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Interesting Enemies For a Diagnostic Database
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.
from article:
"But, according to Cross, the neurologist who originally diagnosed the case as an REM sleep disorder had a very different reaction to the use of the software. When the plumber and his wife handed that doctor the PKC printouts, he shuffled them, left the room, and, Cross says, "returned with a very hostile, angry disposition." Viewing the results as computer-generated quackery, he refused to back down from his original diagnosis."
I read the article. This was the only example I saw...I'd say that's painting a very broad generalization. I also happen to know many doctors that EMBRACE technology.
Sounds to me like this was just one guy he was pissed because his diagnosis was proven wrong, and (like anyone) didn't like it.
Other than that, decent read.
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Doctors are just technicians that happen to work on people. They are no more perfect than the grease monkey at the car dealership. Using a computerized database of information to research the very complex organisms we are is just common sense and is perhaps why computers became popular in the first place. Sure, some doctors will manage to make mistakes using a tool like this, just as some high school kids still can't seem to use a calculator correctly.
Suing for bogus information? One always has to consider the source of information. A dabase like this can be considered only as a helpful tool. Tools help find a working solution, but it takes experience to make it happen. A good doctor is someone who is responsible for using his tools properly, not pushing buttons.
Doctors need to think of this as a tool and not as a threat to their job. Just because I can try to diagnose my problems online dosn't mean I don't see a doctor. I am glad when I visit the doctor and he uses the computer or medical books to check the current best treatments or for other conditions with similar symptons - this shows the doctor is not oblivious to the fact they can't know everything.
As long as the software is properly regulated, just as docotors are, then there really shouldn't be a problem. The doctors can use the software to "help" and then make the final decision on the best course of action, as the computer cannot do that.
- HeXa
After reading this article, I am reminded of a good friend of mine, an M.D./Ph.D. student at Duke University, and some of the stories she tells me. I've heard of doctors that take advise even from an intern as a threat, much less advice from a computer.
The doctors that dismiss this type of aid out of hand are suffering from arrogance of the worst sort... they are dismissing a tool that can be used to further their patients health.
A person who has confidence in their own abilities can evaluate a tool and use the results as they see fit. While they need not use the tool as a crutch, they will use it as it is meant; as an aid to diagnosis.
They hate this because like everyone else they hate to be proven wrong let alone QUESTIONED. OTOH HMOs love this stuff because it represents one less person they have to hire.
Even herbal treatments in the absense of a proper amount of research can be troublesome. People tend to let themselves think that because it is natural, it can't be dangerous.
I think the idea of a public medical knowledge database is an idea long overdue. However, IMHO, there is no substituting the medical doctor's long-time familiarity with both real-life cases of these symptoms/diagnosis/diseases and much of the data contained within such a database.
Also, dealing with a human being rather than a database can be rather reassuring in and of itself. Having a doctor confidently tell you a prognosis and treatment for it is alot more reassuring than seeing even those same words on a screen or piece of paper.
This could be an extremely useful tool. Why any good doctor would be opposed to it is beyond me. A truly professional doctor should be completely willing to defer to specialist or some sort of well-researched body when he is any less than 100% certain of his own work. Really, the only doctors I could imagine this would hurt are the bad doctors.
As a practicing physician (and software engineer since 1978, so don't get in a hissy fit), I have very little use for the program. Not that I don't find the idea of an expert system for diagnosis to be interesting, but it's clinically useless for most of us.
It may come as a surprise to most people, but diagnosis is not the hard part of medicine. Oh, sure, there are the occasional wierdies like the one in the article (and then I'd love to have the program), but mostly the diagnosis is either (a) not remotely in doubt, (b) irrelevant to the treatment (I don't care WHICH virus gave you diarrhea, I just care about hydration and mental status, and I don't need a computer program to help there), or (c) not something I need right now.
Clinical medicine is not mostly about diagnosis. It's mostly about disease management, triage, clinical efficiency, relationship building, and a huge dose of having to deal with every person that walks in the door, regardless of IQ, regardless of psychiatric diagnosis, and regardless of what I personally would like to do with them. Where excatly some peculiar expert system fits in with all that is something of a mystery to me.
(Oh, and surgical medicine is all of the above, plus time-critical eye-hand coordination, plus the routine inability to diagnose anything until you're in the OR, and the expert system is stone useless about then.)
New and better tools to solve problems that don't come up very often are interesting, but hardly something that will revolutionize medicine.
...because their expertise is knowledge based and any knowledge based profession is vulnerable to the same thing that is currently happening with the programming profession: It's being shipped to other countries in order to lower costs while raising profits.
For example, a hospital/HMO combo needs to watch costs, so has local technicians to do the local non-surgical stuff. Information on the patient is interpreted by an MD in India for low bucks, and the local technicians do the final, hands-on work if needed. Only time the hospital/HMO needs a "real" doctor/surgeon is when the patient really needs that level of hands-on work.
Hospitals/HMOs stand to make much bigger profits from this scenario and you can bet your doctor's bottom dollar they know it.
I repeat: Any and every profession which is knowledge based is vulnerable to this type of exporting.
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Everything in the Universe sucks: It's the law!
Too much information is bad for some patients. For example there are books available to doctors which compile every medication available and what the results of the clinical trials were. Every result - from effect on symptoms to side-effects to placebo effects (the side-effects that the people given placebos developed) - in brutal detail. If you prescribe Foo(tm) for illness bar, and the patient looks and sees that a patient given a placebo Foo had a heart attack, what do you think they will do? The rare individual will say "Wow. Weird." and understand that Foo is perfectly safe. But the majority will run away screaming to another doctor and refuse treatment with Foo for the rest of their lives.
Everyone thinks that doctors are just data libraries and that anyone with the same information could do just as good a job. Not true. Most of the job is interpretation. That is why different doctors make different diagnoses. The doctors most respected by other doctors are those that consistently "see" things that others don't ("Well this looks like bar at first, but it reminds me of baz for some reason. Let's do some tests to check that out.").
Serve Gonk.
It's not at all uncommon for people to stop taking prescription drugs when they feel better. And to give the rest to friends or family members with similar symptoms, despite the fact that doing both of these can be very dangerous. Why? Because people "know what they're doing". If someone has the same symptoms as you, they must have the same illness, right?
Isn't it common for medical students, at the very start, to go looking for zebras when they hear hoofbeats? Well when you hear hoofbeats, chances are it just a horse, and doctors know that. But many times the students at the start go looking for odd diseases. All we need is for normal people to type "headache, sneezing, aches, tiredness" into a computer and see things like Bubonic Plague, Ebola, Haunta Virus, and other such things. Nothing spreads panic and fear like a little knowledge.
As the saying goes: "A little knowledge can be a dangerous thing"
Comment forecast: Bits of genius surrounded by a sea of mediocrity.
As someone who will be graduating medical school in about a year, I can point out what my biggest hope/fear is with this kind of software -- and its not what readers have been suggesting in this thread up until now.
... time management. Most patients don't seem to realize what ridiculous time constraints we're on -- the massive patient load we need to see just to tread water and keep the HMOs/hospital adminstrators/etc happy.
The thing that makes me both intensely interested and worried about this method of diagnosis is
One of the most important parts of our training is learning how to balance diagnostic thoroughness with constant efficiency, and we learn all sorts of methods to do this. Any system like this software could seriously disrupt our breakneck pace, and its value is entirely unproven. Since the healthcare system is already stretched to its breaking point in the US, I worry that any changes that lower efficiency will send us into a tailspin.
Conversely, the idea that we could add such a powerful new tool to our arsenal seems like a dream come true. I would be thrilled to spend more time with each patient, to have a system that makes our diagnoses even more accurate and more focused, and to always be able to encompass the latest literature's suggestions and results.
The big hurdle to overcome in testing and implementing a system like this is getting the necessary volunteers. I'm not sure that I would be comfortable (when I'm about $300,000 in debt from medical school) being trained in such an unproven method of diagnostics. I suspect that most other medical students/schools, when faced with the uncertainty of the situation, would be equally reluctant to commit their money and their years to take such a risk when practicing modern medicine is already such an uncertain proposition.
I really take offense to the people here who state that "The AMA are just a bunch of money grubbing..." whatever. These people have no clue as to how much the average doctor gets paid these days.
As a resident ~ $37,000 a year for ~100 to 110 hours of work per week.
As a Primary care physician ~$180,000 for ~80 to 100 hours a week (of course this figure really depends on how much you want to work)
As a specialist ~ it really depends. Usually not above $300,000 a year
And that's after 4 years of college, 4 years of medical school, 3 years of residency, 3 years of fellowship and for some a couple of years post fellowship. And, remember that most people are in the hole ~$180,000 - $200,000 (including interest) after medical school.
So, in my particular case I'll be seeing $300,000 a year after 12 years of getting under mimimum wage. If anyone wanted to cut it more than that, well, then bye, bye medicine. You can go see the baseball players that get $5,000,000 a year (and still want to strike for more money) hooked up with a medical database.
That said, I think that the database is a good idea. Technology is our friend -- already my colleagues and I use software for the Palm platform which finds obscure drug interactions. The PKC is an extension of this kind of functionality. Change is good.
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But I have to point out that this is another fine example of the cult of higher education at work:
"But, according to Cross, the neurologist who originally diagnosed the case as an REM sleep disorder had a very different reaction to the use of the software. When the plumber and his wife handed that doctor the PKC printouts, he shuffled them, left the room, and, Cross says, "returned with a very hostile, angry disposition." Viewing the results as computer-generated quackery, he refused to back down from his original diagnosis. "
This is a fine example of priest-like behavior from our friend, the university graduate. The Holy Word comes only from the university, and must not be questioned. It is handed down from pries to cult member, who will become the next priest.
Do not question the priest; he doesn't want you to know everything he knows is a facade, and that he doesn't really know what's going on. It's a power play, he doesn't want to feel like he wasted 10 years at university for nothing.
It's better to perpetuate the myth of university education than to come clean.
To put this into a perspective the /. crowd will understand (no, it doesn't involve first posting or Natalie Portman and hot grits). What doctors do today is the equivalent of reading a programming language reference manual and then coding in that language using only memory and using compiler messages to work out when you get something right. Sure, after you have been programming in a language for 10 years you could do this but you'll still need to refer to the reference manuals occasionally when venturing into unfamiliar territory.
Using computers to do this is much more effective than trying to write programs that do the diagnosis. Computers can't reason, humans can (well most can ... ok some). To quote Dijkstra, "The question of whether a computer can think is no more interesting than the question of whether a submarine can swim."
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"IAAI (I am an idiot)"
You certainly are. What were seeing here is stereotypical attacks on doctors, due to the strict way the medical profession and services are dealt with.
Imagine for a moment that there was a database created that contained almost every single set of expressions and solutions for (insert your programming language here).
So instead of having software companies and hordes or programmers, companies can get their own software by feeding in to the requirements to this database, and it spits out the necessary code.
Now imagine the outrage you would have amongst programmers and software houses around the world, since they are now effectively redundant.
Just because some doctors are highly paid, and have strict controls on the medical services, doesn't mean their views and outrage should be held contemptable, until you have fully assessed the pro's and cons. You bet your bottom dollar slashdot would give programmers the benefit of the doubt in above situation, so why can't we give doctors some leeway and a reduction of ad-hominem attacks here?
Slashbots: Jealous, selfish and unreasonable. Get over yourself.
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It's interesting that most of the doctors responding are doing so much emothion and so little logic (and this one didn't even read the article carefully). Let's go through the rebuttal...
:). Despite the stereotype, many IT professionals (such as myself) are fit, healthy individuals who exercise regularly, drink plenty of water, and enjoy a proper diet. And those of us who stayed out of the dot-bomb industries (or got out early enough) can afford the best cardiologists money can buy, and don't have to whine and scream about it.
1) "Nothing Beats Pure Data" - Nobody that I'm aware of has posited this idea in the discussion, because it's absurd. Pure data on its own is fairly useless. It's the interpretation of the data that is important. What this tool seems to be designed to do is to make sure that the data is thoroughly collected and at least adequately corrolated against certain rules.
2) "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 we wouldn't, but I would feel much better knowing that her condition was subjected to a thorough and complete analysis; this tool could probably assist in that. I'm sure my mom would agree - she's an experienced RN and regularly has to catch and help fix doctor's mistakes. This is not to say that doctors are incompetent (though some clearly are), but that they are human and fallible just like the rest of us.
3) "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." - This is an hysterical, stupid, cheap shot at eduacted technology professionals not even worthy of a response. But in the intrests of being thorough, I'm giving one anyway
4) "Wait, wait you have to fill out the database.. the computer is better, your HMO says so..." - I don't think it was ever suggested that this tool be used in situations where seconds count.
5) "FIX HEALTHCARE by fixing the mundane problems: [blah blah blah]" - Yes, insurance and tort reform are well-known needs in many industries, including healthacre (at least until they allow us to start hunting lawyers to thin out the herd, prevent overgrazing and starvation, protect the species, etc.). Money? Yeah, let's just throw even more than the current 1/7th of our GNP (at least here in the US) down this rathole...
6) "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." Dude, you're not exactly helping your cause here. And most well-adjusted people don't go around bragging about destroying their families and their lives in pursuit of their careers. I would think that something that could potentially reduce the amount of work that doctors do would improve their families and their lives (unless said doctors are egotistical assholes and their families are better off not having them around).
7) "I hate hearing anecdotal bullshit that this database helped solve my rare sleep disorder that only 1 person in 5 million has. GREAT!" - I bet that girl who almost died would have been thrilled. But that's just me. For all I know she's a masochist.
8) Does it make healthcare faster, more accurate and above all *CHEAPER*.... doubt it.. - And if your reaction of unwarranted hysteria, fear, suspicion, hatred, and loathing of any new tool that may challenge your fragile ego is representitive of your profession, then we'll probably never know. It's a tool to assist in diagnostics. It doesn't trivialize the doctor's contribution to medicine. It doesn't remove you from the process. It doesn't steal your lunch out of the refridgerator. It doesn't make your dick smaller. It's here to help you. Give it an honest before you dismiss it.
And finally, my $.02. I'm a very healthy person (no ongoing medical issues other than bad eyesight). My limited experience with doctors has been mixed. My impression is that there is a bit of a correlation between doctors and experienced IT professionals: they both have to perform complex analysis with limited and often incomplete and inaccurate data. Some approach problems in a thorough and disciplined manner, some are highly intuitive (gifted, or just plain lucky), some are sloppy, rushed, and prone to snap judgements (that no one dare question), and some simply don't give a shit. Unfortunately, most that I've seen seem to fall in the last two categories. Maybe I'm just unlucky, but I seriously doubt it.
Personally, I think the problems are mainly systemic - doctors are spending far too much time performing tasks better suited to nurses and nurse practitioners; they get burned out because they can't do their jobs properly, and thus the downward spiral begins. Most HMOs would be better managed by any four monkeys from our local zoo (of course, the San Diego Zoo has some exceptional monkeys, but still). The number of improvements that could be applied to the health care industry (and schools and universities feeding it) can probably only be expressed using some highly esoteric mathematics. But if something reasonable shows up, you should probably give it a shot.
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6. Find increasing numbers of patients have antibiotic resistent infection as a result of widespread routine over-prescription of antibiotics.
rant
Making a diagnosis is usually following a decision based on observed symptoms. Expert systems excel at this, but you still need, for the time being, someone with enough skill to correctly find and identify the symptoms. That's where the human skill is needed, but studies in the 1980's showed that when fed symptoms, computers were better at identifying more uncommon problems.
A lot of medical school is learning to act like a doctor: to dog the interns and to be just appropriately arrogant with the patients, secretaries, etc. The same can probably be said for most other professional degrees - a large amount is socialization. So of course the MDs don't like it. It doesn't invalidate their actual medical knowledge, but does risk pointing out how much is theater.
Beta is broken and the link to classic doesn't work. Stop wasting our time or there won't be anybody left here.
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.
This is where the AMA's arguments about keeping the highest possible professional standards start to get them into trouble.
The public's expectations are built up to the point where MDs are practically worshipped.
Then, one of them makes a mistake (hey, it can happen, people are fallible).
Compounding the problem is that the colleagues on the state accreditation boards will close ranks and do everything possible to prevent a fellow MD from losing their professional reputation. In the worst abuses, the MD will have to go to a different state. [I won't tell you how angry I get about other problems, such as doctors with strange sexual hangups abusing their patients.]
It's little wonder that you find more and more work being done by P.A.s (Physician Assistants) and by RNs, who can do 90% of the same work but get paid only about 20% of the salary as an MD. [Kind of like a good legal secretary can do 90% of the lawyer's job for for 20% of the salary.]
Not to rag on all doctors. There are many good ones who take their responsibilities seriously, who know what's going on, who care about their patients and take the time to explain medical conditions to them. And, it takes a lot of endurance to get malpractice insurance and to fill out all the fscking forms the HMOs require for payment. It's just that the current medical establishment has built up a system that is broken.
For example, I never see anything like a consumer reports rating of doctors available to the general public. Ratings are avaiable to other physicians or only gotten by word of mouth.
For starters, I wouldn't mind seeing the class rank, GPA and school where my physician got his or her degree.
What I'd really like to know is: which physicians' are most frequently or least frequently used by their colleagues (including the RNs)?
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