Slashdot Mirror
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.
Is that people tend to live the symtoms that their medical complaint suggests. That's why you have to run blind and double blind tests, to weed out people who unconciously fake what they know to be the symptoms.
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.]
OS/2 - because choice is a terrible thing to waste.
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.
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.
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.
As the article points out clearly and several times, doctors are (usually) humans. This means they have personality traits that affect they way they accomplish their work.
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.
Most doctor visits that my kids and I have been to follow a rather simple algorithm:
1. Get swabs of patient mouth and ass
2. Perscribe patient antibiotics and
Codene.
3. Politely send patient away
4. Send swabs to lab
5. Play golf
Table-ized A.I.
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.
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 actually frequently worse than this. (I work currently with 8 doctors, four pediatricians, three internists, and one FP. I've worked with.... Problem two dozen over the last few years. What I say doesn't necessarily reflect on the ones I currently work with.)
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.
Jesus was all right but his disciples were thick and ordinary. -John Lennon
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.
Comment removed based on user account deletion
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.
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.
Help save the critically endangered Blue Iguana