4 ms·

Both the article and some of the discussions here share a lot of commonalities with doctors taking a medical history. There is a certain skill in guiding the co

Both the article and some of the discussions here share a lot of commonalities with doctors taking a medical history. There is a certain skill in guiding the conversation towards useful outputs, while not dictating the exact outputs to a patient who is eager to please with their responses. E.g., medical history taking protocol always says to start with open ended (albeit structured) questions, and converge towards more closed/specific ones when you're sure you've extracted the broader surface and you now want to close in on a differential diagnosis. If you start open and go with the flow but then just let the patient talk without any structure or subsequent attempt to converge, there's a risk that the patient might spend 60 minutes taking about their fluffy dog at home, which wastes time, and doesn't get you anywhere nearer the diagnosis. But, if you skip the open questions and go straight to yes/no diagnostic questions, you will definitely miss the fact that they have a dog at home that they're worried about, and that they'll be self-discharging against medical advice in the next hour to go tend to their dog. So while to an outsider, the conversation might look effortless, in reality the doctor requires considerable skill to be able to strike a balance between open vs closed prompts, as well as the ability to critically sift through the outputs, and decide which outputs are relevant to pursue further and lead to a fruitful direction, versus those that can be safely discarded to remove potentially distracting noise from the conversation (and all while attempting to keep this interaction within a limited number of prompts due to operational time constraints).

Cthulhu_ 3mo ago
Counterpoint, some doctors will zoom in on the most likely problem and misdiagnose. This is in part due to pressure on the health care system (where I live anyway); you can only get a GP appointment for 10 minute blocks, which really isn't a lot. But when a 30-some year old shows up at a rheumatologist with joint pain they will likely go to unusual (at that age) but not unheard of rheumatism/arthritis, not hypermobile spectrum disorder. When a woman goes to a GP with period pain they will be prescribed mild pain killers or anticonception pills and fobbed off, until a decade and much suffering / many more issues later they get diagnosed with endometriosis.
- deleted 3mo ago
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- bonsai_spool 3mo ago
  I think endometriosis is common enough that it would be caught earlier ("Oh, does your joint pain get worse right before you menstruate? Tell me more"), but your point is reasonable. I counter with the platitude that common things are common - especially in fields like primary care, the amount of wasted effort one would expend in pursuing unusual explanations for every presenting symptom is considerable. We thus have to examine patients over time and trust that they will tell us if things have indeed not followed the course of the initial diagnosis.
  - tpoacher 3mo ago
    While this is true as a platitude, I do find that medical colleagues seem to treat this platitude rather overzealously at times, often completely disregarding the posterior probabilities involved. I like to call this the prior-over-posterior fallacy/bias (though one could argue this is simply a variant of the normalcy bias) E.g., I get the whole "if you hear galloping think horses not zebras" adage, but I guarantee you, if someone comes and says "hey when I was in Africa I saw a black and white striped animal galloping really loud", I bet you an uncomfortably large percentage of the "horses not zebras" crowd would still favour a horse over a zebra diagnosis, despite the overwhelming posterior. Combine this with our (otherwise reasonable) tendency of avoiding the information bias of seemingly unnecesary tests, and it becomes a big problem, whereby uncommon conditions are treated as common, thereby often escaping detection altogether, and driving down their apparent prior probability even lower, causing a diagnostic vicious cycle.
    - bonsai_spool 3mo ago
      I hear the complaint, all I can say is that everyone I speak to about this wants to diagnose things correctly while not wasting anybody's time or energy on bad diagnostic workups. > Combine this with our (otherwise reasonable) tendency of avoiding the information bias of seemingly unnecesary tests There isn't a way around this: if you order the test and a value is abnormal, you are now committing yourself to treat a thing. We should not be ordering tests if we aren't ready to follow their results to the logical conclusion. So I would disagree that this is a problem in the way you've framed it.

Cthulhu_ 3mo ago

Counterpoint, some doctors will zoom in on the most likely problem and misdiagnose. This is in part due to pressure on the health care system (where I live anyway); you can only get a GP appointment for 10 minute blocks, which really isn't a lot. But when a 30-some year old shows up at a rheumatologist with joint pain they will likely go to unusual (at that age) but not unheard of rheumatism/arthritis, not hypermobile spectrum disorder. When a woman goes to a GP with period pain they will be prescribed mild pain killers or anticonception pills and fobbed off, until a decade and much suffering / many more issues later they get diagnosed with endometriosis.

deleted 3mo ago
[deleted]
bonsai_spool 3mo ago
I think endometriosis is common enough that it would be caught earlier ("Oh, does your joint pain get worse right before you menstruate? Tell me more"), but your point is reasonable. I counter with the platitude that common things are common - especially in fields like primary care, the amount of wasted effort one would expend in pursuing unusual explanations for every presenting symptom is considerable. We thus have to examine patients over time and trust that they will tell us if things have indeed not followed the course of the initial diagnosis.
- tpoacher 3mo ago
  While this is true as a platitude, I do find that medical colleagues seem to treat this platitude rather overzealously at times, often completely disregarding the posterior probabilities involved. I like to call this the prior-over-posterior fallacy/bias (though one could argue this is simply a variant of the normalcy bias) E.g., I get the whole "if you hear galloping think horses not zebras" adage, but I guarantee you, if someone comes and says "hey when I was in Africa I saw a black and white striped animal galloping really loud", I bet you an uncomfortably large percentage of the "horses not zebras" crowd would still favour a horse over a zebra diagnosis, despite the overwhelming posterior. Combine this with our (otherwise reasonable) tendency of avoiding the information bias of seemingly unnecesary tests, and it becomes a big problem, whereby uncommon conditions are treated as common, thereby often escaping detection altogether, and driving down their apparent prior probability even lower, causing a diagnostic vicious cycle.
  - bonsai_spool 3mo ago
    I hear the complaint, all I can say is that everyone I speak to about this wants to diagnose things correctly while not wasting anybody's time or energy on bad diagnostic workups. > Combine this with our (otherwise reasonable) tendency of avoiding the information bias of seemingly unnecesary tests There isn't a way around this: if you order the test and a value is abnormal, you are now committing yourself to treat a thing. We should not be ordering tests if we aren't ready to follow their results to the logical conclusion. So I would disagree that this is a problem in the way you've framed it.