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That was a fun read. I wish the author mentioned how much he was trying to sell the service for. It could have been $59 a month or $599 a month and with doctors

by nickjj 6y ago

That was a fun read. I wish the author mentioned how much he was trying to sell the service for. It could have been $59 a month or $599 a month and with doctors you could potentially expect the same answer. I'm not a psychologist but some of the author's quoted text came off extremely demeaning in written form. If the author happens to read this, did you really say those things directly to them? For example, Susan (psychologist) was quoted as saying: > "Oh sure! I mean, I think in many cases I'll just prescribe what I normally do, since I'm comfortable with it. But you know it's possible that sometimes I'll prescribe something different, based on your metastudies." To which you replied: > "And that isn't worth something? Prescribing better treatments?" Imagine walking into the office of someone who spent the last ~10 years at school and then potentially 20 years practicing their craft as a successful psychologist and then you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better.

stevewodil 6y ago
It's actually a very good sales question, I don't find it demeaning at all. If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation. It could come off as standoffish but when used correctly it's very effective because it gets the person on the other end to open up more and you try to get to the bottom of their objections.
- na85 6y ago
  >If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation. Assuming that I didn't initiate the call, if I tell some sales punk that I don't need their product and they come back at me with "So you have perfect user retention then?" my answer is going to be "fuck you" followed by ending the call. Arrogance might work in used car sales but it's not a panacea for closing the deal.
  - stevewodil 6y ago
    I'm sure that happens occasionally as well. I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement. They will call the next person on their list, I'm sure it won't matter much.
    - matkoniecz 6y ago
      Incoming spam is unwelcome in general, and I would not assume that this people are trying to help me.
    - na85 6y ago
      >I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement. Oh please. Not every product that's applicable to a given business would necessarily be beneficial to that business. I get it, sales people have to drink the kool aid, but some humility is needed. Your product isn't right for everyone, and the sooner you understand that the sooner you can improve the quality of your lead generation.
      - stevewodil 6y ago
        If you have a vendetta against sales people you can just say that. We are talking about a completely hypothetical situation here, I don't see how you're now implying that the lead generation isn't good enough.
        renewiltord 6y ago
        On HN, people hate cold emails. In real life, I've found that most people will respond or ignore. Like a tiny minority will act like you killed their mother, but that's life. I know you know this, if you're in sales, but I, like many other engineers who read this forum was overly cautious when I first started speaking to people because I anticipated that 99/100 would be upset at having to talk to me. The truth was that 99/100 were willing to speak to me and listening to HN and Reddit set me back farther than I expected until I unlearned that lesson. So I'm saying this for the benefit of all those other engineers like me.
- jrochkind1 6y ago
  I was ready to agree with you because question in the OP wasn't so bad, but "So you have perfect user retention then?" -- seriously? Yeah, that's being demeaning. Maybe being demeaning is a good sales technique, I dunno, but that's definitely being a jerk. But "Are you sure increasing your user retention isn't worth something to you?" or something like that maybe.
  - stevewodil 6y ago
    It really depends on your tonality when you say it. In either case, saying "Are you sure increasing your user retention isn't worth something to you?" is just going to be met with another "No, we don't need it" from the other end. "So you have perfect user retention then?" is a better question because you know for a fact that they can't have 100% user retention and they know that as well so it forces further dialogue.
    - jrochkind1 6y ago
      i guess this is why I'm not a salesperson. If it works it works, but I'm having trouble accepting that it's not demeaning, which was the original contention. Because it's not really a question at all, it's a sarcastic question. Maybe being demeaning gets sales, sure.
      - james1071 6y ago
        Agree with you on that.
      - stevewodil 6y ago
        Think of it more as being a pattern interrupt. They are saying no to you over and over, so by asking the question, "So you have perfect user retention then?" they can either say "No" instinctively which opens your sales pitch because they've now told you they have a user retention problem, or they stop and think about the question in which case you've successfully interrupted the pattern of no's that preceded the question and can further the discussion. There are definitely better examples I could come up with, but now I'm stuck with this one because it's what I quickly typed out earlier.
- rawoke083600 6y ago
  Arg I HATE that angle ! It's like that sales calls.. "Do you like money ?".. if you say no thank you I"m busy... they like... oh so you don't like free money ?
  - konschubert 6y ago
    beep beep beep
dan-robertson 6y ago
The conversations are surely paraphrased and exaggerated—just look at the style of the rest of the article. The position that doctors should be trying new things to improve their care sounds good but in practice most doctors are strongly biased towards the status quo and usually inaction is preferred to a slightly unknown action, even if that action has better expectancy.
- ketzo 6y ago
  I dunno. I think tech people have a tendency to assume they know for certain that they have a better solution, and their words/tone can reflect that in a way that can come off as very insulting to people who have been working in the space for literal decades. Not everyone, and not all the time. But many people, and often enough that it's a stereotype. So I think it's worth considering, particularly when you're looking at a customer base who (by and large) really aren't used to being condescended to. Even if you and I personally aren't offended in the slightest by what OP said on sales calls, it's possible a psychologist in the fourth decade of her career might take "Are you sure that's right?" differently than we would.
  - james1071 6y ago
    He struck me as completely oblivious to what was likely to have been a complete lack of interest. His approach was never going to work, as doctors do not spend their time evaluating drugs in the way that he imagined.
    - pc86 6y ago
      It's a great example of "I'm going to make a pretty chart, and sell to.... $PROFESSION!" It may have been a great product like you and others have said, he hasn't the faintest idea what physicians actually do day-to-day. He had apparently spent $40k over nearly a year before he talked to the first physician.
      - wartijn_ 6y ago
        That's because his first plan was to sell to consumers. Only when that didn't work out he switched to physicians.
worldsayshi 6y ago
If you are to proud to visit stackoverflow or Google to search for best practices you're not a very good developer. Sounds like the same rule should apply to a doctor or psychiatrist. Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended? (Sorry if that came out a bit edgy. But this hole story irks me. It's frustrating when value can't be delivered because of cash flow issues.)
- dikaio 6y ago
  Agree
- ddorian43 6y ago
  > Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended? It's very hard to understand their thinking without being yourself a patient or doctor. TLDR: You need to spend 1K hours as a doctor, or shadowing, or something similar. When you are responsible for people with psychosis your perspective changes. Can't play nosql games with people's lives.
  - perl4ever 6y ago
    One has to be accepting that medical professionals are not superhuman and don't have magic bullets for chronic illness. But I don't know where you are coming from with such a pompous statement about being "responsible" for psychosis. The minimum "responsibility" that I can imagine being taken for a patient who has a crisis would be to move a regular appointment up after (or before) they land in the ER, and in the healthcare system I'm familiar with, it doesn't appear to happen. Are you used to something different? Or maybe you have a different idea of responsibility?
    - ddorian43 6y ago
      It's nothing special, just a job. But people are perplexed and they can't imagine why doctors are like that. I said you have to do the hours to understand, nothing special.
Falling3 6y ago
> you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better. That doesn't really capture the conversation though. Susan specifically said (as you quoted) that it was possible she would use the recommendations of the app. If she took a recommendation that means she agreed it was a better treatment. His question was not whether his algorithm was better than her default prescriptions - because they both agreed that was the case at least some of the time - it was whether it was better enough to be financially worthwhile.
- wolco5 6y ago
  Better didn't factor in for the doctor at any cost even free. This tech could be used to replace the function of this doctor making them less useful.
yunohn 6y ago
You’d be surprised how many doctors neglect the state of the art in medicine... That’s also why second opinions are a thing. Medicine is a science and hence, an ever changing field.
- chefandy 6y ago
  I probably would be surprised if that's true considering that in most states in the US, doctors are required to complete between 20 and 50 hours of structured CME (continued medical education) annually as a prerequisite to relicensure, and every one I've spoken to took it pretty seriously.
  - conductr 6y ago
    They are not unaware of the new stuff. But it doesn’t enter their day to day until it’s reached critical mass or if they’ve identified a couple suitable patients to recommend it to. Eg. Advil’s not working for a patient’s headache so, tell patient to try Tylenol because I learned about it during CMEs. Advil remains default for a long while. In many cases, until this doctors kid replaces him in the practice. Their generation learned in med school that Tylenol should be default.
    - chefandy 6y ago
      Are you a physician, work in medical education, or have some other sort of broader source of information than that of a patient? I've primarily had experience as a patient, but it certainly wasn't what you describe. Obviously anybody limited to a patient's perspective wouldn't have anything more than anecdotal data. Though back in the day, I did support for a CD-ROM based CME product... It was simple software so most of the people who called were in their 70s and 80s and not very comfortable with technology. They all seemed pretty concerned with learning the new stuff.
      - conductr 6y ago
        I worked along side physicians for several years. I'm still in healthcare but more corporate. I have interacted with physicians as a clinician, business partner, and patient. They love to learn that's no doubt. But the OP content was about changing their prescription protocols based on some hacked together ML that has no traditional clout. That was never going to fly; not without some [insert specialty] doctor's endorsement or some medical journal nods. When it comes to the business of healthcare, doctors are generally open to things that will make their jobs easier (they are money motivated creatures too). But, they don't necessarily like learning new things themselves. As a whole, they are rather resistant to change. It took a long time to incorporate any technology bedside (e-charts, etc). As a patient, I/family has been referred to other doctors specifically because they were younger or knew their education differed in a meaningful way. The old guy knew his ways were outdated and we would benefit from the new ways. So he was aware of the new way, but wasn't practicing it.
renewiltord 6y ago
Based on the response he got, it was the right question, actually. People aren't Internet-style insecure in real-life, especially those who have high social cred (like doctors). Even accounting for the humorous exaggeration, the kind of question asked from a professional doctor is less likely to cause them to be offended and more likely for them to just tell you why not. They're not going to be "How dare you question my decades of experience?!". They'll answer like they did in the OP. In The Mom Test, he suggests getting right to the core of a customer's pain points. This is just corollary to that.
- arghwhat 6y ago
  Although do note that doctors are just humans, with all the same flaws. There's just a bias in the kinds of humans that tend obtain the title.
  - overscore 6y ago
    Yeah, I do clinical placements in hospitals as part of volunteer work, and doctors run the range from open and receptive to questions to incredibly arrogant and dismissive. The fact that they agreed to talk to the OP probably means they aren't going to be immediately dismissive, but I'd hesitate to assign any supranormal human traits to doctors.
james1071 6y ago
He had not the slightest idea of how doctors prescribe drugs. The typical doctor has minimal training in evaluating medicines - that is not their job. They defer to so-called opinion-leaders, who are the experts on particular diseases. These people are the targets of drug companies' marketing - think scientific conferences in 5 star hotels in exotic locations. The cost of influencing them would be millions. So,the author was barking up the wrong tree. That's not to say that he didn't have something, but had no idea how to market it.
- intricatedetail 6y ago
  Some doctors use expert systems. They select symptoms and computer spits out possible list of treatments and then doctor picks one. If it doesn't work asks to come back and tries the next one. It's kind of like a human in today's self driving cars. Especially when it comes to mental health and anti-depressants. Essentially tests on production.
  - sxg 6y ago
    This isn't even close to how doctors prescribe medications. You don't prescribe meds without having a working diagnosis. Once you have that, you use the knowledge gained in med school and residency to pick the first line drug. If there are contraindications due to comorbidities (which there often are), you have to figure out what other meds you can use. You can consult online resources (e.g. UpToDate) to look up second, third, fourth line meds as well as advice on specific complicated scenarios. Trial and error with prescription drugs without a diagnosis as you suggest is malpractice. Maybe you're specifically referring to psychiatry? That specialty is uniquely difficult since our understanding of psychiatric diseases is still murky. But even within psychiatry there are best practice guidelines on how to manage and treat different diseases.
    - intricatedetail 6y ago
      This is what I saw my doctors were doing. Also I saw cardiologist comparing my diagnosis using Google images.
webel0 6y ago
> Imagine walking into the office of someone who spent the last ~10 years at school and then potentially 20 years practicing their craft as a successful psychologist and then you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better. As I understand it, this is exactly what new pharmaceutical sales reps are asked to do?
- james1071 6y ago
  It's not hard to get a doctor's attention when he knows you will provide him with golf days and holidays, if he plays his cards right.
  - alexanderskates 6y ago
    At least in the UK, sandwiches are the most that pharma reps can use to bribe doctors with... Which is not to say they aren't effective (you'll get butts in chairs at least, no guarantee they will pay any attention to you though).
    - bencollier49 6y ago
      Damned bribery and corruption act. I could really do with some free holidays and lavish parties. Now it's all branded mugs and that's your lot. Someone offered us free beer and we had to refuse. Oh, the humanity!
- preommr 6y ago
  No, the sales rep is selling the outcome of the knowledge of the medical experts within the company. In the same way the author was selling the outcome of the knowledge of their algorithm.
  - CRConrad 6y ago
    The author was selling the outcome of the knowledge of many expert medical researchers, as summarised by the author's algorithm. As opposed to the sales rep and the medical experts within the sales rep's company, neither the author nor his algorithm have any obvious direct incentive to recommend one medication over another.
serjester 6y ago
His writing style seems similar to Hunter Thompson’s - I wouldn’t read into it too deeply, exaggeration is the backbone. Personally I enjoy it. As for the actual content, there’s a massive difference between customers dying to use your product and them telling you it’d be “neat”. People don’t buy “neat” products. This is why you talk money to them as soon as possible. No real surprise it didn’t work out for him, the incentives just aren’t there. He could have prevented all this by reading the Mom Test - oh well, experience is the best teacher anyways.
wolco5 6y ago
And you back it up with proof but you hear I don't care about better treatment I care about prescribing what I feel works best and what pays best. Science be damned. There in a nutshell is the problem with healthcare. Doctors care about different outcomes. Doctors have this image that they care about your best health outcome but they would always trade an extra dollar over any patient outcome as long as they are legally within guidelines. As a developer. I went to school for a period of time. I have had a 20 year career of sucessful development jobs/projects. If someone walked in without any experience but showed me a better way to develop a project through understandable datapoints I would listen and not ignore them because I was somehow all knowing. I may even buy. Why are Doctors different?
johnisgood 6y ago
Note: psychologists cannot prescribe anything here (Eastern Europe), psychiatrists can. I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. I personally learnt a lot about pharmacology due to my illness, and I know what kind of medications are should not be supposed to be prescribed which the doctor working at the ER at that moment may not. In any case, you could just point out the reasons, I believe. For example: highly lipophilic beta-blockers are an issue in my case as I get anxious over its CNS side-effects that others may take it for performance anxiety, see: propranolol. The doctor prescribing me propranolol would be in the wrong. My own psychiatrist had no clue that lipophilic beta-blockers can cause all sorts of issues (CNS side-effects, such as brain fog) that lead to anxiety and even panic attacks for me. In my case, something like atenolol or even nebivolol would have worked better. Some doctors know this, some do not. I do not reasonably expect them to know everything though. It is sort of a detail that is not known because it is commonly prescribed to the elderly who do not report those CNS side-effects because they attribute them to their old age. There were cases of metoprolol causing hallucinations[1]. The old person attributed it to having some kind of a super power of seeing the dead because their heart stopped for a few seconds and they were "dead". I am not sure if this is the article I posted, but there was such a case. People who research their own specific illness may know better than some doctors, really. Sorry if I was a tad off-topic. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295654/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295654/
- nickjj 6y ago
  > I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. If you're not comfortable with a medication's potential side effects I do think it's worth bringing it up (I'm not a doctor, just an occasional patient) but it really comes down to how it's phrased. There's a very big difference between: "Actually propranolol won't work for me because after Googling around I discovered one of the side effects makes me feel anxious, can we try atenolol or nebivolol based on what I read online?" vs. "I know Googling for medical advice is sketchy but I read one of the side effects of propranolol is brain fog and this really concerns me because my job remains that I stay sharp. I trust your diagnosis and I know just because a side effect is listed I'm not guaranteed to have it, but are there any other beta blockers that we can start with that don't have this side effect and will still work? There's a lot of very carefully selected phrases in the 2nd way of saying the same statement. - Admission that Googling for medical issues isn't usually a good idea on its own to take actionable advice on - You bring up a valid concern about one of the side effects - Saying "diagnosis" vs "advice" is respectful of their decision ("advice" and "opinion" are a bit demeaning because it discredits their decision) - You call out that you know not all side effects will come true (you come off as someone who isn't just blindly Googling stuff, this raises your credibility) - You name drop "beta blockers" which shows you've done a decent amount of research - You let them take the reigns and offer alternative medication, giving them a chance to maybe pick the ones you've researched - You close things out as being optimistic by saying "and will still work" rather than questioning their decision before they give it by saying "think it will work" If I said the 2nd wording to a doctor and they denied my request without even discussing it then I'd leave and look for a 2nd opinion. Asking people questions without demeaning them is a great way to get an honest look at how someone operates.
Gatsky 6y ago
This article was posted before several years ago. The whole premise is bumptious - "I can copy data out of a bunch of papers [which I am in no position to screen for quality or relevance], run a canned 'gold standard' analysis in R [the idea that there is one true way to generate valid data is ridiculous], and then go tell the professionals what they are doing wrong." He even brags that his meta-analysis for depression had more papers than the published one, as if this was a valid metric. The Cipriani meta-analysis he cites was publised in February 2018. His meta-analysis was done in July 2018, and had 324 more papers - what explains this difference, other than obviously sloppy methodology. A proper meta-analysis is a lot of work, researchers spend years on one meta-analysis. The whole concept is ill conceived, and the author is too caught up in themselves to even realise why. Meta-analyses are a good idea, but the mere presence of a meta-analysis does not denote a useful undertaking. The literature is polluted with thousands of meta-analyses. As far as I can see this is mainly because there is software available which lets almost anyone do it, and once someone else has done a meta-analysis it is much easier to do another one because they have already found all the papers for you. The publication rate of meta-analyses far outstrips the publication rate of all papers, and shows some unusual geographic variation (Fig 2) [1]. [1] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-018-0819-1 https://systematicreviewsjournal.biomedcentral.com/articles/...
- sova 6y ago
  Statistically speaking, isn't it sound to throw all the papers into the mulcher and see what comes out the other end? We do use the term "outliers" a lot in statistics, do we not? I understand that the quality might not be up to snuff for some, but won't the law of averages take care of that?
  - hn_throwaway_99 6y ago
    Have you ever used a mulcher to chop up some yard waste, only to accidentally put in some dog shit, and then the whole thing stinks to high heaven? In all seriousness, with meta-analyses it's still "garbage in, garbage out". It only takes one or a few egregiously bad studies to throw off your results if that study has a large sample size but something fundamentally wrong with its methodology or implementation.
cko 6y ago
It was indeed a fun read. As a pharmacist I had a similar 'idea' years ago and got two other pharmacists excited. We were sick of seeing prescribers not follow 'Evidence based medicine' and thought maybe something that took Cochrane Meta Analyses and UpToDate info in a nice interface would be amazing. > I started babbling about network meta-analyses, statistical power, and p-values, but he cut me off. > "Yeah okay that's great but nobody cares about this math crap. You need doctors." So true. As an insider in healthcare I would probably have disregarded this for idealism.
- hef19898 6y ago
  It also sonds a lot like more than one tech / data scientist I met. Applying statistics and tch to a domain they have zero experience in. Kind of giving calculators to 1st grades and hope they know whether or not the results are correct.
Aeolun 6y ago
Just because someone spends 30 years learning something does not mean they learned the right thing.
- hef19898 6y ago
  Just because you didn't have 30 years of learning doesn't mean you know better.
GordonS 6y ago
> I'll just prescribe what I normally do, since I'm comfortable with it This is actually something that drives me absolutely nuts about doctors in the UK (I presume they are the same elsewhere) - inertia. It's like doctors leave medical school with "best practices" about what they should prescribe - like they are glorified, human decision trees - and then across their 40-year career, they never read a paper, never read any new guidance, and general never change. Inertia seems to be a particular problem in the NHS, where doctors have a set list they are willing to prescribe. Why? Because it's what they've prescribed previously, so they are "comfortable" with it. You can see there is a bit of a "chicken and egg problem" with other medications.
- mattowen_uk 6y ago
  There is also the 'NHS approved medication' list that they can only prescribe from, which restricts whats available to you, and it takes years for something newish to make it onto that list (for reasons...) If you want better options, the only choice in the UK is private healthcare. But yeah, I do still agree with you - GPs don't seem to even be up-to speed on the latest info with regard to a patients condition - surely their industry requires on-going professional learning like the rest of us ?
  - DanBC 6y ago
    None of this is true.
    - GordonS 6y ago
      It's not technically true, but there is a lot of truth in it. There are lists of recommended treatments, and there are many restrictions on prescription of medications, expensive ones in particular. At a national level, NICE[0] (or SMC[1] in Scotland) decide what medicines the NHS will pay for, and for what conditions. They determine what medications are licensed for different treatments. They also set guidance on what treatments should be used for different conditions, what the 1st line, 2nd line, 3rd line treatments should be, and what treatments they think should not be used. At a regional level, there are "formulary" groups, which take the national guidance, and make some tweaks - for example, for monetary reasons, they often increase the restrictions on expensive medications, making them harder to obtain. An example of those restrictions might be that the patient has to have been suffering for longer, the impact of the condition has to be more severe, or the patient must have tried several other (cheaper) medications first. For expensive medications, it's often not as simple as a consultant saying "I want my patient to have this" - at a regional or hospital level, there are quotas/limits on how many patients per year will be treated with sich expensive medications, and there are comittees that meet regularly to decide who is worthy. Now, if we put aside those expensive medications for moment: yes, technically consultants are free to use their experience, knowledge and judgement, and prescribe what they see fit (even unlicensed drugs) - but in reality, within the NHS it is uncommon to prescribe outwith the regional formulary guidance, or/and outwith licensed medication uses. There are a number of reasons for this: 1. Consultants take on individual liability when they prescribe unlicensed medicines, and individual hospitals fear legal risk too 2. Consultants will have their balls broken by their department head when they prescribe expensive medications - dept heads have budget responsibility, and in turn they will have their balls broken by the board 3. Consultants regularly meet with others from their department to discuss difficult/unusual cases, and have to justify their decisions to the panel 4. Perhaps it's the workload, but (IME) NHS consultants often have outdated knowledge. I swear some have never so much as read a journal article since they left medical school 30 years previous :( Again IME, private consultants seem to be much more confident to think out of the box with treatments; perhaps it's the commercial competition? [0] https://www.nice.org.uk https://www.nice.org.uk [1] https://www.scottishmedicines.org.uk https://www.scottishmedicines.org.uk

by nickjj 6y ago

stevewodil 6y ago

It's actually a very good sales question, I don't find it demeaning at all. If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation. It could come off as standoffish but when used correctly it's very effective because it gets the person on the other end to open up more and you try to get to the bottom of their objections.

na85 6y ago
>If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation. Assuming that I didn't initiate the call, if I tell some sales punk that I don't need their product and they come back at me with "So you have perfect user retention then?" my answer is going to be "fuck you" followed by ending the call. Arrogance might work in used car sales but it's not a panacea for closing the deal.
- stevewodil 6y ago
  I'm sure that happens occasionally as well. I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement. They will call the next person on their list, I'm sure it won't matter much.
  - matkoniecz 6y ago
    Incoming spam is unwelcome in general, and I would not assume that this people are trying to help me.
  - na85 6y ago
    >I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement. Oh please. Not every product that's applicable to a given business would necessarily be beneficial to that business. I get it, sales people have to drink the kool aid, but some humility is needed. Your product isn't right for everyone, and the sooner you understand that the sooner you can improve the quality of your lead generation.
    - stevewodil 6y ago
      If you have a vendetta against sales people you can just say that. We are talking about a completely hypothetical situation here, I don't see how you're now implying that the lead generation isn't good enough.
      - renewiltord 6y ago
        On HN, people hate cold emails. In real life, I've found that most people will respond or ignore. Like a tiny minority will act like you killed their mother, but that's life. I know you know this, if you're in sales, but I, like many other engineers who read this forum was overly cautious when I first started speaking to people because I anticipated that 99/100 would be upset at having to talk to me. The truth was that 99/100 were willing to speak to me and listening to HN and Reddit set me back farther than I expected until I unlearned that lesson. So I'm saying this for the benefit of all those other engineers like me.
jrochkind1 6y ago
I was ready to agree with you because question in the OP wasn't so bad, but "So you have perfect user retention then?" -- seriously? Yeah, that's being demeaning. Maybe being demeaning is a good sales technique, I dunno, but that's definitely being a jerk. But "Are you sure increasing your user retention isn't worth something to you?" or something like that maybe.
- stevewodil 6y ago
  It really depends on your tonality when you say it. In either case, saying "Are you sure increasing your user retention isn't worth something to you?" is just going to be met with another "No, we don't need it" from the other end. "So you have perfect user retention then?" is a better question because you know for a fact that they can't have 100% user retention and they know that as well so it forces further dialogue.
  - jrochkind1 6y ago
    i guess this is why I'm not a salesperson. If it works it works, but I'm having trouble accepting that it's not demeaning, which was the original contention. Because it's not really a question at all, it's a sarcastic question. Maybe being demeaning gets sales, sure.
    - james1071 6y ago
      Agree with you on that.
    - stevewodil 6y ago
      Think of it more as being a pattern interrupt. They are saying no to you over and over, so by asking the question, "So you have perfect user retention then?" they can either say "No" instinctively which opens your sales pitch because they've now told you they have a user retention problem, or they stop and think about the question in which case you've successfully interrupted the pattern of no's that preceded the question and can further the discussion. There are definitely better examples I could come up with, but now I'm stuck with this one because it's what I quickly typed out earlier.
rawoke083600 6y ago
Arg I HATE that angle ! It's like that sales calls.. "Do you like money ?".. if you say no thank you I"m busy... they like... oh so you don't like free money ?
- konschubert 6y ago
  beep beep beep

dan-robertson 6y ago

The conversations are surely paraphrased and exaggerated—just look at the style of the rest of the article. The position that doctors should be trying new things to improve their care sounds good but in practice most doctors are strongly biased towards the status quo and usually inaction is preferred to a slightly unknown action, even if that action has better expectancy.

ketzo 6y ago
I dunno. I think tech people have a tendency to assume they know for certain that they have a better solution, and their words/tone can reflect that in a way that can come off as very insulting to people who have been working in the space for literal decades. Not everyone, and not all the time. But many people, and often enough that it's a stereotype. So I think it's worth considering, particularly when you're looking at a customer base who (by and large) really aren't used to being condescended to. Even if you and I personally aren't offended in the slightest by what OP said on sales calls, it's possible a psychologist in the fourth decade of her career might take "Are you sure that's right?" differently than we would.
- james1071 6y ago
  He struck me as completely oblivious to what was likely to have been a complete lack of interest. His approach was never going to work, as doctors do not spend their time evaluating drugs in the way that he imagined.
  - pc86 6y ago
    It's a great example of "I'm going to make a pretty chart, and sell to.... $PROFESSION!" It may have been a great product like you and others have said, he hasn't the faintest idea what physicians actually do day-to-day. He had apparently spent $40k over nearly a year before he talked to the first physician.
    - wartijn_ 6y ago
      That's because his first plan was to sell to consumers. Only when that didn't work out he switched to physicians.

worldsayshi 6y ago

If you are to proud to visit stackoverflow or Google to search for best practices you're not a very good developer. Sounds like the same rule should apply to a doctor or psychiatrist. Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended? (Sorry if that came out a bit edgy. But this hole story irks me. It's frustrating when value can't be delivered because of cash flow issues.)

dikaio 6y ago
Agree
ddorian43 6y ago
> Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended? It's very hard to understand their thinking without being yourself a patient or doctor. TLDR: You need to spend 1K hours as a doctor, or shadowing, or something similar. When you are responsible for people with psychosis your perspective changes. Can't play nosql games with people's lives.
- perl4ever 6y ago
  One has to be accepting that medical professionals are not superhuman and don't have magic bullets for chronic illness. But I don't know where you are coming from with such a pompous statement about being "responsible" for psychosis. The minimum "responsibility" that I can imagine being taken for a patient who has a crisis would be to move a regular appointment up after (or before) they land in the ER, and in the healthcare system I'm familiar with, it doesn't appear to happen. Are you used to something different? Or maybe you have a different idea of responsibility?
  - ddorian43 6y ago
    It's nothing special, just a job. But people are perplexed and they can't imagine why doctors are like that. I said you have to do the hours to understand, nothing special.

Falling3 6y ago

> you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better. That doesn't really capture the conversation though. Susan specifically said (as you quoted) that it was possible she would use the recommendations of the app. If she took a recommendation that means she agreed it was a better treatment. His question was not whether his algorithm was better than her default prescriptions - because they both agreed that was the case at least some of the time - it was whether it was better enough to be financially worthwhile.

wolco5 6y ago
Better didn't factor in for the doctor at any cost even free. This tech could be used to replace the function of this doctor making them less useful.

yunohn 6y ago

You’d be surprised how many doctors neglect the state of the art in medicine... That’s also why second opinions are a thing. Medicine is a science and hence, an ever changing field.

chefandy 6y ago
I probably would be surprised if that's true considering that in most states in the US, doctors are required to complete between 20 and 50 hours of structured CME (continued medical education) annually as a prerequisite to relicensure, and every one I've spoken to took it pretty seriously.
- conductr 6y ago
  They are not unaware of the new stuff. But it doesn’t enter their day to day until it’s reached critical mass or if they’ve identified a couple suitable patients to recommend it to. Eg. Advil’s not working for a patient’s headache so, tell patient to try Tylenol because I learned about it during CMEs. Advil remains default for a long while. In many cases, until this doctors kid replaces him in the practice. Their generation learned in med school that Tylenol should be default.
  - chefandy 6y ago
    Are you a physician, work in medical education, or have some other sort of broader source of information than that of a patient? I've primarily had experience as a patient, but it certainly wasn't what you describe. Obviously anybody limited to a patient's perspective wouldn't have anything more than anecdotal data. Though back in the day, I did support for a CD-ROM based CME product... It was simple software so most of the people who called were in their 70s and 80s and not very comfortable with technology. They all seemed pretty concerned with learning the new stuff.
    - conductr 6y ago
      I worked along side physicians for several years. I'm still in healthcare but more corporate. I have interacted with physicians as a clinician, business partner, and patient. They love to learn that's no doubt. But the OP content was about changing their prescription protocols based on some hacked together ML that has no traditional clout. That was never going to fly; not without some [insert specialty] doctor's endorsement or some medical journal nods. When it comes to the business of healthcare, doctors are generally open to things that will make their jobs easier (they are money motivated creatures too). But, they don't necessarily like learning new things themselves. As a whole, they are rather resistant to change. It took a long time to incorporate any technology bedside (e-charts, etc). As a patient, I/family has been referred to other doctors specifically because they were younger or knew their education differed in a meaningful way. The old guy knew his ways were outdated and we would benefit from the new ways. So he was aware of the new way, but wasn't practicing it.

renewiltord 6y ago

Based on the response he got, it was the right question, actually. People aren't Internet-style insecure in real-life, especially those who have high social cred (like doctors). Even accounting for the humorous exaggeration, the kind of question asked from a professional doctor is less likely to cause them to be offended and more likely for them to just tell you why not. They're not going to be "How dare you question my decades of experience?!". They'll answer like they did in the OP. In The Mom Test, he suggests getting right to the core of a customer's pain points. This is just corollary to that.

arghwhat 6y ago
Although do note that doctors are just humans, with all the same flaws. There's just a bias in the kinds of humans that tend obtain the title.
- overscore 6y ago
  Yeah, I do clinical placements in hospitals as part of volunteer work, and doctors run the range from open and receptive to questions to incredibly arrogant and dismissive. The fact that they agreed to talk to the OP probably means they aren't going to be immediately dismissive, but I'd hesitate to assign any supranormal human traits to doctors.

james1071 6y ago

He had not the slightest idea of how doctors prescribe drugs. The typical doctor has minimal training in evaluating medicines - that is not their job. They defer to so-called opinion-leaders, who are the experts on particular diseases. These people are the targets of drug companies' marketing - think scientific conferences in 5 star hotels in exotic locations. The cost of influencing them would be millions. So,the author was barking up the wrong tree. That's not to say that he didn't have something, but had no idea how to market it.

intricatedetail 6y ago
Some doctors use expert systems. They select symptoms and computer spits out possible list of treatments and then doctor picks one. If it doesn't work asks to come back and tries the next one. It's kind of like a human in today's self driving cars. Especially when it comes to mental health and anti-depressants. Essentially tests on production.
- sxg 6y ago
  This isn't even close to how doctors prescribe medications. You don't prescribe meds without having a working diagnosis. Once you have that, you use the knowledge gained in med school and residency to pick the first line drug. If there are contraindications due to comorbidities (which there often are), you have to figure out what other meds you can use. You can consult online resources (e.g. UpToDate) to look up second, third, fourth line meds as well as advice on specific complicated scenarios. Trial and error with prescription drugs without a diagnosis as you suggest is malpractice. Maybe you're specifically referring to psychiatry? That specialty is uniquely difficult since our understanding of psychiatric diseases is still murky. But even within psychiatry there are best practice guidelines on how to manage and treat different diseases.
  - intricatedetail 6y ago
    This is what I saw my doctors were doing. Also I saw cardiologist comparing my diagnosis using Google images.

webel0 6y ago

> Imagine walking into the office of someone who spent the last ~10 years at school and then potentially 20 years practicing their craft as a successful psychologist and then you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better. As I understand it, this is exactly what new pharmaceutical sales reps are asked to do?

james1071 6y ago
It's not hard to get a doctor's attention when he knows you will provide him with golf days and holidays, if he plays his cards right.
- alexanderskates 6y ago
  At least in the UK, sandwiches are the most that pharma reps can use to bribe doctors with... Which is not to say they aren't effective (you'll get butts in chairs at least, no guarantee they will pay any attention to you though).
  - bencollier49 6y ago
    Damned bribery and corruption act. I could really do with some free holidays and lavish parties. Now it's all branded mugs and that's your lot. Someone offered us free beer and we had to refuse. Oh, the humanity!
preommr 6y ago
No, the sales rep is selling the outcome of the knowledge of the medical experts within the company. In the same way the author was selling the outcome of the knowledge of their algorithm.
- CRConrad 6y ago
  The author was selling the outcome of the knowledge of many expert medical researchers, as summarised by the author's algorithm. As opposed to the sales rep and the medical experts within the sales rep's company, neither the author nor his algorithm have any obvious direct incentive to recommend one medication over another.

serjester 6y ago

His writing style seems similar to Hunter Thompson’s - I wouldn’t read into it too deeply, exaggeration is the backbone. Personally I enjoy it. As for the actual content, there’s a massive difference between customers dying to use your product and them telling you it’d be “neat”. People don’t buy “neat” products. This is why you talk money to them as soon as possible. No real surprise it didn’t work out for him, the incentives just aren’t there. He could have prevented all this by reading the Mom Test - oh well, experience is the best teacher anyways.

wolco5 6y ago

And you back it up with proof but you hear I don't care about better treatment I care about prescribing what I feel works best and what pays best. Science be damned. There in a nutshell is the problem with healthcare. Doctors care about different outcomes. Doctors have this image that they care about your best health outcome but they would always trade an extra dollar over any patient outcome as long as they are legally within guidelines. As a developer. I went to school for a period of time. I have had a 20 year career of sucessful development jobs/projects. If someone walked in without any experience but showed me a better way to develop a project through understandable datapoints I would listen and not ignore them because I was somehow all knowing. I may even buy. Why are Doctors different?

johnisgood 6y ago

Note: psychologists cannot prescribe anything here (Eastern Europe), psychiatrists can. I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. I personally learnt a lot about pharmacology due to my illness, and I know what kind of medications are should not be supposed to be prescribed which the doctor working at the ER at that moment may not. In any case, you could just point out the reasons, I believe. For example: highly lipophilic beta-blockers are an issue in my case as I get anxious over its CNS side-effects that others may take it for performance anxiety, see: propranolol. The doctor prescribing me propranolol would be in the wrong. My own psychiatrist had no clue that lipophilic beta-blockers can cause all sorts of issues (CNS side-effects, such as brain fog) that lead to anxiety and even panic attacks for me. In my case, something like atenolol or even nebivolol would have worked better. Some doctors know this, some do not. I do not reasonably expect them to know everything though. It is sort of a detail that is not known because it is commonly prescribed to the elderly who do not report those CNS side-effects because they attribute them to their old age. There were cases of metoprolol causing hallucinations[1]. The old person attributed it to having some kind of a super power of seeing the dead because their heart stopped for a few seconds and they were "dead". I am not sure if this is the article I posted, but there was such a case. People who research their own specific illness may know better than some doctors, really. Sorry if I was a tad off-topic. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295654/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295654/

nickjj 6y ago
> I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. If you're not comfortable with a medication's potential side effects I do think it's worth bringing it up (I'm not a doctor, just an occasional patient) but it really comes down to how it's phrased. There's a very big difference between: "Actually propranolol won't work for me because after Googling around I discovered one of the side effects makes me feel anxious, can we try atenolol or nebivolol based on what I read online?" vs. "I know Googling for medical advice is sketchy but I read one of the side effects of propranolol is brain fog and this really concerns me because my job remains that I stay sharp. I trust your diagnosis and I know just because a side effect is listed I'm not guaranteed to have it, but are there any other beta blockers that we can start with that don't have this side effect and will still work? There's a lot of very carefully selected phrases in the 2nd way of saying the same statement. - Admission that Googling for medical issues isn't usually a good idea on its own to take actionable advice on - You bring up a valid concern about one of the side effects - Saying "diagnosis" vs "advice" is respectful of their decision ("advice" and "opinion" are a bit demeaning because it discredits their decision) - You call out that you know not all side effects will come true (you come off as someone who isn't just blindly Googling stuff, this raises your credibility) - You name drop "beta blockers" which shows you've done a decent amount of research - You let them take the reigns and offer alternative medication, giving them a chance to maybe pick the ones you've researched - You close things out as being optimistic by saying "and will still work" rather than questioning their decision before they give it by saying "think it will work" If I said the 2nd wording to a doctor and they denied my request without even discussing it then I'd leave and look for a 2nd opinion. Asking people questions without demeaning them is a great way to get an honest look at how someone operates.

Gatsky 6y ago

This article was posted before several years ago. The whole premise is bumptious - "I can copy data out of a bunch of papers [which I am in no position to screen for quality or relevance], run a canned 'gold standard' analysis in R [the idea that there is one true way to generate valid data is ridiculous], and then go tell the professionals what they are doing wrong." He even brags that his meta-analysis for depression had more papers than the published one, as if this was a valid metric. The Cipriani meta-analysis he cites was publised in February 2018. His meta-analysis was done in July 2018, and had 324 more papers - what explains this difference, other than obviously sloppy methodology. A proper meta-analysis is a lot of work, researchers spend years on one meta-analysis. The whole concept is ill conceived, and the author is too caught up in themselves to even realise why. Meta-analyses are a good idea, but the mere presence of a meta-analysis does not denote a useful undertaking. The literature is polluted with thousands of meta-analyses. As far as I can see this is mainly because there is software available which lets almost anyone do it, and once someone else has done a meta-analysis it is much easier to do another one because they have already found all the papers for you. The publication rate of meta-analyses far outstrips the publication rate of all papers, and shows some unusual geographic variation (Fig 2) [1]. [1] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-018-0819-1 https://systematicreviewsjournal.biomedcentral.com/articles/...

sova 6y ago
Statistically speaking, isn't it sound to throw all the papers into the mulcher and see what comes out the other end? We do use the term "outliers" a lot in statistics, do we not? I understand that the quality might not be up to snuff for some, but won't the law of averages take care of that?
- hn_throwaway_99 6y ago
  Have you ever used a mulcher to chop up some yard waste, only to accidentally put in some dog shit, and then the whole thing stinks to high heaven? In all seriousness, with meta-analyses it's still "garbage in, garbage out". It only takes one or a few egregiously bad studies to throw off your results if that study has a large sample size but something fundamentally wrong with its methodology or implementation.

cko 6y ago

It was indeed a fun read. As a pharmacist I had a similar 'idea' years ago and got two other pharmacists excited. We were sick of seeing prescribers not follow 'Evidence based medicine' and thought maybe something that took Cochrane Meta Analyses and UpToDate info in a nice interface would be amazing. > I started babbling about network meta-analyses, statistical power, and p-values, but he cut me off. > "Yeah okay that's great but nobody cares about this math crap. You need doctors." So true. As an insider in healthcare I would probably have disregarded this for idealism.

hef19898 6y ago
It also sonds a lot like more than one tech / data scientist I met. Applying statistics and tch to a domain they have zero experience in. Kind of giving calculators to 1st grades and hope they know whether or not the results are correct.

Aeolun 6y ago

Just because someone spends 30 years learning something does not mean they learned the right thing.

hef19898 6y ago
Just because you didn't have 30 years of learning doesn't mean you know better.

GordonS 6y ago

> I'll just prescribe what I normally do, since I'm comfortable with it This is actually something that drives me absolutely nuts about doctors in the UK (I presume they are the same elsewhere) - inertia. It's like doctors leave medical school with "best practices" about what they should prescribe - like they are glorified, human decision trees - and then across their 40-year career, they never read a paper, never read any new guidance, and general never change. Inertia seems to be a particular problem in the NHS, where doctors have a set list they are willing to prescribe. Why? Because it's what they've prescribed previously, so they are "comfortable" with it. You can see there is a bit of a "chicken and egg problem" with other medications.

mattowen_uk 6y ago
There is also the 'NHS approved medication' list that they can only prescribe from, which restricts whats available to you, and it takes years for something newish to make it onto that list (for reasons...) If you want better options, the only choice in the UK is private healthcare. But yeah, I do still agree with you - GPs don't seem to even be up-to speed on the latest info with regard to a patients condition - surely their industry requires on-going professional learning like the rest of us ?
- DanBC 6y ago
  None of this is true.
  - GordonS 6y ago
    It's not technically true, but there is a lot of truth in it. There are lists of recommended treatments, and there are many restrictions on prescription of medications, expensive ones in particular. At a national level, NICE[0] (or SMC[1] in Scotland) decide what medicines the NHS will pay for, and for what conditions. They determine what medications are licensed for different treatments. They also set guidance on what treatments should be used for different conditions, what the 1st line, 2nd line, 3rd line treatments should be, and what treatments they think should not be used. At a regional level, there are "formulary" groups, which take the national guidance, and make some tweaks - for example, for monetary reasons, they often increase the restrictions on expensive medications, making them harder to obtain. An example of those restrictions might be that the patient has to have been suffering for longer, the impact of the condition has to be more severe, or the patient must have tried several other (cheaper) medications first. For expensive medications, it's often not as simple as a consultant saying "I want my patient to have this" - at a regional or hospital level, there are quotas/limits on how many patients per year will be treated with sich expensive medications, and there are comittees that meet regularly to decide who is worthy. Now, if we put aside those expensive medications for moment: yes, technically consultants are free to use their experience, knowledge and judgement, and prescribe what they see fit (even unlicensed drugs) - but in reality, within the NHS it is uncommon to prescribe outwith the regional formulary guidance, or/and outwith licensed medication uses. There are a number of reasons for this: 1. Consultants take on individual liability when they prescribe unlicensed medicines, and individual hospitals fear legal risk too 2. Consultants will have their balls broken by their department head when they prescribe expensive medications - dept heads have budget responsibility, and in turn they will have their balls broken by the board 3. Consultants regularly meet with others from their department to discuss difficult/unusual cases, and have to justify their decisions to the panel 4. Perhaps it's the workload, but (IME) NHS consultants often have outdated knowledge. I swear some have never so much as read a journal article since they left medical school 30 years previous :( Again IME, private consultants seem to be much more confident to think out of the box with treatments; perhaps it's the commercial competition? [0] https://www.nice.org.uk https://www.nice.org.uk [1] https://www.scottishmedicines.org.uk https://www.scottishmedicines.org.uk