7 ms·

Being a doc, I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare. That won't surprise you, I guess. I lon

by rscho 2y ago

Being a doc, I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare. That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes.

pegasus 2y ago
I suspect you're right, and would be interested to hear more.
- rscho 2y ago
  In a nutshell, no amount of lobbying will stop equivalent service for 100x cheaper. Tech does not permeate healthcare for 2 reasons: 1. mostly inapplicable. Everyone is focusing on ML model performance, but really information retrieval in healthcare is dismal and prevents the use of such new tech altogether except in very niche cases. 2. no integration in the workplace. Tech people and docs don't understand each other at all, so docs ask for impossible things, and tech people deliver perfectly functional, totally inapplicable tech.
  - robertlagrant 2y ago
    Me and my team made a piece of successful software for patients and clinicians. It is really difficult, mostly for the reasons you state, but it is possible. It's used in about half the NHS, and I personally know three people who've used our app to successfully manage their pregnancy complication, which is great.
    - whimsicalism 2y ago
      There is less political capture of this process in the UK.
      - robertlagrant 2y ago
        My company/team is an unusual exception. The UK has a much bigger problem with creating tech than the US does. That's why almost all NHS trusts in the UK use US-created EHR systems: Cerner and Epic, mostly. The UK is bad at creating a pro-business/pro-investment environment, so we have to buy in stuff from elsewhere, even though it's not well-suited to our needs. Or best case we find US-based investment for our companies.
        throwaway2037 2y ago
        > The UK is bad at creating a pro-business/pro-investment environment Are there any country's medical system, except the US, that are good at this?
  - whimsicalism 2y ago
    If there are algos out there (and there are) that can accurately provide a strong heuristic on melanoma from a photo and this is being blocked by the state - that seems like an obvious instance of regulatory apparatus stopping an equivalent 100x+ cheaper service. I've discussed with a number of people who work directly on DL for imaging at a major hospital system in Boston. They say that (outside of the doctors they work directly with) fear over competition and losing out on the pricier billings are one of the largest barriers to getting their (very accurate) tech deployed more widely.
    - rscho 2y ago
      Yes, so as usual it's so superior but it's never used. And the people building it say it's stellar, promise! Here's a clue: instead of building a tool, and try teaching people already practicing how and why they should use it, maybe we could actually go see what practitioners are doing and try to integrate into that without requiring 30 additional mouse clicks and the use of a new soft that nobody understands ?
      - whimsicalism 2y ago
        You can find the studies on the recent melanoma classifiers. There are tons showing in various settings that they pretty clearly outperform physicians. If 'additional mouse clicks' is a major barrier to physicians using a tool that leads to far better diagnosis outcomes of a fast-progressing and deadly disease, I'm not sure why that is an argument for why things should continue to be as physician-gated as they are. I will happily perform the 30 extra clicks myself if it is my potential melanoma. But if I were to offer it as a self-serve app ($2 for melanoma diagnoses too cheap to meter), I would be thrown in jail.
        rscho 2y ago
        Yes, we have so many models that completely outclass docs. It's really strange, they're not more widely available don't you think ? Providing so much value, one would think there would be a black market for those, at this point. Or maybe, just maybe, the setting necessary to make things work in large-scale realistic practice is more difficult than what the paper authors would have you believe? No, they would never do that...
ProllyInfamous 2y ago
Myself a med-school-dropout, I've found myself several times telling doctors how I really feel: "You aren't paid enough for the sacrifices you made just to be able to help people that probably aren't going to listen to your advice, anyways." Thank you for your sacrifices, including to the oncoming ML "clinicians."
- pnut 2y ago
  Come on, doctors are some of the most highly compensated wage earners. Every working stiff at all income levels sacrifices disproportionately to their income, and if I were a high school teacher, I'd belly laugh at this doctor pity party.
  - eppp 2y ago
    Some doctors* The front line primary care doctors and nurse practitioners dont make as much as IT people quite often.
    - Sohcahtoa82 2y ago
      From what I understand, the primary care physicians that work for a large medical company don't make much, but ones that run their own practice can make double or even triple, but then they take on enormous risk.
    - whimsicalism 2y ago
      Lets not lump in nurse practitioners. I'm absolutely in favor of giving more responsibilities to NPs and paying them more than they currently are. Data on doctor salaries is very difficult to come by publicly, however H1B salaries indicate the average pay for H1B PCPs is $200k [0]. These are the lowest paid physicians. If you look at the data, many many physicians are making much more than that - with many specialities averaging $300k+. Generally H1B workers make less than comparable native-born (even though that's illegal) so we should view this as a lower-bound. That puts hourly pay for average PCPs lower than the top SWEs, but comparing average with average or specialty with average and you're already quickly outpacing large majority of SWEs. [0]: https://h1bdata.info/highestpaidjob.php https://h1bdata.info/highestpaidjob.php
mypgovroom 2y ago
[flagged]
- teaearlgraycold 2y ago
  Think before you comment
  - neom 2y ago
    https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html y'all know better than to get into this kinda thing.
swayvil 2y ago
Would you say that doctors are overworked?
- rscho 2y ago
  Most docs are overworked for many, mostly bad reasons. Clinical overload is one thing, but healthcare is more like drowning in admin work, these days. So mostly yes, but the true answer is more complex than I can write about in a comment.
  - torginus 2y ago
    The US has 26.1 doctors per capita, while Germany has 42.5, which is a middle-of-the-road number for the developed West. Do you accept the criticism that the US simply artificially limits the supply of doctors, which leads to overwork for physicians, and worse health outcomes for patients? Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
    - slt2021 2y ago
      the admin bloat comes from medical insurance industrial complex. same as in education
    - rscho 2y ago
      All countries control rather strictly who can practice medicine. Yes, there is some amount of protectionism, but that happens almost everywhere. The reason is not only money, but also cultural issues. So yes, I expect that to be a valid criticism, but I don't think opening the floodgates would have the result you expect either. Access to care is a complex problem, and IMO not primarily limited by doc counts in the US. Young docs would absolutely work less for less if possible, I think. Old docs wouldn't. IMO, that's reflected in the rise of big network providers such as Kaiser and friends. In Europe, access to care is better IMO mainly because both patients and docs are far less aggressive, and often quite happy just doing nothing. Which is in fact the true problem about US healthcare: the culture of absolutism.
avgDev 2y ago
So, what is your job? I will be honest, I've had better luck with google than most doctors. I've had doctors say things which were completely incorrect. I've had doctors prescribe unnecessary and not advised meds for what they diagnosed me with(incorrectly). I have friends who are pharmacists and they agree with my opinion, and they interact with doctors daily.
- slaymaker1907 2y ago
  I had to fight with numerous doctors to finally get treated for scabies despite having extremely severe symptoms and despite my partner at the time having scabies. My immune system was apparently good enough to keep it from being easily detected under a microscope, but lo and behold, I had complete symptom remission once the dermatologist I saw went ahead and prescribed an antiparasitic anyways.
- dj_gitmo 2y ago
  I have had the opposite experience. I have had professionals find and treat problems in weeks after wasting years using books and the internet. I am not saying it is impossible, but find good info on the internet, but it has its limits.
  - dietr1ch 2y ago
    There's gotta be errors on both sides, now the question is if we are assessing their risks properly or not. Maybe giving a shot to a low risk thing you read on the internet is worth a try, and maybe booking a doctor visit and getting examined will be worth the time and money. It'd be nice to have this decision tree being built out in the open, ultimately everyone needs it.
- matwood 2y ago
  Doctors are people doing a job just like anyone else. The old joke, 'what do you call someone who graduated last in their med school class? Doctor.' Just like software, there are good ones, bad ones, and average ones. By definition, most are average. I know a few surgeons who are nerds about surgery like many on HN are about technology. But they are also the first ones to tell you not all doctors are the same.
throw123011 2y ago
[flagged]
- tacocataco 2y ago
  We should all strive to automate what we can in a safe manner. The only reason it is seen as a bad thing is that the economic system coerced you into proving you deserve basic necessities.
  - munificent 2y ago
    This is a silly take. I could probably automate hugging my children, but I sure as hell wouldn't want to. We should try to build a world where people get to live with as much safety, dignity, meaning, and reward as we can. We should build a world where if people were given the choice between it and some other world with different parameters, they would choose the former. Automation is a piece of that, but absolutely not an end goal. Often people are happiest when doing things that are not automated.
- spicybright 2y ago
  Would you like this comment pinned to your hospital gown while going in for a surgery? I get your salty about the economics of it, but it's not like doctors are pencil pushers. These are skilled people that will be saving your life one day whether you like it or not.
inglor_cz 2y ago
"I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare" If you have enough time, read this 5-page article. Can this be explained by anything else but naked greed? https://digitalsmiledesign.com/files/Old-Website-Assets/PDF/How-Dentists-Rip-Us-Off.pdf https://digitalsmiledesign.com/files/Old-Website-Assets/PDF/...
antisthenes 2y ago
> That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes. You can explain all you want, but the US is the only country that has exorbitant bills for healthcare culturally normalized for some reason, despite outcomes being roughly the same as other developed countries. Unless your explanation sufficiently addresses that (which I doubt, since you are not an economist), no one will care to listen. So maybe a little less confidence and a bit more humility and empathy (for those that need healthcare and can't afford it).
- rscho 2y ago
  So, if I tell you: 'I'd like help, but when I ask for it I get something worse than what I had at the start', that's me being a typical insufferable doctor, I guess ? We both fit our stereotypes really well, then !
loandbehold 2y ago
Can you explain why optometrist is necessary to buy glasses? Eye exam is already automated to a large extend, and it shouldn't be hard to make it 100% automated by having machine ask questions instead of optometrist. Optometrist already follows a well defined algorithm to come up with prescription by putting a series of lens pairs in phoroptor and asking patient which one is better.
- SkyPuncher 2y ago
  It's not entirely required. You can go on Zenni (and other online stores) and buy a pair of glasses with whatever correction you want. Though, I do largely agree that the actual assessment by an optometrist is literally unnecessary. I've personally had to adjust my prescriptions because the optometrist pushes me to something that strains my eyes.
- kube-system 2y ago
  An eye exam doesn't simply prescribe lenses. They also, for example, evaluate for disease.
whimsicalism 2y ago
I would like to see RCTs on whether the current approach of care gatekept by doctors (ie. prescription for glasses, can't use this melanoma diagnosis tool unless you visit and pay for a derma) actually has any measurable impact on downstream health. It's interesting that we have all these RCTs for drug interventions, but never conduct the RCTs on policy like letting NPs do more procedures, etc.
- rscho 2y ago
  Ah, RCTs! The final truth, the end all of all arguments. I've been working for enough profs to know that the best thing to do with 90%+ medical papers is to transfer them directly to the wastebin, and that includes RCTs.
  - whimsicalism 2y ago
    Yeah, what is a randomized controlled trial when we have your 'gut feel' to rely on. Great showing from the physicians in the comments here, now I can clearly see why we should have trust in your evidence-based practice.
    - rscho 2y ago
      I do clinical statistics. I make such studies. Sorry the sausage is not the way you dreamt it!
      - mrtranscendence 2y ago
        X says "I would like RCTs on this subject", and you reply that most RCTs are worthless. Great, what do you want, a cookie? Presumably they want good RCTs, not low-quality ones.
        rscho 2y ago
        Yeah, I'd like a cookie. I'd also like medicine to become real science. Unfortunately, you can't say by reading the paper, whether the paper corresponds to what's truly been done. In my experience, it often doesn't. What's your personal experience you wish to enlighten us with?

by rscho 2y ago

pegasus 2y ago

I suspect you're right, and would be interested to hear more.

rscho 2y ago
In a nutshell, no amount of lobbying will stop equivalent service for 100x cheaper. Tech does not permeate healthcare for 2 reasons: 1. mostly inapplicable. Everyone is focusing on ML model performance, but really information retrieval in healthcare is dismal and prevents the use of such new tech altogether except in very niche cases. 2. no integration in the workplace. Tech people and docs don't understand each other at all, so docs ask for impossible things, and tech people deliver perfectly functional, totally inapplicable tech.
- robertlagrant 2y ago
  Me and my team made a piece of successful software for patients and clinicians. It is really difficult, mostly for the reasons you state, but it is possible. It's used in about half the NHS, and I personally know three people who've used our app to successfully manage their pregnancy complication, which is great.
  - whimsicalism 2y ago
    There is less political capture of this process in the UK.
    - robertlagrant 2y ago
      My company/team is an unusual exception. The UK has a much bigger problem with creating tech than the US does. That's why almost all NHS trusts in the UK use US-created EHR systems: Cerner and Epic, mostly. The UK is bad at creating a pro-business/pro-investment environment, so we have to buy in stuff from elsewhere, even though it's not well-suited to our needs. Or best case we find US-based investment for our companies.
      - throwaway2037 2y ago
        > The UK is bad at creating a pro-business/pro-investment environment Are there any country's medical system, except the US, that are good at this?
- whimsicalism 2y ago
  If there are algos out there (and there are) that can accurately provide a strong heuristic on melanoma from a photo and this is being blocked by the state - that seems like an obvious instance of regulatory apparatus stopping an equivalent 100x+ cheaper service. I've discussed with a number of people who work directly on DL for imaging at a major hospital system in Boston. They say that (outside of the doctors they work directly with) fear over competition and losing out on the pricier billings are one of the largest barriers to getting their (very accurate) tech deployed more widely.
  - rscho 2y ago
    Yes, so as usual it's so superior but it's never used. And the people building it say it's stellar, promise! Here's a clue: instead of building a tool, and try teaching people already practicing how and why they should use it, maybe we could actually go see what practitioners are doing and try to integrate into that without requiring 30 additional mouse clicks and the use of a new soft that nobody understands ?
    - whimsicalism 2y ago
      You can find the studies on the recent melanoma classifiers. There are tons showing in various settings that they pretty clearly outperform physicians. If 'additional mouse clicks' is a major barrier to physicians using a tool that leads to far better diagnosis outcomes of a fast-progressing and deadly disease, I'm not sure why that is an argument for why things should continue to be as physician-gated as they are. I will happily perform the 30 extra clicks myself if it is my potential melanoma. But if I were to offer it as a self-serve app ($2 for melanoma diagnoses too cheap to meter), I would be thrown in jail.
      - rscho 2y ago
        Yes, we have so many models that completely outclass docs. It's really strange, they're not more widely available don't you think ? Providing so much value, one would think there would be a black market for those, at this point. Or maybe, just maybe, the setting necessary to make things work in large-scale realistic practice is more difficult than what the paper authors would have you believe? No, they would never do that...

ProllyInfamous 2y ago

Myself a med-school-dropout, I've found myself several times telling doctors how I really feel: "You aren't paid enough for the sacrifices you made just to be able to help people that probably aren't going to listen to your advice, anyways." Thank you for your sacrifices, including to the oncoming ML "clinicians."

pnut 2y ago
Come on, doctors are some of the most highly compensated wage earners. Every working stiff at all income levels sacrifices disproportionately to their income, and if I were a high school teacher, I'd belly laugh at this doctor pity party.
- eppp 2y ago
  Some doctors* The front line primary care doctors and nurse practitioners dont make as much as IT people quite often.
  - Sohcahtoa82 2y ago
    From what I understand, the primary care physicians that work for a large medical company don't make much, but ones that run their own practice can make double or even triple, but then they take on enormous risk.
  - whimsicalism 2y ago
    Lets not lump in nurse practitioners. I'm absolutely in favor of giving more responsibilities to NPs and paying them more than they currently are. Data on doctor salaries is very difficult to come by publicly, however H1B salaries indicate the average pay for H1B PCPs is $200k [0]. These are the lowest paid physicians. If you look at the data, many many physicians are making much more than that - with many specialities averaging $300k+. Generally H1B workers make less than comparable native-born (even though that's illegal) so we should view this as a lower-bound. That puts hourly pay for average PCPs lower than the top SWEs, but comparing average with average or specialty with average and you're already quickly outpacing large majority of SWEs. [0]: https://h1bdata.info/highestpaidjob.php https://h1bdata.info/highestpaidjob.php

mypgovroom 2y ago

[flagged]

teaearlgraycold 2y ago
Think before you comment
- neom 2y ago
  https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html y'all know better than to get into this kinda thing.

swayvil 2y ago

Would you say that doctors are overworked?

rscho 2y ago
Most docs are overworked for many, mostly bad reasons. Clinical overload is one thing, but healthcare is more like drowning in admin work, these days. So mostly yes, but the true answer is more complex than I can write about in a comment.
- torginus 2y ago
  The US has 26.1 doctors per capita, while Germany has 42.5, which is a middle-of-the-road number for the developed West. Do you accept the criticism that the US simply artificially limits the supply of doctors, which leads to overwork for physicians, and worse health outcomes for patients? Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
  - slt2021 2y ago
    the admin bloat comes from medical insurance industrial complex. same as in education
  - rscho 2y ago
    All countries control rather strictly who can practice medicine. Yes, there is some amount of protectionism, but that happens almost everywhere. The reason is not only money, but also cultural issues. So yes, I expect that to be a valid criticism, but I don't think opening the floodgates would have the result you expect either. Access to care is a complex problem, and IMO not primarily limited by doc counts in the US. Young docs would absolutely work less for less if possible, I think. Old docs wouldn't. IMO, that's reflected in the rise of big network providers such as Kaiser and friends. In Europe, access to care is better IMO mainly because both patients and docs are far less aggressive, and often quite happy just doing nothing. Which is in fact the true problem about US healthcare: the culture of absolutism.

avgDev 2y ago

So, what is your job? I will be honest, I've had better luck with google than most doctors. I've had doctors say things which were completely incorrect. I've had doctors prescribe unnecessary and not advised meds for what they diagnosed me with(incorrectly). I have friends who are pharmacists and they agree with my opinion, and they interact with doctors daily.

slaymaker1907 2y ago
I had to fight with numerous doctors to finally get treated for scabies despite having extremely severe symptoms and despite my partner at the time having scabies. My immune system was apparently good enough to keep it from being easily detected under a microscope, but lo and behold, I had complete symptom remission once the dermatologist I saw went ahead and prescribed an antiparasitic anyways.
dj_gitmo 2y ago
I have had the opposite experience. I have had professionals find and treat problems in weeks after wasting years using books and the internet. I am not saying it is impossible, but find good info on the internet, but it has its limits.
- dietr1ch 2y ago
  There's gotta be errors on both sides, now the question is if we are assessing their risks properly or not. Maybe giving a shot to a low risk thing you read on the internet is worth a try, and maybe booking a doctor visit and getting examined will be worth the time and money. It'd be nice to have this decision tree being built out in the open, ultimately everyone needs it.
matwood 2y ago
Doctors are people doing a job just like anyone else. The old joke, 'what do you call someone who graduated last in their med school class? Doctor.' Just like software, there are good ones, bad ones, and average ones. By definition, most are average. I know a few surgeons who are nerds about surgery like many on HN are about technology. But they are also the first ones to tell you not all doctors are the same.

throw123011 2y ago

[flagged]

tacocataco 2y ago
We should all strive to automate what we can in a safe manner. The only reason it is seen as a bad thing is that the economic system coerced you into proving you deserve basic necessities.
- munificent 2y ago
  This is a silly take. I could probably automate hugging my children, but I sure as hell wouldn't want to. We should try to build a world where people get to live with as much safety, dignity, meaning, and reward as we can. We should build a world where if people were given the choice between it and some other world with different parameters, they would choose the former. Automation is a piece of that, but absolutely not an end goal. Often people are happiest when doing things that are not automated.
spicybright 2y ago
Would you like this comment pinned to your hospital gown while going in for a surgery? I get your salty about the economics of it, but it's not like doctors are pencil pushers. These are skilled people that will be saving your life one day whether you like it or not.

inglor_cz 2y ago

"I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare" If you have enough time, read this 5-page article. Can this be explained by anything else but naked greed? https://digitalsmiledesign.com/files/Old-Website-Assets/PDF/How-Dentists-Rip-Us-Off.pdf https://digitalsmiledesign.com/files/Old-Website-Assets/PDF/...

antisthenes 2y ago

> That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes. You can explain all you want, but the US is the only country that has exorbitant bills for healthcare culturally normalized for some reason, despite outcomes being roughly the same as other developed countries. Unless your explanation sufficiently addresses that (which I doubt, since you are not an economist), no one will care to listen. So maybe a little less confidence and a bit more humility and empathy (for those that need healthcare and can't afford it).

rscho 2y ago
So, if I tell you: 'I'd like help, but when I ask for it I get something worse than what I had at the start', that's me being a typical insufferable doctor, I guess ? We both fit our stereotypes really well, then !

loandbehold 2y ago

Can you explain why optometrist is necessary to buy glasses? Eye exam is already automated to a large extend, and it shouldn't be hard to make it 100% automated by having machine ask questions instead of optometrist. Optometrist already follows a well defined algorithm to come up with prescription by putting a series of lens pairs in phoroptor and asking patient which one is better.

SkyPuncher 2y ago
It's not entirely required. You can go on Zenni (and other online stores) and buy a pair of glasses with whatever correction you want. Though, I do largely agree that the actual assessment by an optometrist is literally unnecessary. I've personally had to adjust my prescriptions because the optometrist pushes me to something that strains my eyes.
kube-system 2y ago
An eye exam doesn't simply prescribe lenses. They also, for example, evaluate for disease.

whimsicalism 2y ago

I would like to see RCTs on whether the current approach of care gatekept by doctors (ie. prescription for glasses, can't use this melanoma diagnosis tool unless you visit and pay for a derma) actually has any measurable impact on downstream health. It's interesting that we have all these RCTs for drug interventions, but never conduct the RCTs on policy like letting NPs do more procedures, etc.

rscho 2y ago
Ah, RCTs! The final truth, the end all of all arguments. I've been working for enough profs to know that the best thing to do with 90%+ medical papers is to transfer them directly to the wastebin, and that includes RCTs.
- whimsicalism 2y ago
  Yeah, what is a randomized controlled trial when we have your 'gut feel' to rely on. Great showing from the physicians in the comments here, now I can clearly see why we should have trust in your evidence-based practice.
  - rscho 2y ago
    I do clinical statistics. I make such studies. Sorry the sausage is not the way you dreamt it!
    - mrtranscendence 2y ago
      X says "I would like RCTs on this subject", and you reply that most RCTs are worthless. Great, what do you want, a cookie? Presumably they want good RCTs, not low-quality ones.
      - rscho 2y ago
        Yeah, I'd like a cookie. I'd also like medicine to become real science. Unfortunately, you can't say by reading the paper, whether the paper corresponds to what's truly been done. In my experience, it often doesn't. What's your personal experience you wish to enlighten us with?