13 ms·

Doctors Tell All, and It’s Bad

216 points by ivank 12y ago

cesarbs 12y ago
I was just talking to my wife about this. I've recently been to the doctor because of some headaches I was having. They did some blood work, and when it came back I got a call from the doctor saying we should check my liver function again in 3 months. I wasn't very concerned because ever since I was a kid I have heard that (I guess some normal values for me are outside the range considered normal for most people). This week, I logged in to their patient portal because I wanted to look at some previous blood test results. I was absolutely startled when I saw that my AST and ALT counts were pretty high, about twice the upper limit for what is considered normal. But then I realized that I had that blood work done around the time I had started strength training and increased the amount of protein in my diet. A quick online search revealed that a single strength training session increases AST and ALT levels for up to seven days. Considering I had been exercising multiple times a week, it was completely normal for my levels to be elevated. Now, why didn't the doctor simply ask me if I had been strength training? Such a simple question would have explained the abnormal test results and saved me some distress.
- robomartin 12y ago
  The part that blows me away is that you have a patient portal and can see your test results online.
  - cesarbs 12y ago
    I thought that was a common thing. Where do you live?
    - deleted 12y ago
      [deleted]
    - tdfx 12y ago
      I've been to doctors in New Jersey, Pennsylvania, and Florida, and never heard of any such online system for reviewing your results. There's no incentive to provide the results to the patient without an in-person consultation they can bill the insurance company for.
      - laurenstill 12y ago
        This year is the first for physician attestation for MUS2, give it some time. Chances are you will have to actively ask for login information if you are seeing a doctor in a small(er) private practice, as it's likely not a core priority of their EHR software (think 'it's there because it has to be, not because we actually expect anyone to use it'). Of my 6 doctors, 3 have EHRs with patient portals, but none of them are populated with encounter data or visit notes; two don't use an EHR and one is associated with UCSF and uses Epic, so I get MyChart. Last month I was trying to get a copy of my MRI from UCSF, but their cd burner on the PACS was down. They are participants in RSNA image share so patients can opt to import scans into a portal but it took me 3 people in the radiology library before finding someone who knew anything about it.
      - mdd820 12y ago
        Yes there is,.. the empowered patient,.. Nj Hitech has just has assisted 5,500 physicians to EHR's systems, the hospital's are required as well. Patient Portals (PHR's) will follow. We are a start up working with Personal Medical Records (PHR's), making it feasible for you to use set aside insurance funds for wellness products ad services. Keep the faith, maintaining your health and promoting wellness is getting easier !!
  - sixothree 12y ago
    Meaningful Use - Stage 2. Completely amazing to me that more Americans have no idea what's going on in health IT.
  - elpachuco 12y ago
    Recently rolled out at my local hospital. The best part is I get e-mail reminders for all appointments. I also get an e-mail notification when a test result has been logged.
- brandonmenc 12y ago
  This exact thing happened to me - at the Mayo Clinic, of all places. I found the same info after the initial test, then refrained from lifting for a week before the follow up lab work. Tests were normal the second time but had they not been, I'd have been given a (presumably more expensive) ultrasound. My only guess is that the lifting-bad-liver-panel effect isn't something that happens often, since so many people strength train these days.
- fnordfnordfnord 12y ago
  >I logged in to their patient portal Is this "Patient Portal" software some kind of off-the-shelf crapware? It is terrible.
  - 0xfffafaCrash 12y ago
    Unlikely. It's probably the healthcare organization's version of Epic's MyChart which gives patients the ability to access some of their own medical records.
    - zaroth 12y ago
      Epic seems to have completely taken over EMR... And watching doctors and nurses try to use it, just wow.
- untilHellbanned 12y ago
  AST and ALT change all the time. Depending on circumstances, 2x normal isn't particularly notable. Also, strength training isn't necessarily the cause nor is it something a doctor automatically, nor even commonly, flags for concern. The doctor should have asked you about changes in your daily routines, but you have to give them the benefit of the doubt. It's only the doctors job to find relevant data regarding your chief complaint. If they thought 2x changes were something to care about they would have followed up with you about that. Not to be impolite but only to make a point: if you read enough to be distressed, you could have read enough to de-distress yourself.
- toasted 12y ago
  your doctor knew it was probably unimportant, could be caused by a myriad of things, and a repeat blood test in a few months would be normal and mean they could forget about it. Because of the patient portal with its ability for patients to access info they don't understand the significance of, you were "absolutely startled" and "distressed". If you didnt have access to those results then you wouldn't have been concerned. Regardless of all that, you should still have repeat LFT's because you don't know for sure that "strngth training" was the cause of the problem. Honestly, Doctors find navigating the minefield of clinical decision making difficult enough, trying to make judgements on sensitivity/specificity of tests and investigations, positive predictive values, remove confounding, drug company propaganda, publication bias etc etc without patients trying to get into it all as well. Should I spend 1 hour explaining to every fucker with a headache why a CT head is more likely to cause brain cancer than it is to diagnose it? The solution to the US healthcare woes is NOT more patient autonomy and decision making. The solution is moving towards a less money orientated system and trying to encourage altruism and alignment of patient's goals with doctor's actions.
  - nitrogen 12y ago
    Should I spend 1 hour explaining Yes, absolutely. Medicine needs to descend from its status as a high priesthood and be a little more accessible.
    - VLM 12y ago
      The question is if that's the best possible use of his time to improve the lives of the most patients. A stereotypical micro vs macro problem where the best possible micro solution is likely not the best possible macro solution. To some extent its a systemic problem with levels of support. Every customer that calls into a call center claiming space aliens are controlling their minds should not be transferred to argue with the VP of software development for an hour.
      - nitrogen 12y ago
        Possible solutions: reduce the scarcity of doctors capable of explaining ionizing radiation, add more non-doctors who can do more than just draw blood and check vitals, etc. Part of the macro problem is that a lot of micro problems are caused by insufficient communication and a lack of patient knowledge.
kyro 12y ago
The sad truth is that this is due to a variety of problems at a variety of levels. Of course, all that follows is highly dependent on the team, hospital, and location. A the lowest-level, you have doctors who're just assholes. Unfortunately, they don't do a good job at filtering out abrasive personalities upon entry to medical school. In fact, I'd say in some ways they self-select for that type of person. I've worked with heads of departments at huge hospitals who've openly discussed their salaries with me in patient rooms or brushed off a patient's concerns in a condescendingly paternalistic manner only to laugh with colleagues about it the second they step out of the patient's room. I've argued many times with specialists running their own clinic about their exorbitant fees and clever ICD-coding skills -- that some brag about developing -- to squeeze every penny out of insurers, all justified by "we've got to make a living." Assholes in medicine run rampant. Up one level and you have the sheer morbid nature of medicine that physicians deal with on a day-to-day basis. I've given chest compressions to trauma patients with self-inflicted gunshot wounds to the head, and cleaned maggots out of a patient's festering diabetic foot. To the outsider, it is all incredibly shocking and gruesome, but as a physician you grow callous to it. Unfortunately, many times that means growing callous to all emotions and stunting your ability to empathize. Mix that with a superiority complex and you get things like Hispanic Hysteria Syndrome. Go up a level and you've got a huge logistical and resource problem. Hospital physicians, particularly residents at teaching hospitals, are often overloaded with responsibilities and patients. They often feel they cannot give every patient and every obligation full and thorough attention because they are being bombarded by pages for new admissions, calls from other staff, etc. I have seen residents breeze through a list of patients, only giving minimal attention to each, just to avoid being chastised by a superior for not fulfilling all responsibilities in the short time allotted. And when you are severely limited to the number of open beds you have, and you've got a crowded ED, it becomes a game of who can we push out the fastest without killing. At a higher level, you have a hospital who needs to keep the lights on, needs to pay salaries, needs to maximize profits and yet treat patients as best as they can. Unfortunately, many hospitals are being swindled by suppliers who're working through group buying organizations [1], inflating costs and making it difficult for hospitals to hit their margins. There's a lot more I could go on about.
- sillysaurus3 12y ago
exratione 12y ago
People overestimate the state of medicine with respect to autoimmunity, which is funny in a way because they are largely completely in the dark as to how fast medical research is moving in all fields, and think that many types of near future treatment are a lot further away than is in fact the case. The workings of the immune system are rather like the workings of metabolism: the present vast knowledge, the stuff that takes years to learn and which encompasses many disciplines as no one person can know enough of all of it to make a career of that, is actually basically just a sketch of how things work. It is a map at the high level. When it comes to the all-important details there are decades of work left at even at the present pace and with the damn impressive biotechnology the research community has now in order to get to even a moderately complete picture. So there's a reason why many forms of autoimmunity are really hard to diagnose, and why you'll find that a great many diagnoses of exclusion are mild autoimmune conditions: here's what's wrong with you, it's the bucket we put people in when you have some symptoms and all the tests we have come back negative or with ambiguous results. Those tend to be the ones where nothing can be done at present. The author of the article should at least be happy that she is one step up from that situation. The immune system has so many ways of running awry due to malprogramming that there really should be more work done on more gentle ways to reboot it - strip out all immune cells and start over with the patient's stem cells to repopulate it. Aggressive reboot methods involving chemotherapy have been pretty effective when trialed, but that's not something you'd want to do unless there was no alternative. The advent of biologics for immune suppression have turned the research community away from the possibilities of the wipe clean and start over approach, however, which I think might be a mistake in the long run.
- bernardlunn 12y ago
  I agree, research into autoimmunity and chronic inflammation generally in western medicine seems very weak. Its better in traditional chinese and ayurvedic. Elimination diets are one form of "wipe clean and start over approach" that works for some people
SoftwareMaven 12y ago
It's unfortunate that medical care has become almost adversarial. Our system is set up to treat acute conditions, but most people are being seen for chronic problems and our understanding of causes and training for treatments of chronic problems is woeful at best. Worse, both patients and doctors want a pill to make everything better. After dealing with poor health for 30 years; I finally took my health into my own hands. After a series of self-experiments and a lot of journal reading, I now feel like I'm finally reaching health, but every time I see a doctor, it's the same battle ("OMG, your cholesterol is 239; you are a dead man walking!" Yeah, I don't think so). There is a lot of good information out there, but there is also a lot of complete crap, and doctors have to deal with truly informed people as well as people who only think they are informed. Worse, much of their continuing education is not much more than paid infomercials, making it hard to trust they are getting truly balanced information. Add to all of this the fact that you have seven minutes with your doctor to work it all out, and it is failing. There are a few things that can be done, IMO, to help: 1. The AHA, ADA, AMA, AND and other medical organizations need to stop taking so much money from corporate sponsors. 2. Education about and treatment of chronic conditions need to be treated very differently than acute conditions. The treatment for Type 2 diabetes should not default to Metformin. 3. We need more time with doctors to work on treatment plans that can be carried out. 4. Medical school and continuing education needs far more, unbiased education about the value/dangers of nutrition, environmental contaminants, etc, in chronic disease. Alzheimer's prevention starts in a person's 30's[1]. Unfortunately, we see the same kind of care given for stiches as for metabolic syndrome. And it's not working. 1. Based on a current hypothesis that it is the effect of "Type 3" diabetes.
- kaybe 12y ago
  There is metamed which can help you with the research. It seems to have helped at least some people. https://www.metamed.com/ https://www.metamed.com/ (Found a long time ago via LessWrong: http://lesswrong.com/lw/gvi/metamed_evidencebased_healthcare/ http://lesswrong.com/lw/gvi/metamed_evidencebased_healthcare...)
  - ceejayoz 12y ago
    Thought I remembered the name of this one. https://news.ycombinator.com/item?id=5296694 https://news.ycombinator.com/item?id=5296694 One of their first medical advisors was a disbarred doc who lost his license for writing online pharmacy prescriptions. I'd do some serious research into credentials before throwing in the $5-50k they charge. They also had a "health researcher" whose primary credentials were "eagle scout": https://news.ycombinator.com/item?id=5296594 https://news.ycombinator.com/item?id=5296594 https://news.ycombinator.com/item?id=5296724 https://news.ycombinator.com/item?id=5296724
vacri 12y ago
Spend a day in an emergency room, and chances are you’ll be struck by two things: the organizational chaos and the emotional detachment as nurses, doctors, and administrators bustle in and out, barely registering the human distress it is their job to address. There is a difference between 'spend a day' and 'work long-term'. Medical staff are normal people; there's no training that makes you immune to compassion fatigue. When you go into an ER and it's all new to you and chaotic, it seems crazy that these people are in pain and those people just don't care. But do it every working day of your life, and you have to buttress your emotion against it. Not to mention that it's a fine line to walk, showing enough compassion. If you let emotion get the better of you, you'll be less effective in your actual job of helping people. Throw in the occasional patient that is trying to pull the wool over your eyes, and you become to what looks to outsiders as a callous, uncaring individual. It's not to say that all ER staff are saints, but whenever considering the ER environment, don't forget to view it from the shoes of the people who work behind the counter long-term. My own realisation of this buttressing: I used to work as a medical tech in what was essentially an outpatient clinic that did some patients on the ward. I remember one day, several years in, casually wandering up to the ward with my equipment, when I turned the corner and was met by a wailing wall of family coming the other way. "Oh yeah - hospital is not a nice place to be. Normal people only come here when something is really bad...".
- 1123581321 12y ago
  Gallup found that the most effective and the least effective hospital workers were empathetic. The average ones weren't.
- hga 12y ago
  Imagine the mental fortitude necessary to be a "life and death" doctor as I put it (also includes ophthalmologists since loss of eyesight is a very bad thing), knowing that some of your patients will inevitably die, and that sooner or later you're going to make a mistake that will kill one.
  - JshWright 12y ago
    Everybody dies... Everybody makes mistakes... It's all just a matter of delaying the inevitable. Worst case, you fail to delay it at all (or maybe hasten it a bit).
crazy1van 12y ago
Maybe it is because doctors receive so much training or maybe because we are at our most vulnerable when we see them, but I think we lose sight of a few important points when we talk about doctor-patient relationships versus other relationships -- * Doctors are human. Some will do extraordinary things. Some will make mistakes. Some will be assholes. Many will do all three at some point in their lives. * Medicine is a business. There are financial incentives pushing and pulling on the doctor's behavior. Not saying it dictates everything they do, but denying its existence is folly. Just remember, there is a financial transaction involved every time you interact whether you see it or not. * No one cares about your well being more than you and those that love you. Yes, doctors are well educated and, yes, they definitely want to heal you. But they aren't going to stay up all night researching your symptoms, the treatment options, the drug interactions. Your loved ones may start from a far less informed place, but they will give every thing they have to heal you. To them you are a best friend, a sibling, a child, a spouse. To doctors you are one patient out of dozens or hundreds. This backseat google-doctoring infuriates medical professionals, but it is unavoidable. This isn't a condemnation, it is just reality.
- zo1 12y ago
  "Some will be assholes." Agreed, I'm just glad I'm in a position where I can simply walk out on a doctor being an asshole to me. And then proceed to the next practice over. If enough people do that, things would be much better. Unfortunately, that's not always possible.
  - xorcist 12y ago
    You can't do that when it would really matter. Because pain.
    - zo1 12y ago
      Of course, but when you're "in pain", or in a life-threatening situation... Time is more valuable than "politeness". At that point, I wouldn't care if I'm being treated by an asshole, or even Hitler himself.
  - 12y ago
tomohawk 12y ago
Speaking of adversarial - many people do not know that if they leave a facility against medical advice (AMA), insurance will probably not pay for any of the treatment and they'll be stuck with the bill. So, if you get into a situation where you strongly disagree with the physician or where you aren't being cared for properly, you need to be careful how you extract yourself.
- cooper12 12y ago
  Hmm, this startled me so I looked it up and it seems that the research on the matter shows that this belief is the result of misinformation on the part of physicians and patients [1] and that studies [1][2] have shown that of the small percentage of patients whose insurance didn't pay after leaving AMA, the reason for rejection was mainly because of problems with the bill itself. [1] http://www.uchospitals.edu/news/2012/20120203-billing.html http://www.uchospitals.edu/news/2012/20120203-billing.html [2] http://www.ncbi.nlm.nih.gov/pubmed/22331399 http://www.ncbi.nlm.nih.gov/pubmed/22331399
deleted 12y ago
[deleted]
jasonisalive 12y ago
The rhetoric of medical reform draws mostly on economics: Experts differ over, among other things, how to structure “insurance mandates” and what constitutes “overutilization” of a rapidly expanding array of high-tech procedures and diagnostic tests. Sounds like the tell-tale signs of socialist dysfunction, from which all the other problems stem. The solution is simple, but, unfortunately, poorly understood and highly resisted: restore a free market for health goods and services.
- blahedo 12y ago
  Free market solutions don't work for health goods and services, because free market solutions require a feedback loop that is unavailable. At the provider level, in many cases you only have the option to be a repeat customer if they don't give you good service the first time round. At the level of the insurance agencies themselves, an unfettered free market approach pushes them in the direction of denied claims and policy rescissions (as we've seen!), and the customer doesn't (and often can't) discover they've made a bad choice until too late. One thing that would be good about a more free-market-y approach would be an increase in transparency about costs; but that's something that would be an improvement under a socalist or any other model as well.
  - yummyfajitas 12y ago
    Free market solutions work just fine. I fled the semi-socialized US system to enjoy the unfettered free market medical system provided by India at least twice, and will probably do so for future medical treatments. Many medical services are repeated even if good service is provided. For example, 2 years ago I injured both my L5/S1 and L4/L5 disks. 2 years ago L5/S1 was treated, but the L4/L5 was left alone since it did not cause any problems. This year my L4/L5 started causing serious pain - the first guy did a great job so I went back. Another part of the feedback loop is reputation - if one of my friends needs similar treatment they'll probably go to the same guy unless they are very sensitive to cost (I didn't go for cheap). I have no idea where this meme that free market health care looks like the US comes from. Maybe Canadians don't realize there are more possibilities than simply Canadian and US health care?
joshgel 12y ago
I'm a medical resident at a prestigious teaching hospital. I hate to admit it, but I've lost my empathy already. The experience most interns have on day 1 is a massive increase in responsibility and work load as compared to medical school. Whereas most medical students in their 4th year "manage" (under the very close supervision of residents) 2, 3, or maybe 4 patients, on day 1 of intern year they are suddenly expected to be responsible for upwards of 10-12 patients (under supervision, but considerably less supervision than med students). Interns go from spending most of their time studying and learning medicine, to being suddenly, constantly busy with often mind-numbing tasks. We interns joke that we are nothing more than secretaries, doing tasks for our boses all day without time to sit down and think for ourselves, despite the M.D. we just spent years earning. Eventually, we get better at prioritizing, we learn the system, and we learn by doing. But, early in intern year, we can't prioritize, we don't know the system, frankly we can't even keep which patient is which straight in our heads. But, regardless, we still have n number of tasks to do by the end of the day. Spending extra time talking to patients isn't part of n. Empathy isn't an item in n. Figuring out a patient's priorities for their health aren't an item. Those are extras. And to get home on time, after my 12-14 hour shift, all I have to do is my list of n tasks, which is substantial. So, we quickly learned that long conversations with patients are the enemy of getting home on time. And pretty quickly, we start to eliminate those conversations. Then, we figure out that other things patients need, like empathy, a careful history taking and detailed physical exam, family discussions, etc also stand in our way of getting our work done on time. Eventually, we learn the ability to keep our patient's complex medical problems straight and become much more efficient at getting our work done quickly. So, realizing we have more time, some of us go back and start to do the things that really matter to patients, like those things listed above and in the article. But, we've already learned, or forced by the system to learn, that we can get away with not doing those things, so as soon as we get a little extra busy or are a little extra tired, those are the first things we skip. Then, suddenly, we start second year and can now be asked to work 24-28 hours straight, and now we have 18-24 patients instead of 10-12 that we are responsible for and the system again drains us of the very thing we enrolled in medical school to be.
- riahi 12y ago
  Well articulated and 100% true.
kyllo 12y ago
Son of a doctor here. My dad told me not to go to medical school. Reading this makes me so glad I listened.
j_lev 12y ago
Some questions: 1) How far along are we in terms of those computers that were predicted in the 80s to one day replace doctors? Not trying to antagonize but I can't see any harm in having a row of booths with terminals that patients can log into and start answering questions about symptoms, being led through the "troubleshooting" steps, etc. There's a lot of time spent just waiting around in hospitals, waiting rooms, etc. Maybe you could have a swipe card that saves your progress on the terminal, combines it with the lab results. The system wouldn't replace a GP just yet but it would instead work alongside the GP. 2) Are there any crowd-sourced solutions available yet for these cases where doctors clearly have no idea? Someone enters all their symptoms and people discuss online and try to come up with some possible options. 3) How much are insurance companies responsible for the sorry state of health care in the US? I was speaking to my friend who says that he pays $850 bucks a month (up from $800 a month last year) on top of what his company pays. I've heard other stories about people basically being a slave to their company because they can't leave due to the generous benefits. I've also heard that insurance companies pay back only 60 cents in the dollar, so to make up the same $100 a doctor was previously earning he now has to charge about $170 (the other option is to be cut from the network of doctors used by the insurance company). And is this the logical conclusion for health care? Will Canada/Australia head the same direction? Seriously, there is a massive opportunity for the US to fix some of these problems now, yet it just seems that you guys are heading in entirely the opposite direction.
- eknkc 12y ago
  1- If this happens to be like all those websites with symptom matching and finding possible causes, i'll pass. Thanks. I have found out that I, along with my wife and my cat most likely had cancer whenever I looked some symptoms up.
- maxmcd 12y ago
  Partially addressing 1 and 2: As someone who has had Lyme and writes software I can't imagine how we would even get 10% of the way there on #1, and #2 just sounds like a recipe for disaster. Imagine if Reddit took on patient diagnosis. For lyme specifically, the blood tests are generally inconclusive, symptoms vary from person to person and are inconsistent, and even doctors who specialize in lyme seem to disagree on core details of the diseases' effects. If consensus can't be reached even at that level, and if that level of complexity is present in many other ailments (which I assume it is), how would be able to build a beneficial piece of software around that information?
AmadKamali 12y ago
Some thoughts and observations by a practicing anesthesiologist: 1.Improving patient outcomes, improving patient satisfaction, reducing medical errors and curtailing costs etc are very hard problems. There are no easy answers. Doctors know about this( because this affects us also) , routinely discuss it, try to solve/amend whatever is in their power but the overall nature of these problems is such that without nation wide measures and policy changes no concrete improvement can be achieved. 2. Becoming somewhat emotionally detached/blunt etc is a requirement for the job. There is no survival without it. It happens to all doctors. It happens to family and friends of people who end up in hospitals for months. Even with the detachment adverse patient outcomes do affect the treating doctors and this emotional trauma piles up over the years. 3.Same for abrasive personalities. There is so much push and pull going on between doctors of different specialties, between doctors and nurses, between doctors and administration, between doctors and insurance companies, between doctors and patients and their relatives that anybody not strong/abrasive/assertive enough looses his ground which affects both the doctor and the patients under his care adversely. 4.Generally a lay person reading up things on his own doesn't bring anything useful to a discussion with the doctor. Sometimes there are real options in which even the doctor is not sure of benefit/risk ratio. The patients should take decisions in these cases. Same for major operations and interventions. But for majority of cases average lay person is better off following the advice of his doctor than relying something he read on internet. 5. A job of doctor will probably be one of the last jobs to be replaced fully by machines. Just like parenting. 6. Doctors are not against technology or threatened by it. For example a lot of lab tests that are automated now were performed by hand by pathologists.They are very happy to use these new technologies. Their role hasn't diminished. The lack of enthusiasm for health IT software is because most of it sucks.It adds to workload, doesn't provide any value, and adds another layer of responsibility/anxiety. Most doctors will run to anything that only marginally improves their ability to handle workload. And the list can go on. Some interventions that might work are: Checklists. simple, easy to use and practical checklists . Mandatory leave/ time away from patients. The more acute/emergency oriented/high stress specialty , the more the need. For example I think specialists in Anesthesia/critical care/emergency medicine/gynecology/neonatology etc should have 3 months of leave away from patient care every year to stay sane. >fulfilled doctors make for more-satisfied patients. Tackling the problems of Kaiser Permanente’s Colorado medical group, he took the counter intuitive step of demoting “patient-centered care” as a goal, and elevated “preservation and enhancement of career” for doctors to first place. He restored to them the sense that their work is, as Barron Lerner’s old-fashioned father put it, a “rare privilege” to be pursued with a sense of responsibility, rather than harried accountability. ABSOLUTELY TRUE!! There is promise in healthcare analytics, predictive analytics and things like auto flagging of unusual events. Doctors are used to analytics and algorithms and will embrace any good solution to these. Similarly, machine learning/AI can play important role in things like reducing medical errors and postmortem of adverse events. These should be combined with training for human factors. Continued medical education in its present form is very ineffective. Continuing medical education and remedial training/retraining etc need to be customized and focused to meet specific objectives.

216 points by ivank 12y ago

I was just talking to my wife about this. I've recently been to the doctor because of some headaches I was having. They did some blood work, and when it came back I got a call from the doctor saying we should check my liver function again in 3 months. I wasn't very concerned because ever since I was a kid I have heard that (I guess some normal values for me are outside the range considered normal for most people). This week, I logged in to their patient portal because I wanted to look at some previous blood test results. I was absolutely startled when I saw that my AST and ALT counts were pretty high, about twice the upper limit for what is considered normal. But then I realized that I had that blood work done around the time I had started strength training and increased the amount of protein in my diet. A quick online search revealed that a single strength training session increases AST and ALT levels for up to seven days. Considering I had been exercising multiple times a week, it was completely normal for my levels to be elevated. Now, why didn't the doctor simply ask me if I had been strength training? Such a simple question would have explained the abnormal test results and saved me some distress.

robomartin 12y ago
The part that blows me away is that you have a patient portal and can see your test results online.
- cesarbs 12y ago
  I thought that was a common thing. Where do you live?
  - deleted 12y ago
    [deleted]
  - tdfx 12y ago
    I've been to doctors in New Jersey, Pennsylvania, and Florida, and never heard of any such online system for reviewing your results. There's no incentive to provide the results to the patient without an in-person consultation they can bill the insurance company for.
    - laurenstill 12y ago
      This year is the first for physician attestation for MUS2, give it some time. Chances are you will have to actively ask for login information if you are seeing a doctor in a small(er) private practice, as it's likely not a core priority of their EHR software (think 'it's there because it has to be, not because we actually expect anyone to use it'). Of my 6 doctors, 3 have EHRs with patient portals, but none of them are populated with encounter data or visit notes; two don't use an EHR and one is associated with UCSF and uses Epic, so I get MyChart. Last month I was trying to get a copy of my MRI from UCSF, but their cd burner on the PACS was down. They are participants in RSNA image share so patients can opt to import scans into a portal but it took me 3 people in the radiology library before finding someone who knew anything about it.
    - mdd820 12y ago
      Yes there is,.. the empowered patient,.. Nj Hitech has just has assisted 5,500 physicians to EHR's systems, the hospital's are required as well. Patient Portals (PHR's) will follow. We are a start up working with Personal Medical Records (PHR's), making it feasible for you to use set aside insurance funds for wellness products ad services. Keep the faith, maintaining your health and promoting wellness is getting easier !!
- sixothree 12y ago
  Meaningful Use - Stage 2. Completely amazing to me that more Americans have no idea what's going on in health IT.
- elpachuco 12y ago
  Recently rolled out at my local hospital. The best part is I get e-mail reminders for all appointments. I also get an e-mail notification when a test result has been logged.
brandonmenc 12y ago
This exact thing happened to me - at the Mayo Clinic, of all places. I found the same info after the initial test, then refrained from lifting for a week before the follow up lab work. Tests were normal the second time but had they not been, I'd have been given a (presumably more expensive) ultrasound. My only guess is that the lifting-bad-liver-panel effect isn't something that happens often, since so many people strength train these days.
fnordfnordfnord 12y ago
>I logged in to their patient portal Is this "Patient Portal" software some kind of off-the-shelf crapware? It is terrible.
- 0xfffafaCrash 12y ago
  Unlikely. It's probably the healthcare organization's version of Epic's MyChart which gives patients the ability to access some of their own medical records.
  - zaroth 12y ago
    Epic seems to have completely taken over EMR... And watching doctors and nurses try to use it, just wow.
untilHellbanned 12y ago
AST and ALT change all the time. Depending on circumstances, 2x normal isn't particularly notable. Also, strength training isn't necessarily the cause nor is it something a doctor automatically, nor even commonly, flags for concern. The doctor should have asked you about changes in your daily routines, but you have to give them the benefit of the doubt. It's only the doctors job to find relevant data regarding your chief complaint. If they thought 2x changes were something to care about they would have followed up with you about that. Not to be impolite but only to make a point: if you read enough to be distressed, you could have read enough to de-distress yourself.
toasted 12y ago
your doctor knew it was probably unimportant, could be caused by a myriad of things, and a repeat blood test in a few months would be normal and mean they could forget about it. Because of the patient portal with its ability for patients to access info they don't understand the significance of, you were "absolutely startled" and "distressed". If you didnt have access to those results then you wouldn't have been concerned. Regardless of all that, you should still have repeat LFT's because you don't know for sure that "strngth training" was the cause of the problem. Honestly, Doctors find navigating the minefield of clinical decision making difficult enough, trying to make judgements on sensitivity/specificity of tests and investigations, positive predictive values, remove confounding, drug company propaganda, publication bias etc etc without patients trying to get into it all as well. Should I spend 1 hour explaining to every fucker with a headache why a CT head is more likely to cause brain cancer than it is to diagnose it? The solution to the US healthcare woes is NOT more patient autonomy and decision making. The solution is moving towards a less money orientated system and trying to encourage altruism and alignment of patient's goals with doctor's actions.
- nitrogen 12y ago
  Should I spend 1 hour explaining Yes, absolutely. Medicine needs to descend from its status as a high priesthood and be a little more accessible.
  - VLM 12y ago
    The question is if that's the best possible use of his time to improve the lives of the most patients. A stereotypical micro vs macro problem where the best possible micro solution is likely not the best possible macro solution. To some extent its a systemic problem with levels of support. Every customer that calls into a call center claiming space aliens are controlling their minds should not be transferred to argue with the VP of software development for an hour.
    - nitrogen 12y ago
      Possible solutions: reduce the scarcity of doctors capable of explaining ionizing radiation, add more non-doctors who can do more than just draw blood and check vitals, etc. Part of the macro problem is that a lot of micro problems are caused by insufficient communication and a lack of patient knowledge.

kyro 12y ago

The sad truth is that this is due to a variety of problems at a variety of levels. Of course, all that follows is highly dependent on the team, hospital, and location. A the lowest-level, you have doctors who're just assholes. Unfortunately, they don't do a good job at filtering out abrasive personalities upon entry to medical school. In fact, I'd say in some ways they self-select for that type of person. I've worked with heads of departments at huge hospitals who've openly discussed their salaries with me in patient rooms or brushed off a patient's concerns in a condescendingly paternalistic manner only to laugh with colleagues about it the second they step out of the patient's room. I've argued many times with specialists running their own clinic about their exorbitant fees and clever ICD-coding skills -- that some brag about developing -- to squeeze every penny out of insurers, all justified by "we've got to make a living." Assholes in medicine run rampant. Up one level and you have the sheer morbid nature of medicine that physicians deal with on a day-to-day basis. I've given chest compressions to trauma patients with self-inflicted gunshot wounds to the head, and cleaned maggots out of a patient's festering diabetic foot. To the outsider, it is all incredibly shocking and gruesome, but as a physician you grow callous to it. Unfortunately, many times that means growing callous to all emotions and stunting your ability to empathize. Mix that with a superiority complex and you get things like Hispanic Hysteria Syndrome. Go up a level and you've got a huge logistical and resource problem. Hospital physicians, particularly residents at teaching hospitals, are often overloaded with responsibilities and patients. They often feel they cannot give every patient and every obligation full and thorough attention because they are being bombarded by pages for new admissions, calls from other staff, etc. I have seen residents breeze through a list of patients, only giving minimal attention to each, just to avoid being chastised by a superior for not fulfilling all responsibilities in the short time allotted. And when you are severely limited to the number of open beds you have, and you've got a crowded ED, it becomes a game of who can we push out the fastest without killing. At a higher level, you have a hospital who needs to keep the lights on, needs to pay salaries, needs to maximize profits and yet treat patients as best as they can. Unfortunately, many hospitals are being swindled by suppliers who're working through group buying organizations [1], inflating costs and making it difficult for hospitals to hit their margins. There's a lot more I could go on about.

sillysaurus3 12y ago

exratione 12y ago

People overestimate the state of medicine with respect to autoimmunity, which is funny in a way because they are largely completely in the dark as to how fast medical research is moving in all fields, and think that many types of near future treatment are a lot further away than is in fact the case. The workings of the immune system are rather like the workings of metabolism: the present vast knowledge, the stuff that takes years to learn and which encompasses many disciplines as no one person can know enough of all of it to make a career of that, is actually basically just a sketch of how things work. It is a map at the high level. When it comes to the all-important details there are decades of work left at even at the present pace and with the damn impressive biotechnology the research community has now in order to get to even a moderately complete picture. So there's a reason why many forms of autoimmunity are really hard to diagnose, and why you'll find that a great many diagnoses of exclusion are mild autoimmune conditions: here's what's wrong with you, it's the bucket we put people in when you have some symptoms and all the tests we have come back negative or with ambiguous results. Those tend to be the ones where nothing can be done at present. The author of the article should at least be happy that she is one step up from that situation. The immune system has so many ways of running awry due to malprogramming that there really should be more work done on more gentle ways to reboot it - strip out all immune cells and start over with the patient's stem cells to repopulate it. Aggressive reboot methods involving chemotherapy have been pretty effective when trialed, but that's not something you'd want to do unless there was no alternative. The advent of biologics for immune suppression have turned the research community away from the possibilities of the wipe clean and start over approach, however, which I think might be a mistake in the long run.

bernardlunn 12y ago
I agree, research into autoimmunity and chronic inflammation generally in western medicine seems very weak. Its better in traditional chinese and ayurvedic. Elimination diets are one form of "wipe clean and start over approach" that works for some people

SoftwareMaven 12y ago

It's unfortunate that medical care has become almost adversarial. Our system is set up to treat acute conditions, but most people are being seen for chronic problems and our understanding of causes and training for treatments of chronic problems is woeful at best. Worse, both patients and doctors want a pill to make everything better. After dealing with poor health for 30 years; I finally took my health into my own hands. After a series of self-experiments and a lot of journal reading, I now feel like I'm finally reaching health, but every time I see a doctor, it's the same battle ("OMG, your cholesterol is 239; you are a dead man walking!" Yeah, I don't think so). There is a lot of good information out there, but there is also a lot of complete crap, and doctors have to deal with truly informed people as well as people who only think they are informed. Worse, much of their continuing education is not much more than paid infomercials, making it hard to trust they are getting truly balanced information. Add to all of this the fact that you have seven minutes with your doctor to work it all out, and it is failing. There are a few things that can be done, IMO, to help: 1. The AHA, ADA, AMA, AND and other medical organizations need to stop taking so much money from corporate sponsors. 2. Education about and treatment of chronic conditions need to be treated very differently than acute conditions. The treatment for Type 2 diabetes should not default to Metformin. 3. We need more time with doctors to work on treatment plans that can be carried out. 4. Medical school and continuing education needs far more, unbiased education about the value/dangers of nutrition, environmental contaminants, etc, in chronic disease. Alzheimer's prevention starts in a person's 30's[1]. Unfortunately, we see the same kind of care given for stiches as for metabolic syndrome. And it's not working. 1. Based on a current hypothesis that it is the effect of "Type 3" diabetes.

kaybe 12y ago
There is metamed which can help you with the research. It seems to have helped at least some people. https://www.metamed.com/ https://www.metamed.com/ (Found a long time ago via LessWrong: http://lesswrong.com/lw/gvi/metamed_evidencebased_healthcare/ http://lesswrong.com/lw/gvi/metamed_evidencebased_healthcare...)
- ceejayoz 12y ago
  Thought I remembered the name of this one. https://news.ycombinator.com/item?id=5296694 https://news.ycombinator.com/item?id=5296694 One of their first medical advisors was a disbarred doc who lost his license for writing online pharmacy prescriptions. I'd do some serious research into credentials before throwing in the $5-50k they charge. They also had a "health researcher" whose primary credentials were "eagle scout": https://news.ycombinator.com/item?id=5296594 https://news.ycombinator.com/item?id=5296594 https://news.ycombinator.com/item?id=5296724 https://news.ycombinator.com/item?id=5296724

vacri 12y ago

Spend a day in an emergency room, and chances are you’ll be struck by two things: the organizational chaos and the emotional detachment as nurses, doctors, and administrators bustle in and out, barely registering the human distress it is their job to address. There is a difference between 'spend a day' and 'work long-term'. Medical staff are normal people; there's no training that makes you immune to compassion fatigue. When you go into an ER and it's all new to you and chaotic, it seems crazy that these people are in pain and those people just don't care. But do it every working day of your life, and you have to buttress your emotion against it. Not to mention that it's a fine line to walk, showing enough compassion. If you let emotion get the better of you, you'll be less effective in your actual job of helping people. Throw in the occasional patient that is trying to pull the wool over your eyes, and you become to what looks to outsiders as a callous, uncaring individual. It's not to say that all ER staff are saints, but whenever considering the ER environment, don't forget to view it from the shoes of the people who work behind the counter long-term. My own realisation of this buttressing: I used to work as a medical tech in what was essentially an outpatient clinic that did some patients on the ward. I remember one day, several years in, casually wandering up to the ward with my equipment, when I turned the corner and was met by a wailing wall of family coming the other way. "Oh yeah - hospital is not a nice place to be. Normal people only come here when something is really bad...".

1123581321 12y ago
Gallup found that the most effective and the least effective hospital workers were empathetic. The average ones weren't.
hga 12y ago
Imagine the mental fortitude necessary to be a "life and death" doctor as I put it (also includes ophthalmologists since loss of eyesight is a very bad thing), knowing that some of your patients will inevitably die, and that sooner or later you're going to make a mistake that will kill one.
- JshWright 12y ago
  Everybody dies... Everybody makes mistakes... It's all just a matter of delaying the inevitable. Worst case, you fail to delay it at all (or maybe hasten it a bit).

crazy1van 12y ago

Maybe it is because doctors receive so much training or maybe because we are at our most vulnerable when we see them, but I think we lose sight of a few important points when we talk about doctor-patient relationships versus other relationships -- * Doctors are human. Some will do extraordinary things. Some will make mistakes. Some will be assholes. Many will do all three at some point in their lives. * Medicine is a business. There are financial incentives pushing and pulling on the doctor's behavior. Not saying it dictates everything they do, but denying its existence is folly. Just remember, there is a financial transaction involved every time you interact whether you see it or not. * No one cares about your well being more than you and those that love you. Yes, doctors are well educated and, yes, they definitely want to heal you. But they aren't going to stay up all night researching your symptoms, the treatment options, the drug interactions. Your loved ones may start from a far less informed place, but they will give every thing they have to heal you. To them you are a best friend, a sibling, a child, a spouse. To doctors you are one patient out of dozens or hundreds. This backseat google-doctoring infuriates medical professionals, but it is unavoidable. This isn't a condemnation, it is just reality.

zo1 12y ago
"Some will be assholes." Agreed, I'm just glad I'm in a position where I can simply walk out on a doctor being an asshole to me. And then proceed to the next practice over. If enough people do that, things would be much better. Unfortunately, that's not always possible.
- xorcist 12y ago
  You can't do that when it would really matter. Because pain.
  - zo1 12y ago
    Of course, but when you're "in pain", or in a life-threatening situation... Time is more valuable than "politeness". At that point, I wouldn't care if I'm being treated by an asshole, or even Hitler himself.
- 12y ago

tomohawk 12y ago

Speaking of adversarial - many people do not know that if they leave a facility against medical advice (AMA), insurance will probably not pay for any of the treatment and they'll be stuck with the bill. So, if you get into a situation where you strongly disagree with the physician or where you aren't being cared for properly, you need to be careful how you extract yourself.

cooper12 12y ago
Hmm, this startled me so I looked it up and it seems that the research on the matter shows that this belief is the result of misinformation on the part of physicians and patients [1] and that studies [1][2] have shown that of the small percentage of patients whose insurance didn't pay after leaving AMA, the reason for rejection was mainly because of problems with the bill itself. [1] http://www.uchospitals.edu/news/2012/20120203-billing.html http://www.uchospitals.edu/news/2012/20120203-billing.html [2] http://www.ncbi.nlm.nih.gov/pubmed/22331399 http://www.ncbi.nlm.nih.gov/pubmed/22331399

deleted 12y ago

[deleted]

jasonisalive 12y ago

The rhetoric of medical reform draws mostly on economics: Experts differ over, among other things, how to structure “insurance mandates” and what constitutes “overutilization” of a rapidly expanding array of high-tech procedures and diagnostic tests. Sounds like the tell-tale signs of socialist dysfunction, from which all the other problems stem. The solution is simple, but, unfortunately, poorly understood and highly resisted: restore a free market for health goods and services.

blahedo 12y ago
Free market solutions don't work for health goods and services, because free market solutions require a feedback loop that is unavailable. At the provider level, in many cases you only have the option to be a repeat customer if they don't give you good service the first time round. At the level of the insurance agencies themselves, an unfettered free market approach pushes them in the direction of denied claims and policy rescissions (as we've seen!), and the customer doesn't (and often can't) discover they've made a bad choice until too late. One thing that would be good about a more free-market-y approach would be an increase in transparency about costs; but that's something that would be an improvement under a socalist or any other model as well.
- yummyfajitas 12y ago
  Free market solutions work just fine. I fled the semi-socialized US system to enjoy the unfettered free market medical system provided by India at least twice, and will probably do so for future medical treatments. Many medical services are repeated even if good service is provided. For example, 2 years ago I injured both my L5/S1 and L4/L5 disks. 2 years ago L5/S1 was treated, but the L4/L5 was left alone since it did not cause any problems. This year my L4/L5 started causing serious pain - the first guy did a great job so I went back. Another part of the feedback loop is reputation - if one of my friends needs similar treatment they'll probably go to the same guy unless they are very sensitive to cost (I didn't go for cheap). I have no idea where this meme that free market health care looks like the US comes from. Maybe Canadians don't realize there are more possibilities than simply Canadian and US health care?

joshgel 12y ago

I'm a medical resident at a prestigious teaching hospital. I hate to admit it, but I've lost my empathy already. The experience most interns have on day 1 is a massive increase in responsibility and work load as compared to medical school. Whereas most medical students in their 4th year "manage" (under the very close supervision of residents) 2, 3, or maybe 4 patients, on day 1 of intern year they are suddenly expected to be responsible for upwards of 10-12 patients (under supervision, but considerably less supervision than med students). Interns go from spending most of their time studying and learning medicine, to being suddenly, constantly busy with often mind-numbing tasks. We interns joke that we are nothing more than secretaries, doing tasks for our boses all day without time to sit down and think for ourselves, despite the M.D. we just spent years earning. Eventually, we get better at prioritizing, we learn the system, and we learn by doing. But, early in intern year, we can't prioritize, we don't know the system, frankly we can't even keep which patient is which straight in our heads. But, regardless, we still have n number of tasks to do by the end of the day. Spending extra time talking to patients isn't part of n. Empathy isn't an item in n. Figuring out a patient's priorities for their health aren't an item. Those are extras. And to get home on time, after my 12-14 hour shift, all I have to do is my list of n tasks, which is substantial. So, we quickly learned that long conversations with patients are the enemy of getting home on time. And pretty quickly, we start to eliminate those conversations. Then, we figure out that other things patients need, like empathy, a careful history taking and detailed physical exam, family discussions, etc also stand in our way of getting our work done on time. Eventually, we learn the ability to keep our patient's complex medical problems straight and become much more efficient at getting our work done quickly. So, realizing we have more time, some of us go back and start to do the things that really matter to patients, like those things listed above and in the article. But, we've already learned, or forced by the system to learn, that we can get away with not doing those things, so as soon as we get a little extra busy or are a little extra tired, those are the first things we skip. Then, suddenly, we start second year and can now be asked to work 24-28 hours straight, and now we have 18-24 patients instead of 10-12 that we are responsible for and the system again drains us of the very thing we enrolled in medical school to be.

riahi 12y ago
Well articulated and 100% true.

kyllo 12y ago

Son of a doctor here. My dad told me not to go to medical school. Reading this makes me so glad I listened.

j_lev 12y ago

Some questions: 1) How far along are we in terms of those computers that were predicted in the 80s to one day replace doctors? Not trying to antagonize but I can't see any harm in having a row of booths with terminals that patients can log into and start answering questions about symptoms, being led through the "troubleshooting" steps, etc. There's a lot of time spent just waiting around in hospitals, waiting rooms, etc. Maybe you could have a swipe card that saves your progress on the terminal, combines it with the lab results. The system wouldn't replace a GP just yet but it would instead work alongside the GP. 2) Are there any crowd-sourced solutions available yet for these cases where doctors clearly have no idea? Someone enters all their symptoms and people discuss online and try to come up with some possible options. 3) How much are insurance companies responsible for the sorry state of health care in the US? I was speaking to my friend who says that he pays $850 bucks a month (up from $800 a month last year) on top of what his company pays. I've heard other stories about people basically being a slave to their company because they can't leave due to the generous benefits. I've also heard that insurance companies pay back only 60 cents in the dollar, so to make up the same $100 a doctor was previously earning he now has to charge about $170 (the other option is to be cut from the network of doctors used by the insurance company). And is this the logical conclusion for health care? Will Canada/Australia head the same direction? Seriously, there is a massive opportunity for the US to fix some of these problems now, yet it just seems that you guys are heading in entirely the opposite direction.

eknkc 12y ago
1- If this happens to be like all those websites with symptom matching and finding possible causes, i'll pass. Thanks. I have found out that I, along with my wife and my cat most likely had cancer whenever I looked some symptoms up.
maxmcd 12y ago
Partially addressing 1 and 2: As someone who has had Lyme and writes software I can't imagine how we would even get 10% of the way there on #1, and #2 just sounds like a recipe for disaster. Imagine if Reddit took on patient diagnosis. For lyme specifically, the blood tests are generally inconclusive, symptoms vary from person to person and are inconsistent, and even doctors who specialize in lyme seem to disagree on core details of the diseases' effects. If consensus can't be reached even at that level, and if that level of complexity is present in many other ailments (which I assume it is), how would be able to build a beneficial piece of software around that information?

AmadKamali 12y ago

Some thoughts and observations by a practicing anesthesiologist: 1.Improving patient outcomes, improving patient satisfaction, reducing medical errors and curtailing costs etc are very hard problems. There are no easy answers. Doctors know about this( because this affects us also) , routinely discuss it, try to solve/amend whatever is in their power but the overall nature of these problems is such that without nation wide measures and policy changes no concrete improvement can be achieved. 2. Becoming somewhat emotionally detached/blunt etc is a requirement for the job. There is no survival without it. It happens to all doctors. It happens to family and friends of people who end up in hospitals for months. Even with the detachment adverse patient outcomes do affect the treating doctors and this emotional trauma piles up over the years. 3.Same for abrasive personalities. There is so much push and pull going on between doctors of different specialties, between doctors and nurses, between doctors and administration, between doctors and insurance companies, between doctors and patients and their relatives that anybody not strong/abrasive/assertive enough looses his ground which affects both the doctor and the patients under his care adversely. 4.Generally a lay person reading up things on his own doesn't bring anything useful to a discussion with the doctor. Sometimes there are real options in which even the doctor is not sure of benefit/risk ratio. The patients should take decisions in these cases. Same for major operations and interventions. But for majority of cases average lay person is better off following the advice of his doctor than relying something he read on internet. 5. A job of doctor will probably be one of the last jobs to be replaced fully by machines. Just like parenting. 6. Doctors are not against technology or threatened by it. For example a lot of lab tests that are automated now were performed by hand by pathologists.They are very happy to use these new technologies. Their role hasn't diminished. The lack of enthusiasm for health IT software is because most of it sucks.It adds to workload, doesn't provide any value, and adds another layer of responsibility/anxiety. Most doctors will run to anything that only marginally improves their ability to handle workload. And the list can go on. Some interventions that might work are: Checklists. simple, easy to use and practical checklists . Mandatory leave/ time away from patients. The more acute/emergency oriented/high stress specialty , the more the need. For example I think specialists in Anesthesia/critical care/emergency medicine/gynecology/neonatology etc should have 3 months of leave away from patient care every year to stay sane. >fulfilled doctors make for more-satisfied patients. Tackling the problems of Kaiser Permanente’s Colorado medical group, he took the counter intuitive step of demoting “patient-centered care” as a goal, and elevated “preservation and enhancement of career” for doctors to first place. He restored to them the sense that their work is, as Barron Lerner’s old-fashioned father put it, a “rare privilege” to be pursued with a sense of responsibility, rather than harried accountability. ABSOLUTELY TRUE!! There is promise in healthcare analytics, predictive analytics and things like auto flagging of unusual events. Doctors are used to analytics and algorithms and will embrace any good solution to these. Similarly, machine learning/AI can play important role in things like reducing medical errors and postmortem of adverse events. These should be combined with training for human factors. Continued medical education in its present form is very ineffective. Continuing medical education and remedial training/retraining etc need to be customized and focused to meet specific objectives.