14 ms·

Why Doctors Reject Tools That Make Their Jobs Easier

199 points by dsr12 8y ago

carleverett 8y ago
The article talks about thermometers being rejected by some doctors who thought fevers were more qualitative... they're not wrong. Different people have different average body temperatures, so a fever for one person might not be a fever for another person [1]. Obviously it's not smart for a doctor to reject the idea of knowing internal body temperatures at least to have as a data point, but those doctors weren't COMPLETELY off base. https://www.webmd.com/first-aid/normal-body-temperature https://www.webmd.com/first-aid/normal-body-temperature
- chapium 8y ago
  Wouldn’t it be useful to have a tool like a thermometer to establish a baseline value?
  - arama471 8y ago
    if they've already got the fever then it's a bit late for that
    - derefr 8y ago
      Seems like it'd make sense to go into your doctor at some point when you're perfectly healthy and let them measure a bunch of baseline values to put in your medical file.
      - nradov 8y ago
        Body temperature for an individual patient can vary significantly based on time of day, activity level, diet, menstrual cycle, etc. A single point measurement taken once every two years doesn't really give a useful baseline and might even be misleading.
        deleted 8y ago
        [deleted]
        docbrown 8y ago
        Within the parent comment and beyond, it seems people are putting emphasis on a change in temperature but do not state a deviation from the average 98.2°. Even if we did have it though, I don’t think having a longitudinal look at someone’s vital signs (VS) would be misleading in any sense. It establishes a baseline history of the person and deviations will be put in context with the addition charting notes from that visit. While I do agree with a single point not being enough information, nobody is looking at body temperature alone when diagnosing a patient— unless they’re reaching internal temperatures of below 95° and above ~100.9 for hypothermia or hyperthermia respectfully. With each diagnosis there are /x/ number of signs and symptoms that go along with it so it is crucial that we gather as much information on all the VS we can, no matter how minuscule the data may seem.
      - Swizec 8y ago
        It's like my bird's vet said once: If you start measuring, you're gonna find stuff. The more you dig, the more you find. Does it mean your bird is sick? Eh look at him, does he look like a sick bird? My girlfriend can be very ... concerned. We spent $1000 in vet bills before a real avian expert was like "Guys, he's fine. Look how happy he is. He just loves the attention." Apparently one of his tests for vet interns is to tell them "This bird is sick. Figure it out". Then he gives them a perfectly healthy bird. Their bias always makes them find something. Caused by their tests half the time because they're stressing the bird.
        QuercusMax 8y ago
        I've heard similar sentiments around looking at API monitoring graphs when you're not investigating a specific problem. Weird stuff happens all the time, and most of the time it's no big deal.
        cbluth 8y ago
        I have similar sentiments towards the health of humans.
        Fomite 8y ago
        "Diagnostic stewardship" is currently a hot topic in infection control and antimicrobial resistance work for exactly this reason. If we look hard enough, we'll find something to give you antibiotics for, even if you don't need them.
        throwaway287391 8y ago
        > Apparently one of his tests for vet interns is to tell them "This bird is sick. Figure it out". Then he gives them a perfectly healthy bird. Their bias always makes them find something. Seems like the "bias" in that case is likely due to an authority figure intentionally misleading them in the context of a "test", where one naturally assumes they're not being deceived by the very premise of said test? If an actual bird owner came in as a client and said the same (or if the test explicitly told them to assume this is the situation), the interns might very well still realize the client is wrong.
  - f39uyc3 8y ago
    That might be why they take my temperature whenever I go for a regular checkup, or non-cold/flu/fever related concerns? Procedures aren't the same between clinics, though.
bsder 8y ago
Part of the issue is that the doctor is on the hook if the tool fouls up. Consequently, having an extremely skeptical viewpoint on tools is perfectly rational. I can also tell you from discussions with doctors that one of the problems is that the intersection of GUI programmer, competent engineer, and medical domain knowledge is either a null set or a single person. (For example: EEG analysis seems to be a natural fit for ML/AI--enormous amounts of data with events only sporadically scattered in it--yet there is nobody capable of handling the intersection of talents required.)
- rpcastagna 8y ago
  It reminds me of Moneyball; in it, the author points out that the statisticians were frustrated by their inability to get traction within the MLB, but their pitch essentially boiled down to "you guys don't listen to statistics, you should listen to these new ones we just developed," which left unsaid that the statisticians made up new quantifiers because the old ones were ineffective. The MLB had the lived experience of those statistics being ineffective, so they knew Bill James et al were right about that, but the idea that the answer was more numbers that didn't make a lot of intuitive sense was a hard sell. I would also add that my perception from working at a major east coast hospital has actually been that hospital IT clamps down on new tools more than anyone because of HIPAA requirements, etc, that the doctors ignore/don't care about as much as they should. It's a complicated, layered system.
- LeonB 8y ago
  > intersection of GUI programmer, competent engineer, and medical domain knowledge is either a null set or a single person Ah interesting. My neighbor's son is a doctor who needed better software. He trained himself to become a GUI programmer. The resulting company is very succesful. (As reported by his mother, so I'm allowing for some parental bias.)
- jogundas 8y ago
  There is a bunch of ML/EEG devices on the market, it is a commodity technology by now, just google "fda machine learning eeg".
tx21 8y ago
Flashy article title clickbait. Doctors are not fools. If a tool truly made their job easier, it would not be rejected out of hand. Job security for physicians is rarely the issue, there are plenty of sick people.
- munchbunny 8y ago
  I don't completely agree. Medicine has a reputation for being extremely conservative with technology. It's understandable, because you don't want to mess around with people's health, but I also see doctors largely acknowledge that their field is more conservative than it should be. It's apparently also different based on specialization. Opthalmologists apparently have a reputation for being early adopters.
- pavlov 8y ago
  Surgical safety checklists were shown to lower 30-day post-operative mortality by 22%: https://www.cardiovascularbusiness.com/topics/coronary-intervention-surgery/hospitals-using-surgical-safety-checklists-have-22-percent https://www.cardiovascularbusiness.com/topics/coronary-inter... You'd imagine something as basic as checklists would be implemented as standard procedure in modern medicine -- yet this study was in 2013, not 1963. Most likely the majority of surgeons are still dragging their feet on this. It's a very conservative field with lots of big egos.
  - gowld 8y ago
    Checklists make patient outcomes better; they don't make surgeons' work easier.
    - onetimemanytime 8y ago
      I guess killing the patients as soon as the cut them open would be easier for the doctor :), but their job us to heal patients. Anything that improves on outcomes is good. The OP might have suggested that instead of new tools, just use the old checklist system.
rpcastagna 8y ago
Healthcare industry insiders joke: Any theory of the current state of medicine that involves a cardio-thoracic surgeon feeling like they are not completely irreplaceable, one-in-a-trillion geniuses/minor deities, put here on this planet to spare us lesser mortals (as scheduling allows) seems... improbable.
anon4lol 8y ago
As someone who has had several CT scans (and paid for CT scans), the idea that a CT scan is better than a physician feeling your abdomen is absolutely ridiculous. Pumping contrast agents into everyone who has pain is a very bad idea. Moreover, enforcing decisions by algorithmic rules is problematic, especially considering who might be making those decisions.
- DrJaws 8y ago
  Plus radiation. Every CT scan increases your odds of cancer. Also, mammography or even colonoscopies have been proved for most of the population to do more harm than good. cochrane is full of meta-studies about it. The medical industry is very shady.
  - onetimemanytime 8y ago
    >>Plus radiation. Every CT scan increases your odds of cancer. If the doctor makes money from your CT Scan you are absolutely right to question the need. Conflict of interest and all. Sure you increase the chances of cancer but that has to be weighed by what can happen if you don't do the CT Scan.
    - Thriptic 8y ago
      Very few modern insurance plans pay per procedure and that will be done away with entirely as time goes on. Typically physicians are paid a flat rate per patient or a flat rate per diagnosis with a complexity multiplier. This creates an incentive to NOT perform imaging unless it's necessary.
      - telchar 8y ago
        In what country? The US is still mostly per per procedure. There are codes for procedures and for diagnoses and they both get factored into the bill.
        8y ago
Mbioguy 8y ago
"They thoughtlessly order tests and thoughtlessly obey the results." Hacker News, come on. You're better than this. Taking it from the top: The obvious take is that the new tools this is referring to is EMR and things like Watson. Will return to this in a moment. Subjective and objective data both a play a role in medicine. The eye of an experienced person can often see in a blink what would be missed by someone looking only at numbers in a chart. Gestalt, or the fast system of Kahneman, is invaluable when time is a serious concern. But noone starts out that way. The slower, methodical plod of consciously using bayesian thinking is how the art is learned. Hear hoofbeats, think horses, not zebras... trying to weigh all available data and attempting to chart a course that gives patients the best outcomes at the most reasonable costs. Nowadays additional hoops must be jumped through: laws constrain, institutions have policies that must be followed, and most of all care is dictated by what is allowed by the insurance company. Rather than an invisible hand, this is an invisible supervisor robbing much autonomy and initiative from a sense of worthwhile work. Furthermore the ever-present fear of litigation pushes towards a course with more testing than might be suggested by treatment and diagnosis alone: how would this course be defended if things go wrong, as they will for a certain number? All of these things individually stood to reason, but we as a society must keep in mind the cumulative weight of it all. Emergent phenomena isn't just a thing of programs and physics, it's a thing of human systems like healthcare. Back to the article. A happy picture is painted of modern CT scans, yet it neglects the downsides. In 1980 the average per capita dose of radiation was 3.0 mSv, with 0.5 coming from medical imaging. It is now 5.5 mSv and rising, with medical imaging alone exceeding 3.0 mSv. Medical imaging is now a larger source of ionizing radiation than all other sources combined, with particularly high risks for those in utero or pediatrics. Like any other test or treatment, there is a risk/reward ratio. As technology improves, it is more likely to be adopted, not because earlier physicians were anti-technology Luddites, but because the improved technology changed that risk/reward ratio. We are more likely to use imaging with less exposure, or better yet use a modality without that risk. Back to the Bayesian part of thinking... testing isn't perfect. I'd love to see a test that is 100% sensitive and 100% specific. But there are inevitably false positives and false negatives. Tools and tests need to be used in an appropriate situation. For example: I have a test that is 99% sensitive. Great! It'll catch someone with the disease, 99% of the time. So I can thoughtlessly order tests and thoughtlessly obey the results, right? Wrong. What happens if you use it to test for a rare disease that only 0.1% of the population will have? It depends on how specific the test is. How many false positives does it let in? If I test it on 1,000 folks indiscriminately, I'll end up with a basket of folks, only one of which actually has the disease. How many false positives got treated (and possibly harmed by that treatment)? Mammograms work this way (which have fallen a little out of favor in younger demographics without risk factors like the BRCAs), necessitating imaging and invasive biopsies that, upon further collection of data and review, seem not worthwhile for those under 40 and of questionable value under 50. Tools are great! They need to be used appropriately though. Things have a cost, not just financial but physical and temporal. Indiscriminate use of tests and tools is the last thing anyone should want. Nothing to add in a world of advancing technology? Bah. Most would love for its promises to come to fruition. EMR for example. We were promised time savings, with cross-talk between systems for better availability of data and improved patient safety. Mostly what has happened is administrators now have data used to push docs to see more and more patients (and spend less and less time with any one of them), all the while the paperwork stacks up. Somehow the paperwork never quite seemed to go away. Maybe doctors don't reject tools that make their jobs easier. The article is full of tools that were eventually adopted, after all. I can point to many in development that have their ardent advocates, like point-of-care ultrasound among many others. Maybe they don't like tools that were sold as making their jobs easier but mostly don't, and instead benefit insurance companies and conglomerate administrators.
DrNuke 8y ago
The industry is annoyingly conservative but whizzkids pretending to have a better opinion about how to cure insert desease from isolated, mechanistic, non-standard observations of few markers are dangerous.
- Fomite 8y ago
  Yeah - I work a lot in healthcare associated infections, and a good 80% of the stuff I read about "We're from Silicon Valley and we're here to help..." just ends with me going "They're going to kill people."
  - cf498 8y ago
    I think this is something that isnt that present in our profession as it should be. If you are an electrical engineer, it is clear and present, that your products might kill someone if you screw up. The same goes for a mechanical engineer. And it will be your responsibility. If you screw up and should have known better, you might even go to jail for negligence. We on the other hand have the Therac-25. We claim to be on a level of engineering fields. We should also act that way.
    - Balgair 8y ago
      Agreed. The Order of the Engineer is a good place to start and bringing that tradition down into comp-eng/sci would be a nice start. https://en.wikipedia.org/wiki/Order_of_the_Engineer https://en.wikipedia.org/wiki/Order_of_the_Engineer
      - Latteland 8y ago
        Interesting, had not heard of that. What should we computer programmers, we flexible always trying new things without enough tried and true practices think of real engineers, what should they think of us?
        ionised 8y ago
Fomite 8y ago
An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.
- escherplex 8y ago
  Also, for seasoned professionals you have to factor in malpractice and insurance coverage as contributing to the inertia.
  - skwb 8y ago
    I've found mostly these are given mostly as cover. Those are important considerations, but: A) most CDS is considered educational, and therefore is not supposed to replace an expert's opinion B) insurance coverage is sorta BS because most health systems are moving away from pure fee for service revenue models. Besides, I feel like you should maybe do your job as a doctor to ensure the best care for your patients than hyper optimizing your own reimbursement.
    - telchar 8y ago
      Nevertheless there is concern about any data that goes into an EMR. There is always concern about what happens in the worst case scenario where something very bad happens to a patient and their whole record is examined in a courtroom after the fact. If, say, a machine learning model predicts that thing X will happen to the patient and it wasn't acted on, a hypothetical lawsuit may go worse for the provider than if the predicted risk of thing X weren't part of the record. This doesn't mean that the doctors bury their heads in the sand, but it is a part of the reason providers are resistant to adopting these tools. Relying on their own knowledge and intuition may not be better but it won't hurt them as evidence in a hypothetical malpractice suit. The decision support tool has to be sufficiently better to outweigh this. I hold no opinion on the validity of this line of thinking, but I can say that it is part of the calculus, at least for some.
megy 8y ago
> From the thermometer’s invention onward, physicians have feared—incorrectly—that new technology would make their jobs obsolete Is that true, or are doctors incredibly risk averse since they have seen what can happen when something goes wrong, and that is death.
- ivanmaeder 8y ago
  I've also read that physicians can be overconfident in their own abilities: https://www.ncbi.nlm.nih.gov/pubmed/18440350 https://www.ncbi.nlm.nih.gov/pubmed/18440350 > … argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence… More on the combination of algorithms and humans: https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_statistical_prediction https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_... > Meta-analyses comparing clinical and mechanical prediction efficiency have supported Meehl's (1954) conclusion that mechanical data combination and prediction outperforms clinical combination and prediction.
noonespecial 8y ago
The number one thing you can do to get doctors to use your new tool is find a way so that they don't have to enter patient data again. The fear they have isn't that they'll be replaced on the job. The fear they have is that they will be required by some policy to enter yet another copy of the same data into yet another "time saving" system.
vinayms 8y ago
> Too many doctors have resigned that they have nothing to add in a world of advanced technology. They thoughtlessly order tests and thoughtlessly obey the results. Thoughtlessly obeying is undoubtedly a sign of incompetence; a doctor must always use judgement based on patient's condition and not rely on a bunch of numbers, a doctor told me in my teens. However, ordering tech based tests is not thoughtless all the time, at least not with competent doctors. I mean, in this age of self diagnosing based on googling, a doctor not ordering such tests would be seen as incompetent, and even ignorant. Would a doctor risk his reputation, and possibly livelihood, just to prove a point, even when his spidey senses tells him there is nothing severe about the patient's condition when the patient insists on it, directly or indirectly? Only a House would do so. The writer is too eager to generalize for some reason.
HeadsUpHigh 8y ago
As a med student, using shinny new tech in medicine has become a dick measuring contest. There is absolutely no fear of new tech, just professionals rejecting useless unoriginal products that don't actually make our jobs easier. Like the data fad that will just make us manually reenter data into a new data silo for the benefits of other companies who will take no responsibility to the stability required in the field. I absolutely resent some of the interfaces we have to use but at least the CT/MRI reading software doesn't crash. Anything new and shiny does though.

199 points by dsr12 8y ago

The article talks about thermometers being rejected by some doctors who thought fevers were more qualitative... they're not wrong. Different people have different average body temperatures, so a fever for one person might not be a fever for another person [1]. Obviously it's not smart for a doctor to reject the idea of knowing internal body temperatures at least to have as a data point, but those doctors weren't COMPLETELY off base. https://www.webmd.com/first-aid/normal-body-temperature https://www.webmd.com/first-aid/normal-body-temperature

chapium 8y ago
Wouldn’t it be useful to have a tool like a thermometer to establish a baseline value?
- arama471 8y ago
  if they've already got the fever then it's a bit late for that
  - derefr 8y ago
    Seems like it'd make sense to go into your doctor at some point when you're perfectly healthy and let them measure a bunch of baseline values to put in your medical file.
    - nradov 8y ago
      Body temperature for an individual patient can vary significantly based on time of day, activity level, diet, menstrual cycle, etc. A single point measurement taken once every two years doesn't really give a useful baseline and might even be misleading.
      - deleted 8y ago
        [deleted]
      - docbrown 8y ago
        Within the parent comment and beyond, it seems people are putting emphasis on a change in temperature but do not state a deviation from the average 98.2°. Even if we did have it though, I don’t think having a longitudinal look at someone’s vital signs (VS) would be misleading in any sense. It establishes a baseline history of the person and deviations will be put in context with the addition charting notes from that visit. While I do agree with a single point not being enough information, nobody is looking at body temperature alone when diagnosing a patient— unless they’re reaching internal temperatures of below 95° and above ~100.9 for hypothermia or hyperthermia respectfully. With each diagnosis there are /x/ number of signs and symptoms that go along with it so it is crucial that we gather as much information on all the VS we can, no matter how minuscule the data may seem.
    - Swizec 8y ago
      It's like my bird's vet said once: If you start measuring, you're gonna find stuff. The more you dig, the more you find. Does it mean your bird is sick? Eh look at him, does he look like a sick bird? My girlfriend can be very ... concerned. We spent $1000 in vet bills before a real avian expert was like "Guys, he's fine. Look how happy he is. He just loves the attention." Apparently one of his tests for vet interns is to tell them "This bird is sick. Figure it out". Then he gives them a perfectly healthy bird. Their bias always makes them find something. Caused by their tests half the time because they're stressing the bird.
      - QuercusMax 8y ago
        I've heard similar sentiments around looking at API monitoring graphs when you're not investigating a specific problem. Weird stuff happens all the time, and most of the time it's no big deal.
      - cbluth 8y ago
        I have similar sentiments towards the health of humans.
      - Fomite 8y ago
        "Diagnostic stewardship" is currently a hot topic in infection control and antimicrobial resistance work for exactly this reason. If we look hard enough, we'll find something to give you antibiotics for, even if you don't need them.
      - throwaway287391 8y ago
        > Apparently one of his tests for vet interns is to tell them "This bird is sick. Figure it out". Then he gives them a perfectly healthy bird. Their bias always makes them find something. Seems like the "bias" in that case is likely due to an authority figure intentionally misleading them in the context of a "test", where one naturally assumes they're not being deceived by the very premise of said test? If an actual bird owner came in as a client and said the same (or if the test explicitly told them to assume this is the situation), the interns might very well still realize the client is wrong.
- f39uyc3 8y ago
  That might be why they take my temperature whenever I go for a regular checkup, or non-cold/flu/fever related concerns? Procedures aren't the same between clinics, though.

bsder 8y ago

Part of the issue is that the doctor is on the hook if the tool fouls up. Consequently, having an extremely skeptical viewpoint on tools is perfectly rational. I can also tell you from discussions with doctors that one of the problems is that the intersection of GUI programmer, competent engineer, and medical domain knowledge is either a null set or a single person. (For example: EEG analysis seems to be a natural fit for ML/AI--enormous amounts of data with events only sporadically scattered in it--yet there is nobody capable of handling the intersection of talents required.)

rpcastagna 8y ago
It reminds me of Moneyball; in it, the author points out that the statisticians were frustrated by their inability to get traction within the MLB, but their pitch essentially boiled down to "you guys don't listen to statistics, you should listen to these new ones we just developed," which left unsaid that the statisticians made up new quantifiers because the old ones were ineffective. The MLB had the lived experience of those statistics being ineffective, so they knew Bill James et al were right about that, but the idea that the answer was more numbers that didn't make a lot of intuitive sense was a hard sell. I would also add that my perception from working at a major east coast hospital has actually been that hospital IT clamps down on new tools more than anyone because of HIPAA requirements, etc, that the doctors ignore/don't care about as much as they should. It's a complicated, layered system.
LeonB 8y ago
> intersection of GUI programmer, competent engineer, and medical domain knowledge is either a null set or a single person Ah interesting. My neighbor's son is a doctor who needed better software. He trained himself to become a GUI programmer. The resulting company is very succesful. (As reported by his mother, so I'm allowing for some parental bias.)
jogundas 8y ago
There is a bunch of ML/EEG devices on the market, it is a commodity technology by now, just google "fda machine learning eeg".

tx21 8y ago

Flashy article title clickbait. Doctors are not fools. If a tool truly made their job easier, it would not be rejected out of hand. Job security for physicians is rarely the issue, there are plenty of sick people.

munchbunny 8y ago
I don't completely agree. Medicine has a reputation for being extremely conservative with technology. It's understandable, because you don't want to mess around with people's health, but I also see doctors largely acknowledge that their field is more conservative than it should be. It's apparently also different based on specialization. Opthalmologists apparently have a reputation for being early adopters.
pavlov 8y ago
Surgical safety checklists were shown to lower 30-day post-operative mortality by 22%: https://www.cardiovascularbusiness.com/topics/coronary-intervention-surgery/hospitals-using-surgical-safety-checklists-have-22-percent https://www.cardiovascularbusiness.com/topics/coronary-inter... You'd imagine something as basic as checklists would be implemented as standard procedure in modern medicine -- yet this study was in 2013, not 1963. Most likely the majority of surgeons are still dragging their feet on this. It's a very conservative field with lots of big egos.
- gowld 8y ago
  Checklists make patient outcomes better; they don't make surgeons' work easier.
  - onetimemanytime 8y ago
    I guess killing the patients as soon as the cut them open would be easier for the doctor :), but their job us to heal patients. Anything that improves on outcomes is good. The OP might have suggested that instead of new tools, just use the old checklist system.

rpcastagna 8y ago

Healthcare industry insiders joke: Any theory of the current state of medicine that involves a cardio-thoracic surgeon feeling like they are not completely irreplaceable, one-in-a-trillion geniuses/minor deities, put here on this planet to spare us lesser mortals (as scheduling allows) seems... improbable.

anon4lol 8y ago

As someone who has had several CT scans (and paid for CT scans), the idea that a CT scan is better than a physician feeling your abdomen is absolutely ridiculous. Pumping contrast agents into everyone who has pain is a very bad idea. Moreover, enforcing decisions by algorithmic rules is problematic, especially considering who might be making those decisions.

DrJaws 8y ago
Plus radiation. Every CT scan increases your odds of cancer. Also, mammography or even colonoscopies have been proved for most of the population to do more harm than good. cochrane is full of meta-studies about it. The medical industry is very shady.
- onetimemanytime 8y ago
  >>Plus radiation. Every CT scan increases your odds of cancer. If the doctor makes money from your CT Scan you are absolutely right to question the need. Conflict of interest and all. Sure you increase the chances of cancer but that has to be weighed by what can happen if you don't do the CT Scan.
  - Thriptic 8y ago
    Very few modern insurance plans pay per procedure and that will be done away with entirely as time goes on. Typically physicians are paid a flat rate per patient or a flat rate per diagnosis with a complexity multiplier. This creates an incentive to NOT perform imaging unless it's necessary.
    - telchar 8y ago
      In what country? The US is still mostly per per procedure. There are codes for procedures and for diagnoses and they both get factored into the bill.
      - 8y ago

Mbioguy 8y ago

"They thoughtlessly order tests and thoughtlessly obey the results." Hacker News, come on. You're better than this. Taking it from the top: The obvious take is that the new tools this is referring to is EMR and things like Watson. Will return to this in a moment. Subjective and objective data both a play a role in medicine. The eye of an experienced person can often see in a blink what would be missed by someone looking only at numbers in a chart. Gestalt, or the fast system of Kahneman, is invaluable when time is a serious concern. But noone starts out that way. The slower, methodical plod of consciously using bayesian thinking is how the art is learned. Hear hoofbeats, think horses, not zebras... trying to weigh all available data and attempting to chart a course that gives patients the best outcomes at the most reasonable costs. Nowadays additional hoops must be jumped through: laws constrain, institutions have policies that must be followed, and most of all care is dictated by what is allowed by the insurance company. Rather than an invisible hand, this is an invisible supervisor robbing much autonomy and initiative from a sense of worthwhile work. Furthermore the ever-present fear of litigation pushes towards a course with more testing than might be suggested by treatment and diagnosis alone: how would this course be defended if things go wrong, as they will for a certain number? All of these things individually stood to reason, but we as a society must keep in mind the cumulative weight of it all. Emergent phenomena isn't just a thing of programs and physics, it's a thing of human systems like healthcare. Back to the article. A happy picture is painted of modern CT scans, yet it neglects the downsides. In 1980 the average per capita dose of radiation was 3.0 mSv, with 0.5 coming from medical imaging. It is now 5.5 mSv and rising, with medical imaging alone exceeding 3.0 mSv. Medical imaging is now a larger source of ionizing radiation than all other sources combined, with particularly high risks for those in utero or pediatrics. Like any other test or treatment, there is a risk/reward ratio. As technology improves, it is more likely to be adopted, not because earlier physicians were anti-technology Luddites, but because the improved technology changed that risk/reward ratio. We are more likely to use imaging with less exposure, or better yet use a modality without that risk. Back to the Bayesian part of thinking... testing isn't perfect. I'd love to see a test that is 100% sensitive and 100% specific. But there are inevitably false positives and false negatives. Tools and tests need to be used in an appropriate situation. For example: I have a test that is 99% sensitive. Great! It'll catch someone with the disease, 99% of the time. So I can thoughtlessly order tests and thoughtlessly obey the results, right? Wrong. What happens if you use it to test for a rare disease that only 0.1% of the population will have? It depends on how specific the test is. How many false positives does it let in? If I test it on 1,000 folks indiscriminately, I'll end up with a basket of folks, only one of which actually has the disease. How many false positives got treated (and possibly harmed by that treatment)? Mammograms work this way (which have fallen a little out of favor in younger demographics without risk factors like the BRCAs), necessitating imaging and invasive biopsies that, upon further collection of data and review, seem not worthwhile for those under 40 and of questionable value under 50. Tools are great! They need to be used appropriately though. Things have a cost, not just financial but physical and temporal. Indiscriminate use of tests and tools is the last thing anyone should want. Nothing to add in a world of advancing technology? Bah. Most would love for its promises to come to fruition. EMR for example. We were promised time savings, with cross-talk between systems for better availability of data and improved patient safety. Mostly what has happened is administrators now have data used to push docs to see more and more patients (and spend less and less time with any one of them), all the while the paperwork stacks up. Somehow the paperwork never quite seemed to go away. Maybe doctors don't reject tools that make their jobs easier. The article is full of tools that were eventually adopted, after all. I can point to many in development that have their ardent advocates, like point-of-care ultrasound among many others. Maybe they don't like tools that were sold as making their jobs easier but mostly don't, and instead benefit insurance companies and conglomerate administrators.

DrNuke 8y ago

The industry is annoyingly conservative but whizzkids pretending to have a better opinion about how to cure insert desease from isolated, mechanistic, non-standard observations of few markers are dangerous.

Fomite 8y ago
Yeah - I work a lot in healthcare associated infections, and a good 80% of the stuff I read about "We're from Silicon Valley and we're here to help..." just ends with me going "They're going to kill people."
- cf498 8y ago
  I think this is something that isnt that present in our profession as it should be. If you are an electrical engineer, it is clear and present, that your products might kill someone if you screw up. The same goes for a mechanical engineer. And it will be your responsibility. If you screw up and should have known better, you might even go to jail for negligence. We on the other hand have the Therac-25. We claim to be on a level of engineering fields. We should also act that way.
  - Balgair 8y ago
    Agreed. The Order of the Engineer is a good place to start and bringing that tradition down into comp-eng/sci would be a nice start. https://en.wikipedia.org/wiki/Order_of_the_Engineer https://en.wikipedia.org/wiki/Order_of_the_Engineer
    - Latteland 8y ago
      Interesting, had not heard of that. What should we computer programmers, we flexible always trying new things without enough tried and true practices think of real engineers, what should they think of us?
      - ionised 8y ago

Fomite 8y ago

An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I know a ton of colleagues who flinch every time someone mentions that this'll just hook into the EMR system, because they know everything will be broken and tedious for years before another vendor comes along. At a conference I was at recently, I'm nigh positive "Decision Support Tool" was a dirty word.

escherplex 8y ago
Also, for seasoned professionals you have to factor in malpractice and insurance coverage as contributing to the inertia.
- skwb 8y ago
  I've found mostly these are given mostly as cover. Those are important considerations, but: A) most CDS is considered educational, and therefore is not supposed to replace an expert's opinion B) insurance coverage is sorta BS because most health systems are moving away from pure fee for service revenue models. Besides, I feel like you should maybe do your job as a doctor to ensure the best care for your patients than hyper optimizing your own reimbursement.
  - telchar 8y ago
    Nevertheless there is concern about any data that goes into an EMR. There is always concern about what happens in the worst case scenario where something very bad happens to a patient and their whole record is examined in a courtroom after the fact. If, say, a machine learning model predicts that thing X will happen to the patient and it wasn't acted on, a hypothetical lawsuit may go worse for the provider than if the predicted risk of thing X weren't part of the record. This doesn't mean that the doctors bury their heads in the sand, but it is a part of the reason providers are resistant to adopting these tools. Relying on their own knowledge and intuition may not be better but it won't hurt them as evidence in a hypothetical malpractice suit. The decision support tool has to be sufficiently better to outweigh this. I hold no opinion on the validity of this line of thinking, but I can say that it is part of the calculus, at least for some.

megy 8y ago

> From the thermometer’s invention onward, physicians have feared—incorrectly—that new technology would make their jobs obsolete Is that true, or are doctors incredibly risk averse since they have seen what can happen when something goes wrong, and that is death.

ivanmaeder 8y ago
I've also read that physicians can be overconfident in their own abilities: https://www.ncbi.nlm.nih.gov/pubmed/18440350 https://www.ncbi.nlm.nih.gov/pubmed/18440350 > … argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence… More on the combination of algorithms and humans: https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_statistical_prediction https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_... > Meta-analyses comparing clinical and mechanical prediction efficiency have supported Meehl's (1954) conclusion that mechanical data combination and prediction outperforms clinical combination and prediction.

noonespecial 8y ago

The number one thing you can do to get doctors to use your new tool is find a way so that they don't have to enter patient data again. The fear they have isn't that they'll be replaced on the job. The fear they have is that they will be required by some policy to enter yet another copy of the same data into yet another "time saving" system.

vinayms 8y ago

> Too many doctors have resigned that they have nothing to add in a world of advanced technology. They thoughtlessly order tests and thoughtlessly obey the results. Thoughtlessly obeying is undoubtedly a sign of incompetence; a doctor must always use judgement based on patient's condition and not rely on a bunch of numbers, a doctor told me in my teens. However, ordering tech based tests is not thoughtless all the time, at least not with competent doctors. I mean, in this age of self diagnosing based on googling, a doctor not ordering such tests would be seen as incompetent, and even ignorant. Would a doctor risk his reputation, and possibly livelihood, just to prove a point, even when his spidey senses tells him there is nothing severe about the patient's condition when the patient insists on it, directly or indirectly? Only a House would do so. The writer is too eager to generalize for some reason.

HeadsUpHigh 8y ago

As a med student, using shinny new tech in medicine has become a dick measuring contest. There is absolutely no fear of new tech, just professionals rejecting useless unoriginal products that don't actually make our jobs easier. Like the data fad that will just make us manually reenter data into a new data silo for the benefits of other companies who will take no responsibility to the stability required in the field. I absolutely resent some of the interfaces we have to use but at least the CT/MRI reading software doesn't crash. Anything new and shiny does though.