Interesting Enemies For a Diagnostic Database 409
dlh writes: "Boston.com is carrying an article about Dr. Lawrence L. Weed's Problem Knowledge Coupler software. Apparently the medical profession is not exactly thrilled at the idea." Seems access to information is a positive thing, but certain doctors seem to feel threatened by this sort of database.
Well.. (Score:3, Interesting)
If you just payed a TON of money to goto medical school, would you then want all your education flaunted all over a network of information? Probably not, it's the fact that you know something others don't is what makes you money. This applies to specific fields, and research as well.
There is other problems with this sort of thing... (Score:4, Interesting)
Something like this could comprimise the blind tests.
[On the other hand, a lot of subtle bugs in software come from analysing the blind elements. Ie, trying to understand subtle behaviour.]
It's all just EGO (Score:4, Interesting)
In this case, it's ego. Of course no one wants to see a printout handed to them by someone who isn't a professional in the field saying "hey, this computer said you're wrong!" For chrissakes!! I wouldn't either. Of course there should be some level of interest and consession by the professional to review the information and test its validity. A doctor with an ego problem should be avoided just like a network engineer/administrator who thinks he already knows everything he needs to know about any given subject.
So yeah, it's fun to take the immortals down a notch back to Earth reminding them that they're still human. But it should also serve as a reminder to anyone who lives in the ever-growing world of science and technology (this does include medical science) that there is always something new to learn and never to stop challenging the "facts" that have been layed out before us. Oddly, there is no "spontaneous generation" as was once suspected and those "wandering stars" (aka, planets) aren't like other stars for more reason than the fact that they don't move like the rest.
And of course, let us never forget that "science" isn't about proving anything "right" so much as it is about proving things to be wrong. It's never easy to know the truth. But we get closer every time we eliminate that which is untrue.
Re:used a damned large paintbrush didn't he? (Score:2, Interesting)
Re:Human Factor Still Valuable (Score:2, Interesting)
I personally would like it if both the doctor and database agreed on the prognosis.
It would also be interesting to add some sort of artificial learning to the system. Recognizing patterns such as, "people at this clinic seem more likely to display these symptoms, which means that cancer based on the local environment is a strong possibility." or "This patient has a genetic predisposition towards disthymic disorder, and now seems to be showing some of the symptoms. Normally, it would be diagnosed as a sleep disorder, but with the genetic predisposition in mind, we should be weary of that."
ObDisclaimer: IANAMD
Re:Well.. (Score:1, Interesting)
Disagree: The amount of money one pays to go to medical school varies hugely and has little to do with the elitism of the profession. Many state backed institutions are actually rather inexpensive. Schools range from the $30 and $40 grand a year for tuition/academic fees to a cumulative of $35 grand for all four years (for a standard 4 year program). $35 grand is inexpensive for 4 years of training. Most schools that force the premium are those in financial trouble, e.g. plugging financial debts through their grad programs.
Furthermore, what happens with the medical profession has little to do with other "specific fields". Other specific fields demand is limited by funding in their field and available resources. A grad program will only accept grad students with whatever grants (mostly government) and endowments allow to that insitution. (Facilities and size of program are an extension of that funding.) In the medical profession, demand far outstrips supply, yet supply is not ramped up so that there is nearly always a doctor shortage.
This mandated demand is why physician salaries were so high in the 70s and 80s. The only reason they stabilized and have NOT gone up is because of the HMO system, not because of competition within the profession.
Agree: It's a profession, at every stage. Doctors are a strictly controlled supply. Tell that to your doctor or a medical student, and they'll throw a fit (e.g. "I save/improve a life, I should get $120,000+ a year for all my trouble in helping you and the shit I went through in residency, college, and med school..." (the "trouble" is professional hazing and has little to do with training qualified physicians, as well as forced all nighters as right of passage). To take the MCATs (limits on number times test is taken). To apply (monetary and limits on applications). To get in--about 50% of a medical school class is either undergrad alumni of that same school, have a parent or sibling related to the institution, spent heavy time in some health field related activity to the school, or is from an even more deemed elite insitution.
The profession is also tightly controlled as to how many medical schools are accredited to give out MDs or ODs. Combine that with limitations on class size. All this is clearly documented year after year. Occasionally, the AMA will come out and say something like there will be a doctor surplus or whatever in X number of years, but the reality is, they have a rather skewed viewpoint. Not anyone can waltz in and become an MD, thankfully and obviously, nor should they be able to, but still, well qualified people are turned away. 15,000 people apply to single programs with a class size of 150 reguarly. Half of those applicants are *over* qualified to get in.
Some of you may be saying "But doctors are worth/deserve it." Yes, they are. But the fact still remains that the *right* to save your life is given and a near monopoly restricted by the government and profession. The ability to save a life is something achieved and separate for which the opportunity, that right, is not market generated.
It's worse (Score:5, Interesting)
Doctors have bad egos. Really bad. Many of them refuse to acknowledge the shear drudgery of their average daily workings. Like another poster said, every one of her kids visits were the same. Yeah, no kidding. 90-95% of the visits to our office are within a few categories. Colds, heart problems, diabetes, and checkups of various sorts. (There are a couple of others, but not many). Yet it is not at all unusual for doctors to rail at this sort of technology for even these cases. They cling to an absurd belief that each patient is different. That, to put it bluntly, is bullshit. Most patients are the same. This sort of tool would make the routine stuff go MUCH faster, and would help narrow down the weird stuff to where you are doing real tests to really differentiate between two different (or five, or whatever) diagnoses. Of course, when those weird cases are programmed...
Others in this topic have mentioned that docs embrace new tech. Kinda. They embrace new diagnostic tools that they can play with. But they are not as in love with decision making/helping tools. It undermines their education. It undermines the fact that most of them just have incredibly good 'wetware' databases.
I would also discount the actions/thoughts/ideas of younger docs. They frequently change by the time they hit their mid-30's. I've seen it before, I'll see it again. They love the idea when in school/fresh out, but come to believe in their own manifest godhood over time. No mere pile of silicon could be greater than I.
Another problem that I actually do sympathize with is that this is grounds for serious lawsuits. You could claim your doctor did nothing/wrong thing based on what some stupid machine said to do. Any rational person knows the doc shouldn't automatically trust what the machine spits out, but you and I also know that there will be at least one or two docs who, when these things gain wider use, will take an extra martini at lunch, counting on the machine to catch his stupidity, ignoring the fact that the man and machine have to work in concert.
Given the decision support software (the drug interaction databases are one example. The only problem is that EVERY reaction is typically flagged, so you need to know what's going on to interpret the data. Kinda like the discussion of SQUID and other NIDS the other day) I can forsee this making strides. But it will be some time. Twenty years? There are two scenarios where this will happen faster:
First, HMO's and other insurance companies use this software or something similar to find out how quickly their docs are zeroing in on diagnoses. If they find something that lets them diagnose in one visit instead of four, they'll use it. And that's good for them and good for the patient (cheaper, quicker, more accurate care). The other scenario is one wherein the government mandates this sort of testing. Likely it would manifest similar to the HMO model, and be used to cut costs of state-subsidized healthcare. Again, not a bad thing.
The better docs I have spoken with (and being raised by a physician, I've likely spoken with more physicians than the average slashdotter knows) wouldn't mind getting to deal with the tough or fringe cases. That is a challenge. That's interesting. Pap smears and kid shots are rote drudgery.
I hope we'll see this gain prevalence soon, but don't count on it. And, as the article says, docs are more likely than ANYONE to dig in their heels.
Re:Database vs Doctor (Score:3, Interesting)
There was also a well-developed technique of thumping parts of your body while listening with a stethoscope. A skilled practicioner could learn a surprising about about what was going on inside your body from this (very valuable in the days when there were no CAT scans, or even X-rays, and exploratory surgery meant almost certain death from massive infection).
New diseases would presumably be entered in the database the same way that they get into the wetware databases that doctors use now. Patients present with symptoms that don't quite fit anything they know about. They try a treatment, then another, then another.... Over time the pattern of symptoms gets recognized as a new disease, and the treatment becomes standardized.
The difference is that with an expert system this process could be much, much faster than it is with the old-fashioned word of mouth method, or even with journal publications.
As an MD, too late to the discussion perhaps. (Score:3, Interesting)
I'd bet that a very small fraction of the people on the board would trust their mother's care to a database. Of course, can you sue the database for misdiagnosing or missing something. NO, because you didn't give it the relevant data.
The issue here is that the combined use of the physician's skills and a database like this would be very powerful. Unfortunately filling out a LONG list of questions is time-prohibitive unless the patient does it for themselves.
The great thing is that most people on this board are not representative of the world. The rest are not willing to forego a physician's care because of their superior intellect.
Once the techie is in the emergency room with his twinkie-filled coronary arteries and a ten-ton elephant sitting on his chest - he'll be screaming for the best cardiologist money can buy.
Wait, wait you have to fill out the database.. the computer is better, your HMO says so...
FIX HEALTHCARE by fixing the mundane problems.
1) insurance
2) tort law
3) staffing
4) prevention
5) research
6) records / IT
7) education of doctors and patients
8) money
stop belly-aching about egotistical doctors, for every high-profile bastard physician there are twenty doctors who work very hard, destroy their own families and life to care for your families.
I hate hearing anecdotal bullshit that this database helped solve my rare sleep disorder that only 1 person in 5 million has. GREAT!
Does it make healthcare faster, more accurate and above all *CHEAPER*.... doubt it..
Re:One doctor's view (Score:1, Interesting)
Now, if there was software around that had a 5% chance to provide a correct diagnosis I would take it in a minute.
We still don't know what's wrong. You sound so confident in your skills, and I bet you can treat 95% of the patients that come through your door. But what about the other 5%? What about the times you're wrong?
Doctors are so full of themselves. I'm a software angineer and I can be honest in admitting that I know about 5% of the total knowledge base of my profession. Yet is seems that doctors believe they know 90%?
Also, how can it hurt to have patients use diagnostics software before they see a doctor. I usually wait for about 30 minutes. That time could be spent diagnosing my symptoms based on a database that is 100 times as large as your head.
Re:Well.. (Score:3, Interesting)
A new technology is adopted if and only if there are valid scientific - which now means 'able to stand up in court' - studies to support it (or, more cynically, a drug company paying the doctor to use something as part of a 'study'). A new process ... such as not having interns work 48 hours straight ... just isn't going to happen anytime soon. That's part of the old-boys hazing mentality ... we had to do it, so we'll inflict it on those below us! The recently proposed bill to legislate the maximum number of hours an intern could work per week had 100 hours suggested!!! Does this sound like a group who would gladly acccept a 'new' technology just because it _could_ help?
To be fair, many doctors get into the field out of an honest desire to help people ... and this could help adoption of the technology. BUT there are so many forces and traditions against change in the profession, it will be a long time, if ever, before such a technology sees widespread use.
Doctors are using Palm Pilots now ... but it is my understanding that that is for note taking only ... when asked, every company that does software (including some medical software) has so far declined to do anything like the article suggests. The fear of lawsuits has been cited by a couple.
Re:One doctor's view (Score:4, Interesting)
I lost both my parents because of physician error, and I can assure that malpractice lawsuit payouts do not ease the pain, nor did the physicians testimony that they in one case they hadn't considered the correct diagnosis because it was so unlikely, or in the other case, that they hadn't considered the correct diagnosis because they weren't familiar with the condition.
I've been aware of this software for a long time, due to research done in order to show that a doctor was guilty of gross negligence in his misdiagnosis, and I never cease to be amazed at the number of doctors who really, truly believe that they can get everything right, every time, or that having a computer help with diagnosis is somehow different than reading an article in JAMA.
I have a serious question. Will you feel guilty when a patient dies, who would've been saved had you consistently used a system such as this, or will you be glad that you didn't waste 10 minutes to consult a computer?
I may be posting anonymously, but I'm not trolling. I understand there's more to medicine than diagnosis, but I don't understand why doctors can't admit that the 'I'll just remember everything' system that's currently in use is criminally irresponsible.
Re:One doctor's view (Score:2, Interesting)
The ideal system would be a situation in which doctors collaborate (the killer P2P app?) to share information and build complex disease and treatment models.
Re:One doctor's view (Score:4, Interesting)
You seem to be a GP. I would assume your patients routinely report with nonspecific back pain, or with headaches.
The data I've seen suggests that these two symptoms in particular are both pervasive in the patient population and routinely undiagnosed or misdiagnosed. It would be interesting to run a double-blind comparative study of diagnostic efficiency of physicians and laypeople with and without the database...
Re:One doctor's view (Score:4, Interesting)
Indeed, too much focus on just reaching a proper diagnosis can lead to poor care or worse.
Although I'm not an MD, I once had a very interesting case study in an operations research class (management science, statistics, expert systems, etc.). We used decision trees to study different diagnostic and treatment procedures in an actual (although somewhat simplified) healthcare setting. The model considered the results of appropriate/inappropriate diagnosis/treatment, the cost and latency of tests, false positives and negatives, and the differing goals of each key stakeholder.
From memory, the doctors were assumed to be most worried about correct diagnosis and treatment regimen, patients were most interested in the safest and most effective prognosis, and the hospital administrators were concerned about costs and legal liability. We found that optimizing the model for these different goals produced very different outcomes.
The results were somewhat counterintuitive: increasing the accuracy of diagnosis or ordering the most tests did not necessarily increase the probability of a cure, and could even increase the probability of death depending on the role of false positives/negatives, waiting periods, and drug side-effects.
That being said, the software in question seems to be more than a just a simple diagnostic tool. Combined with a patient centric outlook, I see medical expert systems becoming obvious (and essential) reference tools as long as they provide the MD with an ability to tweak the level of detail for minor ailments and to consider clinical experience, risks, local expertise, access to equipment, patient preferences, and so on.
Re:One patient's view (Score:4, Interesting)
Anyway, of those four diagnoses, three were wrong. Based on that, it sure doesn't sound like diagnoses are easy to me! Add to that the fact that I'm pretty good at troubleshooting and I'm one of the few that I know of. Most people flail about trying things at random and, as far as I know, training isn't much help for most of those people. Yes, it's easy to memorize a few pat answers to the most common problems, which is why many people who visit the "doctor" wind up seeing a PA, who forwards to the doctor only those cases whose diagnosis is in doubt, but that's exactly why this sort of thing is important. As time goes on, doctors are going to be less and less likely to see the simple cases.
You mention psychiatric diagnosis, so I'll talk about those. A quick check of my local DMDA chapter shows that some 70% of those suffering from some serious mental illness were misdiagnosed at least once. I can't help but think that a computer program that prompts the asking questions about typical symptoms of mania and schizophrenia would reduce that because most of the misdiagnoses start as a diagnosis of depression because it's what people complain about. I know the doctors don't ask those questions because in the sample that I have (8 so far) none have asked the right questions to make what we (that is, myself and the ill person) now believe is the correct diagnosis.
In any case, since visiting a doctor (and I spend a lot of my time in doctors' waiting rooms so I know this quite well) is something like an hour waiting to see the doctor followed by maybe 10 minutes of answering questions I don't understand, filling out the forms while I wait can't do me any harm even if the diagnosis is not remotely in doubt or irrelevant to the treatment, can it? I mean, it becomes part of the patient history just like the temperature and blood pressure check you're going to do whether I come in with a fever or with a splinter, right?
Heck, I suggest you put terminals tied into that database in the ER waiting room so there'll be something to do while you're waiting the 4-6 hours (on average) it'll take to get to the head of the line.
Re:A MD's perspective? (Score:4, Interesting)
The bills are so high now, because they need to offset the lowball payments that the HMO's give them. I just had a visit to the ER two months ago, and got a notice in the mail from BlueCross that the hospital bill for that day (had an EKG, CT scan, and an MRI) was over $5,000, though they only paid $1,200. Subsequent tests over the next few weeks were paid at even lesser rates (than the 20% from the ER visit).
Re:Statistics and disruptive technologies (Score:3, Interesting)
1. Obscure/remote health issues. People who have spent even a week in a different part of the Unites States than where they live may contract illnesses that a doctor back in their local hometown may never have heard of, and hence can't diagnose.
For example, here in the SouthWest (Arizona, So. Cal, Nevada) there is a soil/dust borne fungus that when inhaled can cause flu like symptoms. Unless you are from the area a doctor is very unlikely to diagnose Valley Fever properly. If left untreated the fungus can disperse to other tissues, the blood and bone. Death is not uncommon if left untreated. A computer system would be able to take travel history in to account and offer Valley Fever as a possible diagnosis. The doctor then steps in and orders the proper labs for a complete diagnosis. As a partner to the health professional such a database/expert system could 'save' many lives.
2. Doctor's power issues. I can't tell you how often a doctor grimmaces when I call them by their first name instead of "Dr. Important". They are people and I am people, I refuse to cower to their concentrated training in a particular field. I certainly don't expect them to call me Mr. Important when I meet them in a business meeting in my field of expertese.
Not all doctors are like that I know. All of the docs I see on a rgular basis are well grounded and have no problems with a first-name basis relationship. In my personal experience they are also much more likey to make me an interactive part of the heath care process instead of treating me as an object or a mere disease to be cured. The catalyst for more doctors to give up that power-centric relationship is for the patients to not tolerate it. Either explain to your existing doctor what relationship you want to have, or find another doctor.
I've just about gone to court several times with doctors. I'd (for example) have a 2pm appointment. I'd show up at 1:50pm, sign in and wait. At 2:15pm if I was not being seen by the doctor I got up and left. Often the office attemtped to charge me for the appoitment, or a cancelled appointment fee. I told them I had a 2:00 appointment and that the doctor was the one who cancelled the appointment by not showing up on time. If they don't respect my time, they don't respect me and I don't do business with them.
Re:One patient's view (Score:3, Interesting)
1) Because every single person is different. Every disease can present differently is different people.
2) Lack of time. An average family doc spends about 8 minutes per patient. This is due to a number of things. You actually have to earn enough money to pay for your practice and have a salary on top of that. There are way more sick people than there are time and resources to treat them. Obviously it would be great to meet with every patient and their family for an hour, but it's not practical, so there is a trade off. In this short span of time things will be missed. That's a shortcoming of the system not the physician.
3) Lab tests are expensive and these costs are born by the indiviual, insurance companies, or the government, all of whom have a vested interest in keeping costs low. You don't test for rare diseases, unles there is an overwhelming reason to do so, simply because the above groups cannot or will not pay.
4) There are bad physicians. Fact of life.
Personally I think that this database would be useful, although I doubt that there would be much in there that doesn't exist in the literature already.
What I object to is the portrayal of physicians as bumbling buffoons bent on preserving their undeserved elite status at the cost of proper health care.
People expect too much from a family physican. They cannot possibly know enough to accurately treat and diagnose every problem. The database described already exists in the form of medical encyclopediae and internet databases and colleague's advice. Using these resources physicans are mostly right most of the time. It is unreasonable to expect more than that.
Re:It's worse (Score:4, Interesting)
Yeah, I'm surprised how much this has been discounted. Although PKC makes a point about calling recommendations "primary options" to distinguish from hard advice and transfer responsibility to the provider, there is still a high degree of editorial decisions that the software publisher is making.
It's unclear from the story or their website [pkc.com] as to how conflicting research is treated. Are different journals or studies weighed differently? How about incorporating common clinical practice that might not show up in the published articles? Or academic theories that are widely used for diagnosis and treatment but have not been conclusively proven?
In their FAQ [pkc.com] they state that "Every question contained in a Coupler is there because an action recommended by the medical literature depends upon its answer". What if there are no conclusive actionable recommendations, but results can be inferred from related studies? Does that mean that there are any gaping holes in their content? Is this counter to a systemic approach?
Good software should be able to handle all of these questions, provide a usable and adaptive user interface, avoid unnecessary data entry, provide for local input and overrides, and maintain primary responsibility with the MD. So far, besides some good results, we have no evidence as to the quality of their program (although a tour [pkc.com] is available on their site). And what happens if PKC is so widely adopted that it becomes the Microsoft of medical software or the AOL of medical content?
As they are currently positioned they shouldn't so causally brush off their legal exposure. They might be better off repositioning the same service as a faster and more accurate method of accessing research and best practise rather than as a guided decision making tool. This might alleviate the fears of certain doctors while also stressing that the decision lies with the practioner and the advice comes from third parties.
Re:Typical unthinking replies.... (Score:2, Interesting)
Why in the world would you give someone's (here, a doctor's) views and outrage NOT be contemptable if he has not even evaluated the software package and looked at a printout? We are not dealing with programmers and their software, so your claim that we should give "leeway" is utterly ridiculous. Physicians deal with human lives, and they screw them up--they should be open to tools that assist them.
The physician gave a standard knee-jerk response which IS stereotypical. And that stereotype is very justified.
I've mentioned to medical colleagues in the past that "our responsibity is to put ourselves out of business." They were shocked and outraged and they WILL alieniate your sorry ass. Tell something controversial to a prof, even a slight challenge, and watch your subjective evaluations hit the floor.
The role of medicine and health professions is not make money but to heal and alleviated suffering. It IS to put itself out of business and the sooner the better. But it is in the business. It is a clear conflict of interest that the majority of doctors (not all) clearly and knowingly participate in.
Your very own analogy taken back to medicine would be like someone coming up with an all around cure and then the medical profession demanding a regulatory backlash so only they can administer it. It's ridiculous, greedy, and monopolistic. And you just stated you support it because you want to give them "some leeway". Please. If the technology is there and it gives benefit to the individual, not the industry or the profession, the better.
Having been to medical school and have MPH training, know several doctors personally in both academic, research, and in practice, taken health law as well as health econoics courses, I probably am far better versed than your insulting, cow'd comments.
Re:One doctor's view (Score:1, Interesting)
if in IT, do you know what doping the silicon means?
do you know every declarative language ever written? do you even know what a declarative language is?
if stranded on a desert island, can you build your own processor? your own operating system? your own programming languge?
the fact is that 99% of programmers don't even know 5% of the 'profession'. Most only know the tight little circle of stuff they've been exposed to.
If you think you know more, you're only kidding yourself.
Remember, lives are on the line here (Score:3, Interesting)