bayesian thinking!

jepper 11y ago

Very interesting article, his previous book 'The emperor of all maladies' is also highly recommended. A lot of medicine is not level III evidence or better backed. As both a doctor (surgical attending) and programmer medicine feels not just like debugging a very complex non linear machine. Patient psychology is one of the hardest parts of the job. Is the stomach pain caused by a psychical problem or can it be functional? The use of protocols (part of the science) can help in catching non typical presentations of illnesses, especially if the patient is not adequate in presentation (drunk, very young, old, trauma etc). But sometimes medicine comes down to an art, when you have the feeling something does not add up, you have to dig. The same with (older) attendings with very attuned diagnostic skills due to lots of experience that can help solve non-obvious cases.

Madmallard 11y ago
Too bad it's all standardized now so the quality of care goes down for everyone. Doctors that actually care about making their patients better need to be able to deviate and research for themselves... and not be overwhelmed.
- HelloMcFly 11y ago
  What makes you believe that standardization results in lower quality for everyone?
cantrevealname 11y ago
> medicine feels not just like debugging a very complex non linear machine One way in which medicine is not like debugging is the hours spent by a physician vs a programmer. I (as a programmer) have sometimes spent 100 hours tracking down a bug whereas I've never seen a physician spend more than a few minutes trying to diagnose an illness. Even with a gravely ill person, my experience has been that an attending physician has never spent more than about 15 minutes on the diagnosis (or to be a bit more generous, let's say several 15-minute re-evaluations as new information came to light, such as blood test results). It's a strange contrast. I considered my bugs to be serious bugs, and it was worth 100 hours to diagnose it correctly. But my bugs are nothing compared to a human life. Why is our medical system OK with quick diagnosis? Does it all come down to money or would more time available to the physician make no difference because [medicine is art not science / some other reason]?

mathattack 11y ago

Interesting. For a while I've felt that Medicine isn't the science it's cracked up to be - or at least our knowledge of the state of the art is never as certain as presented by science. It seems to have many false paths of thought similar to economics. In the spirit of confirmation bias, I recently listened to a great podcast relevant to the topic [0] which discusses why this is. It's more than just lazy statistics. [0] http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.html http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.htm...

moobsen 11y ago

AFAIK, the most important law of medicine is "First, do no harm." The rest is basically the details. https://en.wikipedia.org/wiki/Primum_non_nocere https://en.wikipedia.org/wiki/Primum_non_nocere

JoeAltmaier 11y ago
Yet doctors routinely do harm - chemotherapy, amputations etc. Its part of many therapies to make a patient hurt. So that's a noble goal, but modern medicine left it behind a century ago.
- nisa 11y ago
  These things are not taken lightly and are done to reduce more harm or to avoid death. What's the alternative?
  - JoeAltmaier 11y ago
    The point is, "Do no harm" is sophomoric. Harm is, sometimes, the way to do a greater good. Save a life. Restore function. Remove cancer.

jerryhuang100 11y ago

technically i think it's called stochastic systems biology