[zefalt]

I don't know why some people on hackernews have such a bias for deriding physicians. If you don't like the care you get, go somewhere else and get another opinion. Of course the bell curve of probabilities exist in medicine...just like it exists in every other field or more broadly the universe.

This article is about the potential downsides of radical transparency...not just the default level of transparency. For many years/decades, records have always been available to patients upon request. This new immediate availability is something entirely different and brings about another set of problems.

Imagine having 15 minutes to see a patient, document on the chart, order labs/imaging, and provide disposition to a patient. Then, they have free reign to message you regarding some irrelevant piece of data in the chart or labwork that you need to respond to. Too much patient access does have problems, and I can provide you some mundane examples. I documented about an excoriation in one of my charts, and the patient calls back complaining that I called them a skin picker and wanted me to change my documentation. If you google excoriation, you do not get the medical definition or understanding of the word but a link to excoriation disorder. Another patient wonders why their eosinophil percentage is 0.1% above the upper limit of normal.

To me, the chart serves more as a note to colleagues who have the relevant understanding to piece together what happened during the visit. Giving patients immediate access to their charts will have very little benefit in my opinion given the high prevalence of EMRs and easy access to charts for anyone that actually cares.

To say that most doctors are terrible is one of the worst takes I've read. Most doctors are probably average, and their average medical knowledge is likely a standard deviation or two above the average patient.

The whole death by medical error thing is also of uncertain evidence. See: https://www.mcgill.ca/oss/article/critical-thinking-health/m...

[areoform]

    > The whole death by medical error thing is also of uncertain evidence. See: https://www.mcgill.ca/oss/article/critical-thinking-health/m...

I've read the McGill article before; what it fails to mention is that the analysis has been performed multiple times by multiple parties and the results have repeatedly converged on the same point: somewhere between tens of thousands of human beings to one hundred fifty thousand human beings (at the very least) have their lives cut short because someone messed up. These statistics are for the US alone. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070928/ https://effectivehealthcare.ahrq.gov/products/diagnostic-err...

And more often than not, their colleagues who spot the mistake don't report it, a fact that's neatly labelled as a "disclosure gap" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793994/

It is perfectly reasonable to argue that the estimates are wrong. In that case, the solution is quite simple. Record data on misdiagnosis and physician failure, but that's a solution that the AMA has opposed (while talking about the ethical duty of disclosing medical error, of course).

    > The AMA and the American Hospital Association vehemently opposed an attempt by President Bill Clinton to create a mandatory reporting system for serious errors. The groups launched a multimillion-dollar advertising campaign that said mandatory reporting would drive medical errors underground. From 2000 to 2002, they spent $81 million on lobbying efforts, according to campaign statistics collected by the Center for Responsive Politics.
    
   > Mandatory reporting was dead on arrival.

https://www.kxan.com/investigations/a-long-time-before-congr...

There is no other civilian profession where death at this wide a scale is acceptable. Or, is taken as a matter of due course.

There is no other civilian profession where this has been the norm for centuries.

Every time a plane crashes, we perform investigations, improve, and fix. Every time there's a loss of crew on a human-rated spacecraft (or a loss of an autonomous vehicle), there's an investigation to fix what happened. Every time a bridge or a building collapses due to structural deficiencies, there's an effort to study what went wrong and how to fix it.

These reflexive investigations are pervasive everywhere. Except medicine.

Every single time the veil has been lifted, there has been something deeply ugly underneath. For example, doctors are the reason why so many women end up falling prey to Goop, because medical professionals fail — at a systemic level — to take their concerns seriously. The problem exists everywhere from the GP level to surgery,

    > While associations were consistent across most subgroups, patient sex significantly modified this association, with worse outcomes for female patients treated by male surgeons (compared with female patients treated by female surgeons: aOR, 1.15; 95% CI, 1.10-1.20) but not male patients treated by female surgeons (compared with male patients treated by male surgeons: aOR, 0.99; 95% CI, 0.95-1.03) (P for interaction = .004).

https://www.researchgate.net/profile/Angela-Jerath/publicati...

For non-technical readers,

https://www.health.harvard.edu/blog/women-and-pain-dispariti...

https://healthjournalism.org/blog/2018/11/women-more-often-m...

https://www.smithsonianmag.com/smart-news/western-medicines-...

https://www.nytimes.com/2022/03/28/well/live/gaslighting-doc...

The problem is fractal and replicates across societal out-groups (and to a lesser degree for in-groups). For example, doctors saying things like, "black people have thicker skins,"

https://www.aamc.org/news-insights/how-we-fail-black-patient...

https://batten.virginia.edu/about/news/black-americans-are-s...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

Pick your out-group for a given society and you'll find systemic medical failure. The in-group is rarely much better off; they're still subject to the same capriciousness, merely to a lesser degree. See: the systemic failure of doctors to diagnose heart disease, https://www.bhf.org.uk/informationsupport/heart-matters-maga...

    > It looked at NHS data over nine years, which involved 243 NHS hospitals, and about 600,000 heart attack cases. Around one third, 198,534 patients, were initially misdiagnosed.

If you're on the receiving end of care, it becomes very clear, very quickly that there's something wrong with the picture.

When a field is this deficient, radical reform is necessary to save lives.

[zefalt]

> I welcome the day artificial intelligence makes most doctors obsolete.

Guess you deleted this part.

When this becomes reality, let me know. If a better system existed given the current set of parameters, I believe it would have come into existence. Give me any medical condition, and I would take my chances in the US healthcare system over any other option.

My argument is not that physicians are error proof or that they don't cause harm through errors. It is to refute your claim that "most doctors are terrible".

Your AI system would only be accurate at diagnosis if it has all the pertinent data and unlimited resources. Patients often provide an unclear history, their symptoms are not common for their underlying condition, and there are not enough resources to do a full workup for every complaint.

Regarding your second link regarding misdiagnosis in emergency rooms, you just need to look at the PERC rule or the HEART score that ED physicians use for evaluating for pulmonary embolus or acute coronary syndrome to get a somewhat clearer picture of the deviation. Even with scores of zero, there will be a substantial amount of missed diagnoses. Not everyone who goes to the emergency room is going get a full cardiac evaluation or a CT angiogram of the chest if their symptoms don't suggest the illness. There are not enough resources to do this.

https://www.mdcalc.com/calc/347/perc-rule-pulmonary-embolism

https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-e...

Of course other civilian professions don't have death rates this high. They don't deal with dying people every day. Again, I'm not claiming that the medical field is perfect as it is. I just believe you are mischaracterizing data for which there are many intricacies.

You are also throwing out a lot of strawmen regarding race and sex which bears little relevance to your initial claim.

Regarding your final piece of data about the amount of misdiagnosed heart attack cases, look at the following sentence in the same article

> It estimated that, if heart attack patients were correctly diagnosed initially then – over the decade of study – over 250 deaths per year might have been prevented.

250 * 9 = 2250 preventable deaths over a 9 year period.

Far less alarming than the data you present of 198,534 missed diagnoses.

[bullen]

The reason people are skeptical about doctors (both philosophical and medical) is that they make their own market.

In simpler terms: the sicker you are, the more they earn.

Just like computer consultants earn more the worse they deliver, because if they built the perfect system, they would no longer be needed.

[zefalt]

This is simply not true.

Healthcare still follows the basic supply/demand curve, and demand is at record levels. It's just as capitalist as much of the rest of the economy. State regulations regarding professional licensure do serve as a limiting factor for supply, but many fields also have similar licensing requirements before being able to practice.

Most doctors do not make more the sicker you are. The majority are salaried though some organizations do provide extra depending on volume seen or RVUs. They also have very little say on the volume as it is mostly decided by managers.

Some examples:

  - patients with falls/trauma

  - millions of obese individuals seeking treatment with GLP-1 receptor agonists for weight loss

  - cancer

Certainly, these individuals were not made sick just so the healthcare industry could make a profit. Also, I don't believe there will ever be a perfect system.

[areoform]

    > Guess you deleted this part.

It detracted from the overall point. But yes, I do look forward to the day artificial intelligence mostly replaces humans in this industry. I think the benefits are self-evident.

    > If a better system existed given the current set of parameters, I believe it would have come into existence.

One of these "parameters," as your call them, includes the AMA and doctors restricting the number of new doctors who can be trained in the past https://usatoday30.usatoday.com/news/health/2005-03-02-docto... , actively fighting against allowing Nurse Practitioners and other trained providers from providing routine services that would lessen the requirement of doctors https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope... , fighting against collection of misdiagnosis data (as mentioned above), lobbying against banning pharmaceutical companies from giving money or gifts to doctors (in fact, the majority of doctors say that accepting these gifts is OK, despite research repeatedly showing that these nudges change behavior and lead to practises like overprescribing opiates — https://www.statnews.com/2020/12/04/drug-companies-payments-... ), refusing to adopt practises that reduce mortality (see: the checklist example from above) and on and on.

This trend is not unique to the US. Similar efforts exist everywhere doctors do. The profession was associated with status in the past (and still is). Doctors are fighting and have fought tooth and nail to preserve the benefits they accrue from this status.

As you're a physician, I think you should take a moment to put yourself in the shoes of a third party. Imagine there's a Profession X. Members of this Profession X, and organizations that represent Profession X, have fought to make outcomes of people who interact with them worse in measurable ways. What would you think if a member of Profession X made an equivalent claim? Would you give it equal weight?

    > Your AI system would only be accurate at diagnosis if it has all the pertinent data and unlimited resources

No, it doesn't need unlimited resources. Just better sensors and more data. We'll get there sooner or later. It's an inevitability. There are too many smart people working towards this end because of the reasons outlined above.

    > Patients often provide an unclear history, their symptoms are not common for their underlying condition, and there are not enough resources to do a full workup for every complaint.

Medicine is the only profession I know of where its practitioners fight against gathering more data points. The argument goes that the more you look, the more you find and that's bad etc.

If you take some time to reflect on it, these fairly common claims make no sense. The more data we collect, the more data we have to understand what the true distribution of human biology looks like. The more data we have, the more information we can gather to better understand how to treat when needed, and distinguish between things that are critical and aren't.

As to the claim that there aren't "enough resources," the truth is that we can create the resources. Lateral flow tests, for example, have dropped significantly in price and what we can test with them has greatly increased. We can also automate how these tests are read — an effort I've been peripherally involved in. We can build labs on chips and mass produce the silicon, https://en.wikipedia.org/wiki/Lab-on-a-chip . We can take commodity sensors and use better algorithms to detect subtle things — for example, using IMUs on a patient's bed in an ER setting as a type of ballistocardiograph to passively monitor their heart function.

We have the technology to do all of this and more. We also have the capability to invent new things that do more. But we choose not to. This status quo is a choice.

    > Regarding your second link regarding misdiagnosis in emergency rooms, you just need to look at the PERC rule or the HEART score that ED physicians use for evaluating for pulmonary embolus or acute coronary syndrome to get a somewhat clearer picture of the deviation. Even with scores of zero, there will be a substantial amount of missed diagnoses. Not everyone who goes to the emergency room is going get a full cardiac evaluation or a CT angiogram of the chest if their symptoms don't suggest the illness. There are not enough resources to do this.
    
    > 250 * 9 = 2250 preventable deaths over a 9 year period.

    > Far less alarming than the data you present of 198,534 missed diagnoses.

With all due respect, I feel like you've validated my argument in these paragraphs. Medicine is a safety critical industry that doesn't behave like it's a safety critical industry.

If a process had a 33% rate of failure, for any other safety critical system, there would be a sustained effort to research and develop a better alternative.

Perhaps we need better sensors — maybe we could embed a dozen or so IMUs around the patient and measure the forces to see the performance of their heart https://journals.biologists.com/jeb/article/225/10/jeb243872.... Perhaps we need to expand the metrics we look at. Perhaps the way things are measured at the bedside should be changed. There are many things we can do to reduce the absurdly high process failure rate of 33%.

Detecting and treating disease early leads to better outcomes. 198k people were denied this better outcome.

    > 250 * 9 = 2250 preventable deaths over a 9 year period.

The data is for the UK. As the population is roughly a fifth of that of the US, let's do some rough math and multiply that number by 4 (instead of 5, to be conservative). That's 1,000 lives per year, or a death every 8 hours.

What does this rate look like when compared to other safety critical systems? The one I'm most familiar with is aerospace. Within civilian aerospace, parts are rated to 1 failure in 1 billion hours of operation. Or, more broadly, safety critical systems are designed to hit the goal of 1 death per 1 billion hours. https://dl.acm.org/doi/10.1145/332051.332078

    > Of course other civilian professions don't have death rates this high. They don't deal with dying people every day. Again, I'm not claiming that the medical field is perfect as it is. I just believe you are mischaracterizing data for which there are many intricacies.

All of the statistics I've given were for people killed via mistake. These are people who would have otherwise lived. They died because a medical professional made a mistake. That's an important distinction.

Furthermore, although medicine deals with the sick and the dying, it's not the only industry where a very small mistake could equal death.

Small mistakes, like a bolt not being tightened correctly, on an airplane can lead to catastrophic failure (and have!). And yet, an upward of 2.3 billion person trips occur safely every year via airplanes. Between 2012 and 2021, in seven of these ten years, no airliners crashed. No catastrophic failures occurred.

By contrast, the total number of ER visits is 131.3 million. As I've stated, tens of thousands of these visits lead to death for the patient via error. Per year.

Why are these fields so different?

I believe that the difference is in the margins. One has a culture of excellence. The other has the culture of shrugging. The smallest change in outcome probabilities adds up for processes. Improving a process by 0.5% to 0.05% per case doesn't seem like much, but it adds up.

Interestingly enough, great doctors recognize this. The very best doctors fight in these margins,

    > “Let’s look at the numbers,” he said to me, ignoring Janelle. He went to a little blackboard he had on the wall. It appeared to be well used. “A person’s daily risk of getting a bad lung illness with CF is 0.5 per cent.” He wrote the number down. Janelle rolled her eyes. She began tapping her foot. “The daily risk of getting a bad lung illness with CF plus treatment is 0.05 per cent,” he went on, and he wrote that number down. “So when you experiment you’re looking at the difference between a 99.95-per-cent chance of staying well and a 99.5-per-cent chance of staying well. Seems hardly any difference, right? On any given day, you have basically a one-hundred-per-cent chance of being well. But”—he paused and took a step toward me—“it is a big difference.” He chalked out the calculations. “Sum it up over a year, and it is the difference between an eighty-three-per-cent chance of making it through 2004 without getting sick and only a sixteen-per-cent chance.”

From the cystic fibrosis piece.

Medicine has failed to broadly adopt this culture.

> You are also throwing out a lot of strawmen regarding race and sex which bears little relevance to your initial claim.

They aren't treated seriously by their doctors. That leads to poor outcomes.

Ideally, medicine should take every possible cause of process failure seriously, especially if that cause is observed to be this common.

[what-the-grump]

A small piece of stone fell off the facade of a building in NYC, killed someone like 50 years ago, now we spend billions up-keeping buildings every year. How the hell is anything in the medical industry not held to at least that standard.

And then people wonder why mask mandates don’t work, and there is a mistrust of vaccines and doctors.