4 ms·

> And shameful (for them.) 1. A single positive outcome with N=1 should generally not be the basis for making a medical recommendation. 2. It takes a mountain

• tilne 1y ago
  Regarding 3: Shouldn’t the medical system be optimizing for patient outcomes rather than the business their in? Regarding the first two: I think the anecdote being from 1995 suggests there would have been time to put together said mountain of research. I’m not agreeing that this is shameful for the original doctor, but I do think it’s shameful if avenues for potential research are not taken because it’s inconvenient for the hospitals.
  • vkou 1y ago
    Yes, it should. But cost is also important to patients. Or it would be in any universe that made sense.
  • Spooky23 1y ago
    It is at cancer centers. Community oncologists don’t have the resources to do it. Example: https://www.medicalnewstoday.com/articles/cancer-time-of-day-may-matter-for-diagnosis-treatment#How-circadian-rhythm-affects-cancer-treatment https://www.medicalnewstoday.com/articles/cancer-time-of-day...
    • raylad 1y ago
      This was Sloan-Kettering. They gave morning infusions because it was convenient. To get my father the evening infusion we had to hire private duty nurses to come to his apartment.
• vlovich123 1y ago
  I agree n=1 generally isn’t enough, but something like this is easily something you ask for volunteers for as an experiment. There’s 0 risk, you’re taking the same drug. The only reason a given time is selected anyway is for administrative ease not because there’s medical requirements.
  • vkou 1y ago
    Its not easy to ask if it messes with staff scheduling.
    • vlovich123 1y ago
      Clearly they did it for one patient and it was a good result. Doctors and staff generally care about their patients and given there’s plausible scientific reasoning why this worked, they’d help figure out how to make staffing work for 3-5 more patients for a limited time. Additionally, positive results like this start to travel by word of mouth so if this is successful it means more funding for the hospital and more patients seeking care from them. That’s how it should work but bureaucracy of medical care is typically resistant to things like that.
      • vkou 1y ago
        In any medical system in the world, you'll find that staff scheduling is the singular, most important constraint for patient care. That they did it for one patient does not mean that they can do it for everyone - especially when it's not clear if it actually helped, due to a small sample size.
        • vlovich123 1y ago
          I didn’t say everyone. I said do it as a pilot for 2-5 more patients so that you don’t write it off as a fluke, then give a talk at a conference. If you’re having good results then you can talk with the administrators how to make this a more serious program if there’s actually good results and desire to scale this up. Nowhere do you start from 0 and go to 100. You take baby steps scaling up to see if the results hold.
• chiefalchemist 1y ago
  It shameful in the sense we all know there are circadian rhythms. We know the human body is not uniform from waking to shut eye. With this in mind health care therapies should be intentionally administered at various times - as wide as possible; from that perhaps outcomes will vary. You don’t need a study to look for opportunities to optimize a process.
• vidarh 1y ago
  Given the scheduling was clearly not based on a medical recommendation in the first place given they were prepared to change it, then even a single datapoint suggesting it might have an impact should be reason to do at least minimal investigation into whether #3 might be better served by altering the schedule. Since they clearly could alter the schedule, offering a limited number of later slots and comparing results would seem like the prudent response.
  • TeMPOraL 1y ago
    > Since they clearly could alter the schedule, offering a limited number of later slots and comparing results would seem like the prudent response. There's a difference between a doctor entertaining a medically-irrelevant suggestion from a patient (or patient's family), vs. assuming that the subsequent improvement was related to it, and then making that decision for some other patients (or suggesting it to them). The former is being accommodating, the latter is making treatment changes without good reason. Improvement or no change aren't the only two possible outcomes for a patient. They could also get worse. What's worse, often neither improvement nor decline are obviously related to the treatment, or treatment changes. Maybe it's the circadian rhythm thing. Maybe it's some delayed effects of something unrelated about the patient, that just coincided with your intervention. Maybe it's just a response to a change - any change. Or maybe it's just completely random. The point is, you don't know. You might feel like you do, or maybe it really looks obvious - but from N=1 you don't actually know, not enough to potentially bet other people's health on it. Because maybe you do go ahead, and make a schedule change to another few patients - and few days later, suddenly and for no apparent reason, one of them goes into critical condition and dies soon after. Good luck convincing the grieving family, your colleagues, the board - and your own conscience - that the schedule change could not have possibly caused this. You won't, because you don't actually know.
    • vidarh 1y ago
      They are already making treatment choices without good reason when they set or change the schedules. They could already have made it worse with prior scheduling decisions, without having any idea. Intentionally choosing to ignore a possibly harmful effect of the current lack of scheduling rules seems to me as blatantly unethical or worse as taking reasonable steps within what is already permitted to try to address a possible negative effect. If concerned about making the schedule change for them: Provide the option. Add appropriate warnings if you like. But also consider that any grieving families that finds out after the fact that there might be a known benefit to changing the scheduling would be equally hard to convince that you've not acted unethically and done harm.
• NiloCK 1y ago
  1. The N=1 positive result isn't the sole basis for expanded effort. The basis the is the compelling, research backed, causal mechanism that predicted the scheduling adjustment's success. 2. Does it? Speaking directly out of my butt here (not in healthcare, not an academic), but the OP spoke of pretty acute symptoms specific to a treatment plan. If the treatment program is at all common, then a very straightforward A/B split of non-intervention / intervention. Heck, even a questionnaire of past patients cross-referenced with historical records of appointment times could go a long way to validate the hypothesis. 3. This degree of specialization is for insects. If literal MDs in the field are too atomized to even surface research proposals, then that feels like an awful waste of edge-research capability.
  • Aerroon 1y ago
    And if the A/B test says that your intervention made the situation worse? Now the doctor is held liable for that.
    • s1artibartfast 1y ago
      Not how it works. Doctors have wide latitude to treat patient based on their personal medical intuition. You already have doctors dosing patients at all times of day. If an A/B test shows evening is optimal, all the morning administrators will not suddenly become liable retroactively. Hell, they wont even be liable if they keep doing it in the morning because it fits their schedule better.