[HN Gopher] Debugging the Doctor Brain: Who's teaching doctors h...
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Debugging the Doctor Brain: Who's teaching doctors how to think?
Author : jseliger
Score : 93 points
Date : 2024-04-20 13:10 UTC (9 hours ago)
(HTM) web link (bessstillman.substack.com)
(TXT) w3m dump (bessstillman.substack.com)
| barbariangrunge wrote:
| In Canada, subjectively, it feels like the quality of newer
| doctors has gone up dramatically. The training must be a lot
| better these days. I've been impressed, especially when you go in
| to a clinic where they actively take in students for their
| practicums - the old doctors are often stepping up their game as
| well
| mlinhares wrote:
| There's considerable research on the subject:
| https://www.mdlinx.com/article/are-older-doctors-wiser-not-n...
| sampo wrote:
| > https://www.mdlinx.com/article/are-older-doctors-wiser-
| not-n...
|
| Link doesn't work in Europe, redirects to https://eu.m3.com/.
| flakeoil wrote:
| It should be quite naturally so as a lot has happened in the
| field of medicine in the last 30-40 years. A 60 year old doctor
| who was trained 35 years ago uses old knowledge and techniques.
| Even though doctors get some updates via conferences and
| articles in journals and maybe some hand on course, they cannot
| absorb all that new knowledge in practice.
| throwaway8877 wrote:
| Perhaps. But they have advantage of 30-40 years of
| experience.
| Kalium wrote:
| It's my understanding that the significance of that age can
| and does vary wildly. In some specialties, age makes errors
| more likely: https://psnet.ahrq.gov/issue/radiologist-age-
| and-diagnostic-...
| prmph wrote:
| But here's the things I'm not clear about: Surgeon get
| immediate feedback if they make mistakes because their
| patient might die or get severely disabled, but is there
| any feedback to GPs about the effectiveness of their work?
|
| Let's say someone is not treated that well by his doctor
| for a chronic condition. He gets to the emergency in a
| different hospital and probably dies. Does his GP get to
| know about it?
|
| For example, many doctors in my country believe that Left
| Ventricular Hypertrophy (LVH) on an ECG is nothing much to
| worry about, as long as there is no anatomical LVH showing
| up on an Echocardiogram. Yet, study after study online
| concludes that ECG LVH is a serious marker of cardiac
| pathology distinct from (but related to) from anatomical
| LVH.
|
| How do doctors who operate on this assumption going to
| learn from experience, if they mostly don't know that their
| patients have cardiac events as a result?
| xyzzy123 wrote:
| Surgeons don't get immediate feedback because the
| advisability of procedure X ends up being a statistical
| matter that might not be decided in the surgeon's
| lifetime. It depends what it is. They will have opinions
| of course, but will work with the system and follow
| process.
| Calavar wrote:
| > Surgeon get immediate feedback if they make mistakes
| because their patient might die or get severely disabled,
| but is there any feedback to GPs about the effectiveness
| of their work?
|
| I disagree with this. If a patient dies from a surgical
| complication, it is often weeks or months later, on a
| nonsurgical service because there are no surgical options
| left for the patient.
|
| > Let's say someone is not treated that well by his
| doctor for a chronic condition. He gets to the emergency
| in a different hospital and probably dies. Does his GP
| get to know about it?
|
| Yes, they get to know about it. But ascribing cause and
| effect in a chronic disease is difficult.
|
| Eventually everyone will die, even if they get perfect
| treatment. I'm not saying there's no such thing as
| medical error - in some cases there is clear and obvious
| error - but what's much more common is a situation of
| "Did I do the wrong thing, or did I do the right thing
| but they were so sick that they died anyway?" And there
| are often many years separating cause and effect, which
| muddies the picture even further. That's why learning
| from specific patient outcomes is tricky and why doctors
| lean so heavily on evidence based medicine, which means
| learning from large medical trials with rigorous
| statistical controls.
|
| > For example, many doctors in my country believe that
| Left Ventricular Hypertrophy (LVH) on an ECG is nothing
| much to worry about, as long as there is no anatomical
| LVH showing up on an Echocardiogram. Yet, study after
| study online concludes that ECG LVH is a serious marker
| of cardiac pathology distinct from (but related to) from
| anatomical LVH.
|
| There's a difference between serious pathology and
| serious pathology you can do something about. I agree
| that LVH on EKG is a bad sign, even if the ultrasound is
| normal. But what is your GP going to do about it? There
| are many test results that are abnormal and/or correlated
| with bad outcomes, but only a subset of those can be
| labeled with a concrete diagnosis that is well understood
| medically, and only a subset of those can be treated.
|
| All your GP can do for an ECG finding of LVH is advise
| blood pressure control, cholesterol control, exercising
| frequently, and other things that are generally good for
| heart health.
|
| On the other hand, if there is anatomical LVH, then the
| next question is whether there's hypertrophic obstructive
| cardiomyopathy. That's a concrete diagnosis where we know
| a lot about the underlying mechanism, which leads to
| specific advice like avoiding strenuous activity. And
| some patients with HOCM can benefit from a septal
| ablation. That's why anatomic LVH gets more attention
| from doctors.
| prmph wrote:
| > Yes, they get to know about it.
|
| I'm curious. How do they get to know about it? Maybe the
| process differs between countries. I'm from Ghana, by the
| way.
|
| > All your GP can do for an ECG finding of LVH is advise
| blood pressure control, cholesterol control, exercising
| frequently, and other things that are generally good for
| heart health
|
| Mostly true, but taking ECG LVH more seriously helps the
| patient understand how important it is for them to
| improve their general heart health. It also makes LVH
| regression (which is possible in more cases than doctors
| believe) a therapeutic target.
| Calavar wrote:
| I'm in the US. Part of my hospital's workflow for a
| deceased patient is calling their GP's office to notify
| them of the death. As far as I am aware, this is mandated
| by state law. If a patient is discharged, a summary of
| their hospital course is faxed to their GP's office at
| the time of discharge. Or transmitted electronically, if
| possible.
| flakeoil wrote:
| 30-40 years of experience using the old knowledge and
| techniques.
| SoftTalker wrote:
| Human biology doesn't change in 30-40 years.
|
| 90% of what doctors do is completely routine and they all
| know and keep up with what the "standard of care" is for
| common conditions and in many cases it's the same today
| as was the standard of care in 1984.
|
| Sure, if you have something unusual you might want to go
| to a younger specialist or a specialty clinic where they
| focus on leading-edge care for that condition.
|
| A 60-year old GP will do fine for your annual physical.
| dandy23 wrote:
| The biology doesn't change of course, but the procedures,
| drugs, medical devices, treatments and overall knowledge
| and best practices does.
|
| An annual physical is such a small and simple subset of
| the total medical field so not sure why you bring it up.
| nradov wrote:
| Physicians are required to complete a certain number of hours
| of continuing medical education every year. These are
| training courses (online or in person) which have to meet at
| least some minimal quality standards; it's not just showing
| up at a conference. But whether they actually keep their
| skills current or just check the boxes depends on the
| individual.
| Tijdreiziger wrote:
| Not in all countries. Doctors in e.g. Japan aren't required
| to take any continuing education (IIUC).
|
| (This is my understanding as a layman, so I'm happy to be
| corrected if wrong.)
| flakeoil wrote:
| It's quite hard to learn something completely new by taking
| 1 or 2 week courses once a year.
|
| I had a 55+ year old dentist who wanted to pull out my
| tooth and replace it with a bridge. The tooth was cracked
| and 1/3 of the tooth had fallen off. Luckily he worked only
| half time and was on vacation a lot so difficult to get an
| appointment so I got to see a young dentist who could fix
| the tooth by repairing it (building up the missing part).
| She said it could last a month or forever, but if not
| lasting then the next option would be a titanium implanted
| tooth. Making a bridge would have been considered
| malpractice nowadays she said. The old dentist was probably
| a master at putting in bridges, but if that method is bad
| and he never practiced the other technique, which you
| probably cannot learn in a 1 week yearly course, then tough
| luck.
|
| Not the perfect example maybe, but imagine you have learnt
| assembler and C in school and programmed in that for 30
| years doing say embedded applications. You maybe update
| yourself regularly in that very field of assembler and C.
| Then one day you are asked to program a web app using HTML,
| javascript and CSS and complete it in the same time and
| with the same quality result as someone who has learnt it
| in university and with a few years work experience. Quite
| hard.
| Aerbil313 wrote:
| Not the perfect example. OT, but dentistry is unlike
| other fields of medicine, a huge amount of the practice
| is outright scam. See past thread:
| https://news.ycombinator.com/item?id=37022911
| sn9 wrote:
| At least in the US, the widespread use of Anki by medical
| students has actually impacted the way standardized testing are
| written/graded IIRC.
| thenerdhead wrote:
| In 2021 I presented my doctor a hypothesis that a COVID infection
| I had recently was persisting in my body leading to long term
| symptoms. They told me I was completely wrong and that RNA
| viruses do not do that.
|
| Fast forward to today and the NIH director and leading scientists
| believe this has backing proof.
|
| https://www.ucsf.edu/news/2024/03/427241/covid-19-virus-can-...
|
| https://www.science.org/content/article/long-covid-trials-ai...
|
| It has taken me almost three years to convince my doctor on the
| rationale of using therapeutics acting as COVID antivirals to
| treat my chronic symptoms. I now have to wait until clinical
| trials present data hopefully this summer to at least try.
|
| So I hope this is a story to show that patients are helping
| doctors think. And it is very slow going.
| gavinray wrote:
| Hypothetically, if one had good reason to believe a certain
| medication/treatment would work, and has some degree of risk-
| tolerance, they could acquire said medication online from other
| countries without trying to convince some doctor willing to
| listen to prescribe it.
| thenerdhead wrote:
| People have and have been successful. Especially repurposing
| HIV/AIDS drugs and ordering Paxlovid from India. Mostly due
| to USA prices being ridiculously high and insurance companies
| refusing to prescribe more than a 5 day dose.
|
| The other major challenge is that certain approved drugs in
| other countries can be held by shipping due to FDA approval.
| bingbingbing777 wrote:
| Not sure why you would be taking Paxlovid for long covid.
| thenerdhead wrote:
| There is rationale in the science article I posted above.
| The current hypothesis is viral reservoirs that are
| replication competent. Here is the blurb as well:
|
| > Paxlovid targets virus that is rapidly replicating--
| which may or may not be the case for the virus lingering
| in Long Covid cases.
| pc86 wrote:
| In 2021 there was almost no evidence of persistent long-term
| symptoms because very, very few people had COVID far enough in
| the past (and survived) to have these symptoms start to show
| up. It's completely reasonable for a front-line GP physician to
| not go down a rabbit hole like that because their lay patient
| has a hunch.
| thenerdhead wrote:
| Not true. There has been evidence of long term symptoms
| months after the first wave in 2020. By 2021 established
| hypotheses of viral persistence existed.
|
| Viral persistence(2021): https://www.frontiersin.org/journals
| /microbiology/articles/1...
|
| Persistent symptoms(2020):
| https://pubmed.ncbi.nlm.nih.gov/32644129
| randm_sequence wrote:
| I've come to the same conclusion about long COVID in April
| May of 2020. The evidence is shockingly overwhelming and
| has been grossly ignored. Some of us have found cocktails
| that work. Would love to discuss if you are interested.
| refibrillator wrote:
| _> The center for Medicare and Medicaid is the primary source of
| graduate medical education (residency) funding. Per the Graham
| Center interactive GME data tool Mt. Sinai received around $175k
| a year per resident, and pays them a salary of $84,479\year,
| leaving 90K to pay for their "education."_
|
| This is straight up fraud and should be treated as such.
|
| My wife wanted to be a nurse her whole life, went to school and
| got a good job, after 3 years at the hospital she had to quit for
| her own sanity. Every nurse and resident in her circle had a
| similar story.
|
| U.S. hospitals are for profit assembly lines. Managers with MBAs
| that have never worked a shift on the floor in their life see
| staff as fungible. Throwing a pizza party when patient quotas are
| met, instead of you know, hiring more to relieve overworked and
| stressed employees.
|
| Seemingly every motivated and caring person in this field is
| systematically chewed up and spit out.
| anon291 wrote:
| According to https://en.wikipedia.org/wiki/Mount_Sinai_Hospital
| _(Manhatta..., Mt Sinai is a 'non-profit', but in my opinion,
| we need a much more expansive definition of 'for-profit'. It's
| true that there are no shareholders, but the salaries the
| executives make is a form of profit, and ought to be treated as
| such. In some ways it's worse because in a company, the board
| sets the CEOs and execs compensation, and can adjust it
| according to their own financial interests (which means there's
| less desire by CEOs to 'waste', because waste means the board /
| shareholders make less money, and then their compensation is
| lowered -- theoretically).
|
| In a non-profit, the board uses arbitrary criteria, the board
| is incentivized to waste all money on executive compensation,
| because that means the execs throw them excellent parties,
| galas, soirees, and other social events where they can network
| with more people to make more profit in their for-profit
| ventures. Ask me how I know.
| steveBK123 wrote:
| Hospital donations are also interesting to me as you get
| billionaires donating amounts of money that.. a FAANG
| engineer could feasibly have left to give on their demise. Or
| giving amounts similar to like their 3rd homes value and
| getting a wing named after them (though the donation clearly
| only pays for a small fraction of the construction).
|
| Similarly I have a friend whose spouse is extremely talented
| with a PHD (not MD), and has worked in admin roles at a big
| nonprofit NYC hospital as well. They have at times had pretty
| similar compensation, one working at a hedge fund and the
| other working at a nonprofit hospital. Interesting that. Each
| side can argue they need to attract talent, and one can argue
| that hospital admin is closer to doing good for society. It
| is just surprising to see nonprofit and very high
| compensation.
| cycomanic wrote:
| I find this notion completely alien. Paraphrasing (with some
| exaggeration): "it's outrageous we are paying people working
| at hospitals/schools/non-profits high salaries, they really
| should be doing it from the goodness of their hearts. The
| only people that should be earning big bucks are the
| engineers devolving the tech to keep us addicted to social
| media, the ad tech that extracts more value from every person
| and the fiance people to extract the maximum from the general
| economy to funnel it into some rich pockets! Really people
| working on things that are actually good for society, should
| be happy with that and work for free! "
| salawat wrote:
| It's a systematic thing. As long as management is decoupled
| from actually doing the job one is expected to manage, that
| outcome will be inevitable as a consequence of the overarching
| fiscal optimization function being applied Procrustean Bed
| style to all fields of capitalistically orchestrated human
| endeavor.
| pc86 wrote:
| You're talking about two unrelated things. Non-clinical MBAs
| running hospitals is very obviously dumb, but so is pretending
| the only cost of a resident is the salary they're paid
| directly.
|
| > _Every nurse and resident in her circle had a similar story._
|
| Most don't quit after 3 years.
|
| > _U.S. hospitals are for profit assembly lines._
|
| Absolutely true, regardless of the actual IRS profit
| classification.
| Aurornis wrote:
| > This is straight up fraud and should be treated as such.
|
| Running a residency program takes resources, staffing, and
| people. If you expect everyone in the doctor education and
| residency chain to work for free, there wouldn't be much of a
| residency program to speak of.
|
| It's a reality of life: doing things within a business takes
| money. I know some people scoff at the idea of health care
| being a business, but even in government-run programs there are
| still budgets to be managed and costs to be paid.
|
| > U.S. hospitals are for profit assembly lines. Managers with
| MBAs that have never worked a shift on the floor in their life
| see staff as fungible. Throwing a pizza party when patient
| quotas are met, instead of you know, hiring more to relieve
| overworked and stressed employees.
|
| Your view is very US-centric, but this is a common story in
| other countries too. Healthcare is a very complicated and
| demanding field, and it has high turnover rates outside the US
| as well. The harsh reality is that these organizations are
| operating like any other: They compensate as necessary to reach
| the supply/demand equilibrium. As long as new people continue
| to seek out and take the jobs at a high enough rate to keep the
| organization running, they're not going to arbitrarily increase
| compensation.
|
| That's always the answer: It's supply and demand equilibrium.
| We can complain all we want about who "should" be paid more or
| similar musings, but as long as the jobs are filled
| sufficiently at the current rate and the system keeps chugging
| along, that's how it will be.
| phkahler wrote:
| >> This is straight up fraud and should be treated as such.
|
| They have to cover overhead for that person. In e gineering
| that adds 30 to 50 percent. I think doctors have additional
| overhead, like malpractice insurance, and since this is an
| educational environment more oversight. 2x doesn't seem bad.
| 77pt77 wrote:
| > see staff as fungible
|
| It's like that in almost every field.
| ryan93 wrote:
| Seems like a good thing that purdue lets many students into
| engineering who can't hack it(i couldn't!). If they didn't have
| mayn failing that would mean they would be rejecting too many
| edge case students who might be able to make it through the
| program.
|
| Don't get her argument that someone willing to show up to a
| 7:30am class is necessarily smart enough for o-chem. Tendentious
| Kalium wrote:
| The author prefers to believe that it was poor instruction. The
| implication is that because they were willing to show up for a
| 7:30am lecture, they were capable of making it.
|
| On the one hand, the author is on to something. Most people
| learn _much_ better with intensive, one-to-one instruction than
| with large lectures. The real issue, as with all educational
| programs, is the cost in time and money to teach. More
| personalized, intensive training from more specialists in
| teaching a specialized subject simply costs more to get the to
| the same goals as bulk lectures. Nobody wants to say "There
| was a very rational cost-benefit analysis and I lost out".
| Instead, it's all framed as a need to dedicate more time and
| money at an already demonstrably drawn-out and expensive
| process.
|
| On the other hand, a person's ability and willingness to show
| up at 7:30am are probably irrelevant. No matter how relevant it
| _feels_ to a person who wants to show their dedication,
| passion, and drive.
| dap wrote:
| But, assuming we take the facts of the post at face value,
| there clearly wasn't a rational cost-benefit analysis that
| resulted in only teaching large lecture-style courses and
| deliberately serving only those who could thrive that way.
| The instructor's claim was not that the author needed more
| instruction that wasn't available (indeed, they turned her
| away from seeking such instruction). Rather, it was that
| people like her simply can't "hack it", which the author
| demonstrated to be false.
| gopher_space wrote:
| I just wish I had known that o-chem gets easier if you
| start first thing in the morning.
| Kalium wrote:
| There was no cost-benefit analysis on offer, you are
| correct. This is not the same as there being none, though.
| Weed-out courses are a classic example implemented at the
| institutional level - they exist to find as early as
| possible who is likely to be compatible with the
| educational program to come. Like any system working on
| messy humans (who like to defy neatly delineated
| categories), there are marginal cases who just need a
| little help to flip from one category to the other. The
| author calculated that they were such a marginal student
| and invested accordingly. This should not be confused for
| assuming that every passionate, driven student is a
| marginal case who just needs a little help.
|
| The author is essentially arguing at length for a greater
| emphasis on benefit and less on cost. Not just in o-chem,
| but at every stage of medical training.
| wisty wrote:
| They were complaining about a weed-out class being a weed-out
| class. The students wanted to get into an extremely
| prestigious career. Weed-out courses exist because there's a
| limited number of prestigious spots, or because most students
| need the pressure to work harder. It would make sense if she
| then explained that we should make medicine less prestigious
| (letting far more students become doctors) but that wasn't
| the point.
|
| The point was that learning the fundamentals was prioritised,
| instead of "deep learning". However there's a ton of research
| that suggests that in many cases, learning the fundamentals
| is one of the best ways to get students to start the process
| of deep learning. Obviously there's a point where
| overtraining the fundamentals is no longer a good thing (e.g.
| trying to memorise every possible edge case and combination)
| but that's a rare edge case. In most cases, simply getting
| the grips with the basics quickly, then thinking for yourself
| (e.g. looking at hard cases rather than asking how someone
| can teach you how to think at a higher level) is what works.
|
| Education has a long-running holy war between implicit vs.
| explicit instruction (though "implicit instruction" has a lot
| of name changes as it always seems to lose credibility and
| need rebranding). Saying "we need to stop teaching students
| what to think, but how to think" isn't deep, it's a cliche,
| and it needs a lot more than vague criticisms of explicit
| instruction to be worth listening to.
|
| Probably the worst thing about the "deep learning" crowd is
| that so many of them are in medicine, where it kind of works.
| You can teach medical students badly, and they'll figure
| things out. Giving them more independence and teaching badly
| (while pretending to be wise) can perversely work, in some
| ways, for medical students who've survived the weed-out
| classes. But then a few academic studies on how to teach
| medical students better (apparently they haven't yet learnt
| how to learn, or how to think critically?) is then used to
| convince politicians, education academics, and other people
| who understand little about teaching that it's the best way
| to teach reading in underprivileged elementary schools.
| CobaltFire wrote:
| In the military we train this as being "brilliant on the
| basics" with the follow on, as you said, that it is the way
| to train an adaptable and competent professional who works
| in high stress situations.
| p1esk wrote:
| _The real issue, as with all educational programs, is the
| cost in time and money to teach._
|
| LLMs should help with that.
| ohnononomahboi wrote:
| That the answer to a cultural-intellectual problem is monetary is
| not fully convincing to me. Do we really want 30% more attending
| physicians of the orientation this article describes?
|
| These all seem like valid, but unrelated complaints. On one hand,
| there is a complaint that doctors are judged subjectively, rather
| than objectively. But in the next breath those same objective
| metrics are skewered as deductive and maybe even greedy.
|
| The current attending physicians, according to the author, have a
| population-wide cultural problem where they don't believe they
| should have to teach. The author's solution to this problem is to
| hire more attending physicians.
|
| Many of the issues raised in this article merit investigation,
| but this piece feels too eclectic in its thesis to serve as a
| launchpad for policy direction.
| WaitWaitWha wrote:
| I know we hold doctors in high regard, but I must decline in
| allocating some magical "vibe" or "spidey-sense" as the article
| writes.
|
| In my opinion a well built system will replace _all doctors_ in
| non-research, medical functions.
|
| The notion that somehow one needs "vibe" to recognize something
| is wrong when Gladys in the example "vomited a huge quantity of
| blood" is concerning, and wee bit self-aggrandizing. The doctor
| reacted because there was clear evidence of an issue, not because
| supernatural abilities.
|
| > A doctor's foundational clinical mental models are built during
| residency...
|
| And, sad to say often stays that way for the rest of their
| careers. Anecdotally, I have seen this clearest with dentists and
| ophthalmologists. They will fossilize into their own thinking and
| unable or unwilling to pick up new methods and procedures (unless
| sufficiently incentivized by the selling company).
|
| another problem is frailty. I walked out on Monday dental
| appointment when I could tell the dentist had a "rough weekend".
| I do not need a person with a hang-over digging in my mouth with
| sharp spinning objects.
|
| A system that is updated near real time with new research, new
| medical advances, not getting tired or distracted is more
| preferable to me than a human. Maybe the actions are not
| performed by the machine, it just prompts the human to do and
| feed the information back, maybe it will also perform the
| actions. All is possible in the future.
|
| When it comes to research and emotional interaction, yes, doctors
| still hold an edge.
| dap wrote:
| I don't think anybody would claim it's supernatural. Only that
| for doctors who have seen lots of patients, they (their
| subconscious?) pick up on signals that they cannot consciously
| articulate, which means they can't be easily taught or checked
| for. (Over time I think we do catalog more of these things but
| it takes a lot of instances and some explicit reflection before
| people can identify and describe the pattern.) I've got plenty
| of criticisms for doctors and medicine but I absolutely think
| this is true because I experience the same in my own personal
| and professional life.
| andai wrote:
| Agree with most of what you said, which is unfortunate (except
| for the silver lining that machines have the potential to
| massively increase both the supply and quality of medical
| treatment).
|
| One bit puzzles me though, why would human doctors have an edge
| in research? Wouldn't the "person" who can read a trillion
| times more, remember everything, cross-reference it, and
| monitor billions of realtime data points (from billions of
| patients) for patterns, have a _slight_ advantage?
| WaitWaitWha wrote:
| My conjecture is that _some_ research requires a type of out
| of the box thinking that is not readily available in current
| technical solutions.
| cycomanic wrote:
| I find it interesting that you are so bullish on AI to
| replace doctors. Similar to fully autonomous driving, I think
| we need a leap towards GAI to really replace doctors. At the
| moment we see way too many failure modes that seem to be
| inherit in how ML systems work.
|
| Don't get me wrong I think ML systems will be great helper
| systems but I don't see them replace doctors any time soon,
| if not for the simple reason that a person is much more
| likely to trust another person than an electronic system and
| that is actually part of both diagnostics and treatment
| rscho wrote:
| Almost all medical specialties require a massive amount of
| know-how, and are only very weakly data-driven. I'm an
| anesthesiologist, and even anesthesia is weakly data-driven.
| Honestly, people who think AI can replace a doc in the current
| state of tech do not understand anything about practical
| medical care. The day of AI will come, but not today nor in the
| close future.
| devilbunny wrote:
| A patient who is vomiting blood does not need a "vibe" or
| "spidey-sense" to figure out something is wrong. There are,
| however, a surprisingly large number of situations in which
| doctors have to work with rather less information about what is
| going on, especially when you move to the hospital.
|
| I'm an anesthesiologist, so I don't have a clinic at all. I
| meet you just before surgery and we go. Vibes and spidey-senses
| matter a _lot_ , because I don't have time to run down a two-
| week-long investigation of your problem - I have to fix it
| right now or you're dead.
|
| Could AI improve me? Probably. Can the AI observe the way
| humans can? Not yet. Can they intervene like humans can? Not
| even close. When you have an autonomous robot that can
| successfully run down the American Society of
| Anesthesiologists' difficult airway algorithm, you're getting
| there.
| bjornsing wrote:
| > The notion that somehow one needs "vibe" to recognize
| something is wrong when Gladys in the example "vomited a huge
| quantity of blood" is concerning, and wee bit self-
| aggrandizing. The doctor reacted because there was clear
| evidence of an issue, not because supernatural abilities.
|
| For the record: The doctor stayed in the room due to a "spidey-
| sense" or "vibe". The impressive part was predicting the vomit,
| not reacting to it.
| Calavar wrote:
| A lot of this really hits home. Some of my personal observations
| across residency and practice:
|
| 1. There are some attendings who have a subconscious inbuilt
| assumption that there are "good" residents and "bad" residents
| and that any team will contain a mix of both, even if it's a team
| of just two residents. God forbid that you should be just a
| "good" resident paired with a superstar resident, because then
| you are the one who must get the "bad" label by default. If this
| happens early enough in residency, it may be the first piece of
| feedback that your program director gets about you, which puts
| you at risk of being labeled "bad" by the program at large and
| finding yourself being pushed towards a remedial track. I feel
| that residency programs are shockingly bad at identifying which
| residents actually need remediation. Residents with serious
| knowledge or work ethic issues can get ushered along through the
| program, while very bright residents who don't understand how to
| play up their own successes get put on remediation plans.
|
| 2. More generally, confidence is often misinterpreted as skill,
| and introversion is often misinterpreted as a lack of skill. Many
| attendings are shockingly bad at differentiating the two.
|
| 3. Departmental culture has a huge effect on residency education.
| I trained at a busy county hospital and now practice at an ivory
| tower type place. Much to my surprise, I think the EM program
| here (which gets residents who were the cream of the crop of
| their med school classes) does a worse job of treating patients
| than the county hospital (which failed to even fill its residency
| class a couple years ago). The difference, at least in my view,
| is that attendings at the county hospital were extraordinarily
| hands on, which taught residents that a "normal" ED physician is
| extraordinarily hands on. As another example, the ED at my
| current hospital is very aggressive with CT scans, to the point
| that probably 20% of the patients that I admit have been
| panscanned (CT scan from head to pelvis). I attribute this to
| attendings here being more risk averse in cases with a ~1%
| possibility of malpractice. And it trickles down to the residents
| too, because again, that's what their reference for "normal" is.
|
| 4. Basic science education in med school is a joke and needs to
| be overhauled from the ground up. As it stands, 1st year is
| "pure" basic science, 2nd year is learning about the library of
| various diseases, and 3rd year is learning how to treat those
| diseases. I still remember reading the nephrology section of my
| 1st year textbook, a large chunk of which was a breakdown of why
| cystatin C is a better indicator of GFR than creatinine and a
| description of a procedure in which contrast is injected into the
| renal artery and sampled at the renal vein to measure true GFR,
| worked out step by step with mathematical equations. What was
| never mentioned: What the hell is GFR even used for anyway? Why
| would someone want to measure it? These pieces don't fall into
| place until 2nd and 3rd year.
|
| Imagine if you learned symbolic algebra in 3rd grade but the
| concept of a word problem wasn't introduced until two years
| later. That's essentially what medical school basic science
| education is.
|
| The faculty who design med school curricula are not blind to this
| issue, but their attempts at fixing it are laughably bad. There
| is "case based learning" where 1st year students are told a
| vignette about a hypothetical patient and are asked to generate a
| differential (a list of possible diagnoses) before they dive into
| the basic science component. This turns into a comedy skit show
| because 1st year students barely know any diseases, they are only
| vaguely familiar with the symptoms even for the ones they do
| know, and they haven't had much, if any, explicit teaching on how
| to generate a differential.
|
| Why not take a more vertical slice approach to teaching?
| Introduce a limited number of bread and butter diagnoses in 1st
| year and gradually layer on rarer and more complicated diseases
| in 2nd and 3rd. Put more weight on the basic science aspect in
| 1st year, put more weight on aspects that require knowing a large
| number of diseases (like generating a differential) in 2nd and
| 3rd year.
| andai wrote:
| I think part of this is about staying up to date. I'm not sure if
| there's a legal requirement for ongoing training? But I've had
| the experience of going to an older physician and being told my
| theory is impossible, based on a hypothesis that was disproven in
| the early 1970s (incidentally, right after the physician
| graduated).
| abhisuri97 wrote:
| Yes. Doctors in the US have to get a certain amount of
| Continuing Medical Education (CME) credits (usually done by
| attending conferences and lectures).
| WalterSear wrote:
| So they are being taught by the pharmaceutical industry?
| ugh123 wrote:
| In the US, it seems like insurance companies teach doctors how to
| think.
|
| How many times have we all heard from a doctor "we don't like to
| do so many tests each year because of costs"
| tombert wrote:
| Really? I feel like whenever a doctor sees that I have really
| good insurance they feel the need to use _every single machine
| they have_ as a diagnostic. I generally don 't care because my
| copay is generally the same regardless and I figure it is good
| to be thorough, but I do realize that is probably driving up
| the costs for everyone in the long run.
| notnaut wrote:
| "really good insurance"
|
| I'd guess a massive % of the us population is having a
| different experience than you.
| tombert wrote:
| Sure, my wife and I had to deal with that not too long ago
| when I was unemployed and had to use the subsidized
| MetroPlus stuff in NYC. It wasn't as bad as I thought it
| would be but it was definitely not as good as my fancy PPO
| I get from sexy desk jobs.
|
| I guess what I am getting at is that insurance sort of
| makes things worse for everyone here. When a person comes
| in with good insurance the doctor has incentive to abuse
| it, artificially driving up costs, making it harder for
| people with crappy/no insurance to get the treatments they
| need because insurance won't cover it. It's a messy system.
|
| A large part of me would prefer that we abolish private
| insurance entirely, but I fear that's not likely in the
| states.
| dandy23 wrote:
| I think OP is quite right that insurance drives tests and
| costs up because contrary to what we think it is good for
| the insurance companies if the doctor bill is high because
| then people buy more expensive insurances and thus higher
| revenue for the insurance company.
|
| If the cost would be low there would be no need for an
| insurance.
| rscho wrote:
| I wouldn't say "teach". But you're right that docs are forced
| to obey insurance companies. Not only in the US, but everywhere
| insurance companies are a thing. Yet, docs are almost always
| the main target for complaints, while insurance companies act
| in a very capitalistic way by optimizing for C-suite bonuses.
| Aerbil313 wrote:
| > Not only in the US, but everywhere insurance companies are
| a thing.
|
| No, not at all. Insurance exists in plenty of places, without
| significantly influencing doctors' treatment.
| rscho wrote:
| I'd be interested in an example.
| cameldrv wrote:
| Yeah like almost everything wrong in the economy, the question
| is where is the stabilizing feedback loop? Where can patients
| choose something better, and how do they get the information to
| choose the best option?
| Calavar wrote:
| On the contrary, US doctors are significantly more aggressive
| with testing and treatment than doctors in most other
| countries. There's multiple reasons for that, but I think the
| main one is trying to CYA in the event of a malpractice
| lawsuit.
| ugh123 wrote:
| Source? And does more (or "significantly more") even mean
| it's making a difference? It's well known that younger and
| younger people are being diagnosed with cancer, yet only a
| few major tests have been recommended to be done sooner
| (colon, prostate, breast) and by just a few years.
| roughly wrote:
| It's kind of incredible that we've let a bunch of weenies with
| MBAs put our lives and health in the kind of risk that the modern
| medical system puts us in. Every single story from a doctor or a
| nurse over the last decade involves being overworked, not having
| time to actually diagnose patience, lack of sleep, and rapid
| burnout. On the patient side, what we get for that level of
| hospital "efficiency" are medical bills that would bankrupt
| anyone below the top 3% if they don't have insurance, rapidly
| rising medical insurance costs, and what could charitably be
| described as prescription drug costs that are not based on the
| cost of the drug.
|
| The business side, though, is going swimmingly, so there's that,
| at least.
| KRAKRISMOTT wrote:
| The doctors themselves have as much to blame for this too, not
| to mention most hospital administrators are MBAs with a
| healthcare background, they are not art students.
|
| Medicine perpetuates a hazing culture of overworking residents
| thanks to a jumped up medicine pioneer who took too much
| cocaine. They refuse to come up with a way to train doctors at
| scale and instead restrict it to physical residency spots,
| keeping their compensations high. Train doctors like engineers,
| break up the medical unions and lobby groups with the anti
| trust act and most of the problems will be solved.
| SoftTalker wrote:
| Exactly, it's the AMA that's a big part of it. Doctors could
| stop this by just refusing to work that way. They are the
| ones with the knowledge and skills and licenses to do what
| they do, so they are ultimately in the driver's seat.
| rscho wrote:
| Refuse to work that way?? And how are we supposed to do
| that? Stop working until our requirements are met and leave
| everyone on their own during that time? Who do you think
| people would blame? The C-suite execs?
|
| The only choice you really have is to leave medicine. After
| dedicating ten years of your life to it's study, a fucking
| huge debt and no guarantee of finding a better life
| elsewhere.
| verisimi wrote:
| It's easy to get what's going on once you realise it's a
| sickness industry, nothing to do with health.
|
| You want lots of sick people to treat a lot. Doctors being
| short on time etc, is fine - it's business.
| prashp wrote:
| This is not unique to the US where MBAs / business-minded
| people are the driving factor for healthcare workers being
| overworked.
|
| In Canada most fully-trained doctors are paid per patient (AKA
| fee-for-service)[1] and so there is a huge incentive to rush
| through as many patients in a day, which results in overwork
| for the residents (who are salaried) and nurses (also
| salaried), and no time for adequate education of medical
| students and residents.
|
| [1] https://www.dr-bill.ca/blog/billing-tips/physician-
| payment-m...
| bjornsing wrote:
| It seems to me that nobody teaches anybody how to think. Instead
| we teach people to do things that require thinking, and trust
| that they will develop an ability to think as a "byproduct".
| Which is a bit strange to me, since there are definitely some
| general principles that can be taught.
| sn9 wrote:
| This person _fucking gets it_.
|
| I want to force every software engineer and manager and MBA and
| anyone else to read this until they've internalized it.
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