8 ms·

My issue with doctors: Recently, my dad was sick with a pretty bad cough. Like, so bad that he couldn't speak without coughing. He fainted twice from minute lo

by scarmig 10y ago

My issue with doctors: Recently, my dad was sick with a pretty bad cough. Like, so bad that he couldn't speak without coughing. He fainted twice from minute long coughing fits, one of those times hitting his head his head on the stove on the way down, leaving a deep cut and blood everywhere. He went to at least three different doctors. He got a scan of his chest. Everything looked clear, and all of the doctors were stumped. Things were pretty bad. I mentioned this to a UCSF resident friend, and her immediate response was "Oh, is he on <some blood pressure medication I forget the name of>?" I was like, uh, let me see. Called my mom, she checked, and, lo and behold, he was on it. So his doctors took him off it and within a week he was better. This coughing wasn't some obscure side effect of the medication she knew through sheer brilliance: it's a side effect that's been widely known since the 1970's. Hell, it was on the drug's Wikipedia page. So there's a couple morals you could take from this. One would be, wow, doctors are smart to be able to diagnose an issue based on a single symptom and some reasonable assumptions about a patient's background! The other is that the median doctor is pretty worthless; spending tens of thousands of dollars gives you no guarantee you'll see someone competent; and that a medical system that relies on you grabbing drinks with a UCSF resident to get good results is fundamentally broken. Machine learning and expert systems don't have to be as awesome as the best doctors to be valuable. They don't need to be better than competent doctors, even. They just need to provide a bare level of competence to provide a huge amount of value.

cdelsolar 10y ago
Atenolol? I'm not a doctor but I'm reasonably sure it's this.
- fifteenforty 10y ago
  Not this. ACE inhibitors tend to cause a cough. You tend to get this side effect pretty quickly. It doesn't just occur randomly months or years after starting the drugs unless of course something else changes in your health.
inopinatus 10y ago
You didn't say whether the medication was declared at the initial admission. Nonetheless the thing I took away most from your remark is a reminder to be aware of side-effects. Or more broadly, a reminder that patients are participants in their own treatment, and that the existence of doctors doesn't excuse us from responsibility toward ourselves & those we care for.
jazoom 10y ago
That's quite a lot you've taken away from one anecdote. ACE-inhibitors are well-known to cause a cough but not like the one you're describing. If I was to guess I'd say he had a respiratory tract infection that magically disappeared (as they do) not long after ceasing the medication. This is a common type of scenario where lay people get confused about correlation and causation, and is one of the reasons you need doctors to help you. Even if it was the medication, like I said, this sounds like a somewhat unusual case. You'll probably spend the rest of your life thinking the doctors didn't know what they were talking about, but in my experience with doctors (I have a lot of that since I'm a doctor myself), even the "median" ones are far better at diagnosing things than lay people.
- pizza 10y ago
  I think that a median doctor + a statistical classification scheme > a median doctor alone, though.
  - jazoom 10y ago
    Sure. And most of us would be super keen to use that. In fact, ED doctors in particular use heaps of things like that. Maybe instead of rule systems we will eventually use deep learning algorithms.
- temp246810 10y ago
  I don't know - if you're at all in a profession that requires problem solving, it can be quite jarring to work with a doctor. For any given complaint, most will just tell you that your test results are in the normal range (don't get me started on this "normal range") and tell you there's nothing they can do. I live in the bay area and have had a few GPs over the years, some from well known institutions. Doctor's seem to put in the minimal amount of effort to get you out of their office in the allotted 20 minutes so that they can move on to the next patient. I have multiple anecdotes similar to OP's - times where if it weren't for my insisting or my own inkling to visit a specialist I just would never have been helped. Are there goood GP's? I'm sure there are - but to casually dismiss OP's statement is a bit ironic - since casually dismissing is part of the biggest problems as far as my own experience with doctors.
cheez 10y ago
It's not doctors. I am working on software for the OR right now and I had never taken a biology course. The amount of stuff you need to know is IMPOSSIBLE. No, it is literally impossible. The human body is beyond ridiculously complicated and this is why most doctors pattern match for everything they've seen before. This is why, if I were an MD, I would be latching on to ML as quickly as I possibly could. There is a TON of money to be made here, sadly, I do not have the domain expertise to make it, though I am picking it up pretty quickly.
kevinalexbrown 10y ago
> the median doctor is pretty worthless This seems fairly disrespectful. I suppose you mean that the median doctor isn't perfect, but do you have any idea how many hours residents put in? You might think carefully before calling the median one worthless, and ask whether they're really, truly wasting their lives in the service of others. Less emotionally, I find it hard to believe that half of doctors proved essentially no benefit. > it's a side effect that's been widely known since the 1970's Guess how many side effects have been widely known since the 1970's? For clarity: I am 100% in favor of thinking critically about a doctor's advice, having received contradictory diagnoses before.
- ncouture 10y ago
  > Guess how many side effects have been widely known since the 1970's? Does this make it fine not to expect a doctor to inspect the list of known side effects for drugs his patients are taking? I've heard this very story a few times already, perhaps the sources of data widely accepted by doctors are not up to par with what non-doctors consider as accurate, in some cases anyway.
  - kevinalexbrown 10y ago
    Without knowing this specific case, I can't say for sure. But my broader point is that the knowledge base required of doctors is so huge that even if it's not excusable, it is understandable. Like online community moderation, it's really easy to point to cases where doctors got it wrong and assume it's all for naught. Absolutely the accuracy of doctors should be improved, but the bar is not "are you as good as a UCSF resident?" (one of the best programs nationally) but "are you better than nothing?" It just seems crazy to me to suggest that the median doctor, i.e. at least half, is worthless.
    - saiya-jin 10y ago
      yeah, arrogant comment that was. I presume the guy always does his work at 100% or more, flawless, checking every detail and aspect, thinking 10 minutes before saying anything... We all have our tiny and bigger faults, yet somehow when it comes to health we expect impossible. I have similar crappy experiences like most people here, and tended to hate all medical personnel uniformly. Then I started dating a young doctor - still can't wrap my head around how overworked over-stressed and underpaid piece of shit work that is. Bear in mind that we're talking about biggest university hospital in Switzerland. Working ridiculous amount of hours (normal shift can be 10-13 hours, overtime unpaid), night shifts that will just mess you up mentally, crazy and dangerous patients, drug addicts, very real danger of contracting stuff like HIV or hepatititis C by single tiny mistake, or actually killing somebody by overlooking some tiny fact about N-th patient that night. You can end your career for life and end up in jail and/or with lifelong debt by one mistake. ONE. Even after directly saving life of 500 other people. Compared to my comfy corporate job, where I earn much more, did get mistake or two in production over last 5 years (nothing critical like making loss, but still), well... We should be thankful that anybody clever is actually still doing that job. Most of them could earn more and have actually a life someplace else. Blame how system is setup much more than individuals forced to exist in it.
marcell 10y ago
A recent MD friend of mine mentioned that the standards in medical school are much higher today than 20 or 30 years ago. While this is pretty anecdotal, you may have better luck with doctors who graduated more recently. Perhaps someone with experience from medical school can comment. Separate from that, I've had similar experiences. The median doctor I've interacted with isn't able to put in effort to really understand an individual case, and it's very easy to get overlooked or ignored. I've run into a few exceptions but that is the general rule. Source: wife had pregnancy with complications, young children.
- Spooky23 10y ago
  The downside is that at least in my experience the newer doctors seem to be docbots. Lousy bedside manner. I've had the dubious honor of spending quality time in a few hospitals with sick relatives in the last year. The nurses rock, and PAs and NPs seem to do what residents used to do. The residents in particular seem to be clueless. With electronic records, they can't look at the chart as easily and aren't situationally aware.
  - ozi 10y ago
    It seems that at any given program either the residents are amazing and the fellows are mediocre of vice versa. It's a common fallacy to want an older, experienced physician vs. a resident or fellow. There are exceptions like specialized surgical procedures. Generally speaking though, when physicians leave the academic environment they rarely get better. Residents and fellows (and physicians who stay in academia) spend a huge amount of time on education - it's built into every day they're at work. Things like case conferences, morning reports, and Morbidity and Mortality reviews. When you enter private practice it is completely up to you to stay educated and current. Sure, you may attend SGIM once a year and read monthly journals, but that is nothing compared to the structured learning environment they left behind. I will take a good resident at a county hospital over a private hospitalist any day. Even at exceptional Tier one hospitals the level of dumb shot that happens with lazy private physicians can be jaw dropping. The private hospitalist is going to order some labs and consults, round on you once a day (maybe) and that's about it. A good resident will discuss your case at length with their interns, co-residents, fellows, and attendings.
colomon 10y ago
Was it Lisinopril? A cough is a recognized side effect of it, but I think something as severe as you are describing would be fairly rare? While I think you might be overreacting a bit here, I have a similar story. I had an irritated, gunky eye for the better part of a year. Was bounced around multiple doctors, including one specialist, and had all sorts of really annoying treatments I was supposed to do. Finally got bounced to a specialist at a major teaching hospital. Took him five minutes to correctly diagnose me, and the major part of the fix involved instantly stopping all of the things recommended by the other doctors. (The rest of the fix was simply to make sure my eye was protected while sleeping.) So yeah, I think there is a lot of value that might be added by an expert system that is familiar with the slightly more exotic things that can go wrong with your health.
naveen99 10y ago
Angiotensin receptor blockers can give you a cough. Almost all drugs have side effects. You got to read the drug information yourself and watch for known side effects. Start one new medicine at a time so you know which one is giving new side effects. By the way, reducing salt intake is amazing for lowering blood pressure.
Itsdijital 10y ago
I just want to add something really important onto this. ALWAYS READ EVERYTHING YOU CAN ABOUT DRUGS YOU ARE PRESCRIBED! Sorry for all caps, but it is super important. Not that your dad is in the wrong, lots of people have justified (to a degree) trust in their doctors. However doctors are people and just by that alone aren't perfect. A few years ago my doctor prescribed me an antibiotic for an ongoing illness I had. I read the entire pamphlet for it and did some reading online about it. All before taking it. Turns out it can cause seizures if it interacts with polypropylene glycol, one of the main ingredients in e-cig juice, which I use daily. I had told my doctor I use an e-cig. Really I cannot stress how important it is to be knowledgeable about the drugs you are taking.
- ekianjo 10y ago
  i agree with your advice. but on japan for example drugs are given ouT of their package with no info whatsoever about side effects and all. just like candies. what do you do with that?
  - annnnd 10y ago
    Interesting... So you just have to trust your doctor, no matter what? Does doctor explain the reasoning behind giving you the pills?
    - ekianjo 10y ago
      hardly. consultation including prescription is five minutes tops.
- annnnd 10y ago
  This! I view doctors more and more like any other service provider. Their goals (removing symptoms / being on time for next appointment / staying within budget / maybe even prescribing drugs I get commission on) are not necessarily aligned with mine: identifying and removing the root cause for disease. So the decisions I make are my own, but I take the input from doctors and try to do as much research as possible. Needless to say, I don't take prescription drugs unless strictly necessary. Once you view your GP as a mechanic, you can make much better decisions. Sure, their "cars" are more complex, but the role they play is similar. If you want your body to function well, you are responsible for it, not the doctors. They just help you out.
Shinkei 10y ago
Really happy you wrote this anecdote because it illustrates a point that physicians are arguing about a lot right now--how to measure quality care. Is it readmission rates, is it 30-day mortality, is it getting all the required screening exams for each patient... we don't know. In the US, the CMS is trying to mandate many of these and it's really hard to measure quality of care. For example, I am a radiologist. Probably 90% of my cases are mundane and are either normal or have 'easy' pathology that I can readily detect and quickly report. Another 9% is a mixed bag of things that take a lot more time--something I need to reference or think a bit more about or possibly show a colleague. And then there's the 1% that is truly a 'make' or 'break' case. My sub-specialty training and experience can really shine in these situations and I can easily dispense a diagnosis or make a 'tough call' where another might equivocate or defer to more imaging or a follow-up. I like to think I'm not being paid for that 90%... I'm being paid for the other 9+1% That's where I truly add value in the system. But how would I measure my 'success' rate when even the best eventually make mistakes given a long enough time and there is often not a gold standard for diagnosis or even long term follow-up/resolution to many of the tough cases I've seen. Studies have been done where experts review a sampling of cases and that's essentially what we do now for quality control--we randomly review a few prior exams for a case we are reading and then submit feedback based on our opinion on the same case. In these studies, trained radiologists do very well and make clinically significant mistakes only rarely. But here's the problem. Let's say we use machine learning to interpret a scan, something like a CT of the chest to look for a pulmonary embolus. On that scan, the machine may see an incidental pulmonary nodule. Well that's fine, we have good data on how to follow-up on those and what to recommend. Well, what about an anterior mediastinal lesion? Now it's not as clear. The differential is wide and dependent on age, sex, symptoms, history, etc. Let's say we build that logic tree, let the machine learn from 1000 anterior mediastinal mass cases with tissue diagnosis. Well guess what, we do those studies all the time and it turns out that NOTHING is 100% sensitive AND 100% specific. You have to sacrifice one for the other... it's a balance. So, you would need to build ROC curves for every possible finding on every scan and decide that 1% of the time you will miss a cancer to save having to biopsy an extra 20 people... or maybe you want to miss cancer only 0.1% of the time, but that means you'll have to biopsy an extra 200 people and one will have to be hospitalized from complications. You think they will be happy knowing you made that decision? Guess what, we are already doing that with Mammography. The screening guidelines that the different societies and agencies argue about are this very rationale... how many women should be allowed to die to prevent those extra biopsies, false positive workups and all the things that come with that. I welcome machine learning into medicine. Guess what, it's destined to be mired in the same ethical dilemmas we face everyday. I have a feeling I'll make it to retirement.
copperx 10y ago
In the doctors's defense, most people know that blood pressure medication may cause coughing. At least most people with hypertension. Your dad's case is like complaining about constant nosebleeds while taking Aspirin every day. It's a bit obvious, to be honest.
- ozi 10y ago
  Given the symptoms, discontinuing an ace inhibitor is one of the very first things you would try.
dbbolton 10y ago
>"Oh, is he on <some blood pressure medication I forget the name of>?" I'll bet the farm it was lisinopril, or another ACE inhibitor. The ACEI cough is notorious enough that any 1st year medical student probably should have been able to piece this together. The problem is not that those doctors were ignorant. It's more likely that they did not ask the right questions to get a proper history. You should ask every patient to list their medical problems and medications unless it is a routine follow-up when nothing has changed. Something else that can happen is patient ignorance (and I am not insinuating your dad was guilty of this, or making a value judgment on people who are). Often times you can't get a proper past medical history or medication list unless the patient brings all of their prescription bottles to the office. E.g.: >"What medications are you on?" >"Well, I'm on a sugar pill, a water pill, a cholesterol pill, a stomach pill, and some allergy medicines." >"Ok, do you know the name of that sugar pill?" >"It's a little white pill. I think it starts with an 'F'. No wait, I'm thinking of my water pill." or >"Do you have any medical problems?" >"No." >[glances at meds list] "Ok, so why do you take metformin, hydrochlorothiazide, atorvastatin, omeprazole, cetirizine..."

by scarmig 10y ago

cdelsolar 10y ago

Atenolol? I'm not a doctor but I'm reasonably sure it's this.

fifteenforty 10y ago
Not this. ACE inhibitors tend to cause a cough. You tend to get this side effect pretty quickly. It doesn't just occur randomly months or years after starting the drugs unless of course something else changes in your health.

inopinatus 10y ago

You didn't say whether the medication was declared at the initial admission. Nonetheless the thing I took away most from your remark is a reminder to be aware of side-effects. Or more broadly, a reminder that patients are participants in their own treatment, and that the existence of doctors doesn't excuse us from responsibility toward ourselves & those we care for.

jazoom 10y ago

That's quite a lot you've taken away from one anecdote. ACE-inhibitors are well-known to cause a cough but not like the one you're describing. If I was to guess I'd say he had a respiratory tract infection that magically disappeared (as they do) not long after ceasing the medication. This is a common type of scenario where lay people get confused about correlation and causation, and is one of the reasons you need doctors to help you. Even if it was the medication, like I said, this sounds like a somewhat unusual case. You'll probably spend the rest of your life thinking the doctors didn't know what they were talking about, but in my experience with doctors (I have a lot of that since I'm a doctor myself), even the "median" ones are far better at diagnosing things than lay people.

pizza 10y ago
I think that a median doctor + a statistical classification scheme > a median doctor alone, though.
- jazoom 10y ago
  Sure. And most of us would be super keen to use that. In fact, ED doctors in particular use heaps of things like that. Maybe instead of rule systems we will eventually use deep learning algorithms.
temp246810 10y ago
I don't know - if you're at all in a profession that requires problem solving, it can be quite jarring to work with a doctor. For any given complaint, most will just tell you that your test results are in the normal range (don't get me started on this "normal range") and tell you there's nothing they can do. I live in the bay area and have had a few GPs over the years, some from well known institutions. Doctor's seem to put in the minimal amount of effort to get you out of their office in the allotted 20 minutes so that they can move on to the next patient. I have multiple anecdotes similar to OP's - times where if it weren't for my insisting or my own inkling to visit a specialist I just would never have been helped. Are there goood GP's? I'm sure there are - but to casually dismiss OP's statement is a bit ironic - since casually dismissing is part of the biggest problems as far as my own experience with doctors.

cheez 10y ago

It's not doctors. I am working on software for the OR right now and I had never taken a biology course. The amount of stuff you need to know is IMPOSSIBLE. No, it is literally impossible. The human body is beyond ridiculously complicated and this is why most doctors pattern match for everything they've seen before. This is why, if I were an MD, I would be latching on to ML as quickly as I possibly could. There is a TON of money to be made here, sadly, I do not have the domain expertise to make it, though I am picking it up pretty quickly.

kevinalexbrown 10y ago

> the median doctor is pretty worthless This seems fairly disrespectful. I suppose you mean that the median doctor isn't perfect, but do you have any idea how many hours residents put in? You might think carefully before calling the median one worthless, and ask whether they're really, truly wasting their lives in the service of others. Less emotionally, I find it hard to believe that half of doctors proved essentially no benefit. > it's a side effect that's been widely known since the 1970's Guess how many side effects have been widely known since the 1970's? For clarity: I am 100% in favor of thinking critically about a doctor's advice, having received contradictory diagnoses before.

ncouture 10y ago
> Guess how many side effects have been widely known since the 1970's? Does this make it fine not to expect a doctor to inspect the list of known side effects for drugs his patients are taking? I've heard this very story a few times already, perhaps the sources of data widely accepted by doctors are not up to par with what non-doctors consider as accurate, in some cases anyway.
- kevinalexbrown 10y ago
  Without knowing this specific case, I can't say for sure. But my broader point is that the knowledge base required of doctors is so huge that even if it's not excusable, it is understandable. Like online community moderation, it's really easy to point to cases where doctors got it wrong and assume it's all for naught. Absolutely the accuracy of doctors should be improved, but the bar is not "are you as good as a UCSF resident?" (one of the best programs nationally) but "are you better than nothing?" It just seems crazy to me to suggest that the median doctor, i.e. at least half, is worthless.
  - saiya-jin 10y ago
    yeah, arrogant comment that was. I presume the guy always does his work at 100% or more, flawless, checking every detail and aspect, thinking 10 minutes before saying anything... We all have our tiny and bigger faults, yet somehow when it comes to health we expect impossible. I have similar crappy experiences like most people here, and tended to hate all medical personnel uniformly. Then I started dating a young doctor - still can't wrap my head around how overworked over-stressed and underpaid piece of shit work that is. Bear in mind that we're talking about biggest university hospital in Switzerland. Working ridiculous amount of hours (normal shift can be 10-13 hours, overtime unpaid), night shifts that will just mess you up mentally, crazy and dangerous patients, drug addicts, very real danger of contracting stuff like HIV or hepatititis C by single tiny mistake, or actually killing somebody by overlooking some tiny fact about N-th patient that night. You can end your career for life and end up in jail and/or with lifelong debt by one mistake. ONE. Even after directly saving life of 500 other people. Compared to my comfy corporate job, where I earn much more, did get mistake or two in production over last 5 years (nothing critical like making loss, but still), well... We should be thankful that anybody clever is actually still doing that job. Most of them could earn more and have actually a life someplace else. Blame how system is setup much more than individuals forced to exist in it.

marcell 10y ago

A recent MD friend of mine mentioned that the standards in medical school are much higher today than 20 or 30 years ago. While this is pretty anecdotal, you may have better luck with doctors who graduated more recently. Perhaps someone with experience from medical school can comment. Separate from that, I've had similar experiences. The median doctor I've interacted with isn't able to put in effort to really understand an individual case, and it's very easy to get overlooked or ignored. I've run into a few exceptions but that is the general rule. Source: wife had pregnancy with complications, young children.

Spooky23 10y ago
The downside is that at least in my experience the newer doctors seem to be docbots. Lousy bedside manner. I've had the dubious honor of spending quality time in a few hospitals with sick relatives in the last year. The nurses rock, and PAs and NPs seem to do what residents used to do. The residents in particular seem to be clueless. With electronic records, they can't look at the chart as easily and aren't situationally aware.
- ozi 10y ago
  It seems that at any given program either the residents are amazing and the fellows are mediocre of vice versa. It's a common fallacy to want an older, experienced physician vs. a resident or fellow. There are exceptions like specialized surgical procedures. Generally speaking though, when physicians leave the academic environment they rarely get better. Residents and fellows (and physicians who stay in academia) spend a huge amount of time on education - it's built into every day they're at work. Things like case conferences, morning reports, and Morbidity and Mortality reviews. When you enter private practice it is completely up to you to stay educated and current. Sure, you may attend SGIM once a year and read monthly journals, but that is nothing compared to the structured learning environment they left behind. I will take a good resident at a county hospital over a private hospitalist any day. Even at exceptional Tier one hospitals the level of dumb shot that happens with lazy private physicians can be jaw dropping. The private hospitalist is going to order some labs and consults, round on you once a day (maybe) and that's about it. A good resident will discuss your case at length with their interns, co-residents, fellows, and attendings.

colomon 10y ago

Was it Lisinopril? A cough is a recognized side effect of it, but I think something as severe as you are describing would be fairly rare? While I think you might be overreacting a bit here, I have a similar story. I had an irritated, gunky eye for the better part of a year. Was bounced around multiple doctors, including one specialist, and had all sorts of really annoying treatments I was supposed to do. Finally got bounced to a specialist at a major teaching hospital. Took him five minutes to correctly diagnose me, and the major part of the fix involved instantly stopping all of the things recommended by the other doctors. (The rest of the fix was simply to make sure my eye was protected while sleeping.) So yeah, I think there is a lot of value that might be added by an expert system that is familiar with the slightly more exotic things that can go wrong with your health.

naveen99 10y ago

Angiotensin receptor blockers can give you a cough. Almost all drugs have side effects. You got to read the drug information yourself and watch for known side effects. Start one new medicine at a time so you know which one is giving new side effects. By the way, reducing salt intake is amazing for lowering blood pressure.

Itsdijital 10y ago

I just want to add something really important onto this. ALWAYS READ EVERYTHING YOU CAN ABOUT DRUGS YOU ARE PRESCRIBED! Sorry for all caps, but it is super important. Not that your dad is in the wrong, lots of people have justified (to a degree) trust in their doctors. However doctors are people and just by that alone aren't perfect. A few years ago my doctor prescribed me an antibiotic for an ongoing illness I had. I read the entire pamphlet for it and did some reading online about it. All before taking it. Turns out it can cause seizures if it interacts with polypropylene glycol, one of the main ingredients in e-cig juice, which I use daily. I had told my doctor I use an e-cig. Really I cannot stress how important it is to be knowledgeable about the drugs you are taking.

ekianjo 10y ago
i agree with your advice. but on japan for example drugs are given ouT of their package with no info whatsoever about side effects and all. just like candies. what do you do with that?
- annnnd 10y ago
  Interesting... So you just have to trust your doctor, no matter what? Does doctor explain the reasoning behind giving you the pills?
  - ekianjo 10y ago
    hardly. consultation including prescription is five minutes tops.
annnnd 10y ago
This! I view doctors more and more like any other service provider. Their goals (removing symptoms / being on time for next appointment / staying within budget / maybe even prescribing drugs I get commission on) are not necessarily aligned with mine: identifying and removing the root cause for disease. So the decisions I make are my own, but I take the input from doctors and try to do as much research as possible. Needless to say, I don't take prescription drugs unless strictly necessary. Once you view your GP as a mechanic, you can make much better decisions. Sure, their "cars" are more complex, but the role they play is similar. If you want your body to function well, you are responsible for it, not the doctors. They just help you out.

Shinkei 10y ago

Really happy you wrote this anecdote because it illustrates a point that physicians are arguing about a lot right now--how to measure quality care. Is it readmission rates, is it 30-day mortality, is it getting all the required screening exams for each patient... we don't know. In the US, the CMS is trying to mandate many of these and it's really hard to measure quality of care. For example, I am a radiologist. Probably 90% of my cases are mundane and are either normal or have 'easy' pathology that I can readily detect and quickly report. Another 9% is a mixed bag of things that take a lot more time--something I need to reference or think a bit more about or possibly show a colleague. And then there's the 1% that is truly a 'make' or 'break' case. My sub-specialty training and experience can really shine in these situations and I can easily dispense a diagnosis or make a 'tough call' where another might equivocate or defer to more imaging or a follow-up. I like to think I'm not being paid for that 90%... I'm being paid for the other 9+1% That's where I truly add value in the system. But how would I measure my 'success' rate when even the best eventually make mistakes given a long enough time and there is often not a gold standard for diagnosis or even long term follow-up/resolution to many of the tough cases I've seen. Studies have been done where experts review a sampling of cases and that's essentially what we do now for quality control--we randomly review a few prior exams for a case we are reading and then submit feedback based on our opinion on the same case. In these studies, trained radiologists do very well and make clinically significant mistakes only rarely. But here's the problem. Let's say we use machine learning to interpret a scan, something like a CT of the chest to look for a pulmonary embolus. On that scan, the machine may see an incidental pulmonary nodule. Well that's fine, we have good data on how to follow-up on those and what to recommend. Well, what about an anterior mediastinal lesion? Now it's not as clear. The differential is wide and dependent on age, sex, symptoms, history, etc. Let's say we build that logic tree, let the machine learn from 1000 anterior mediastinal mass cases with tissue diagnosis. Well guess what, we do those studies all the time and it turns out that NOTHING is 100% sensitive AND 100% specific. You have to sacrifice one for the other... it's a balance. So, you would need to build ROC curves for every possible finding on every scan and decide that 1% of the time you will miss a cancer to save having to biopsy an extra 20 people... or maybe you want to miss cancer only 0.1% of the time, but that means you'll have to biopsy an extra 200 people and one will have to be hospitalized from complications. You think they will be happy knowing you made that decision? Guess what, we are already doing that with Mammography. The screening guidelines that the different societies and agencies argue about are this very rationale... how many women should be allowed to die to prevent those extra biopsies, false positive workups and all the things that come with that. I welcome machine learning into medicine. Guess what, it's destined to be mired in the same ethical dilemmas we face everyday. I have a feeling I'll make it to retirement.

copperx 10y ago

In the doctors's defense, most people know that blood pressure medication may cause coughing. At least most people with hypertension. Your dad's case is like complaining about constant nosebleeds while taking Aspirin every day. It's a bit obvious, to be honest.

ozi 10y ago
Given the symptoms, discontinuing an ace inhibitor is one of the very first things you would try.

dbbolton 10y ago

>"Oh, is he on <some blood pressure medication I forget the name of>?" I'll bet the farm it was lisinopril, or another ACE inhibitor. The ACEI cough is notorious enough that any 1st year medical student probably should have been able to piece this together. The problem is not that those doctors were ignorant. It's more likely that they did not ask the right questions to get a proper history. You should ask every patient to list their medical problems and medications unless it is a routine follow-up when nothing has changed. Something else that can happen is patient ignorance (and I am not insinuating your dad was guilty of this, or making a value judgment on people who are). Often times you can't get a proper past medical history or medication list unless the patient brings all of their prescription bottles to the office. E.g.: >"What medications are you on?" >"Well, I'm on a sugar pill, a water pill, a cholesterol pill, a stomach pill, and some allergy medicines." >"Ok, do you know the name of that sugar pill?" >"It's a little white pill. I think it starts with an 'F'. No wait, I'm thinking of my water pill." or >"Do you have any medical problems?" >"No." >[glances at meds list] "Ok, so why do you take metformin, hydrochlorothiazide, atorvastatin, omeprazole, cetirizine..."