[ipnon]

Similarly the main calculator used in the US to calculate 10-year risk of cardiovascular incident literally cannot compute scores for people under 40.[0] There are two consequences to this. The first is that if you are under 40 you will never encounter a physician who believes you are at risk of heart attack or stroke, even though over 100,000 Americans under 40 will experience such an incident each year. The second is that even if you get a heart attack or stroke due to their negligence they will never be liable because that calculator is considered the standard of care in malpractice law!

Governing bodies write these guidelines that act like programs, and your local doctor is the interpreter.[1] When was the last time you found a bug that could be attributed to the interpreter rather than the programmer?

[0] https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate...

[1] It’s worth considering what medical schools, emergency rooms, and malpractice lawyers are analogous to in this metaphor.

[lazyasciiart]

I had a heart attack at 35, despite not really having other risks. A sibling who had a heart attack is the biggest risk factor, but later my sister did not qualify for a study on heart attack risk because she was only 39.

My ER notes literally say “can’t be a heart attack but that’s what it looks like, so we’ll treat it as one for now”, which is a little unnerving.

[rscho]

> is a little unnerving

Why so? You were lucky! You had a low probability for the diagnosis, but the doc made the right decision. That's to be celebrated.

> did not qualify for a study on heart attack risk because she was only 39.

Criteria for studies are designed to test a specific hypothesis. There are many possible reasons why your sister was not eligible, and not all of them bad.

[yapyap]

> Why so? You were lucky! You had a low probability for the diagnosis, but the doc made the right decision. That's to be celebrated

cause they still said “can’t”

[rscho]

If this doc meant it in the literal sense of 'can't', why go through with the workup, then? This is IMO evidence that the doc meant 'very unlikely, but let's check'. I agree words are important, but still the right decision was made and that's cool.

[rendaw]

I think the issue is "can't" is present tense, and the conclusion _after_ treating. In otherwords, they still think it isn't a heart attack.

[lazyasciiart]

Yes. It is unnerving to see how strong a role “luck” played in getting me treated.

She did not qualify because she was not have any risk factors, defined as being over 40, overweight, high cholesterol, or metabolic disorder. If she had been 41 she would have qualified.

[rscho]

> if you are under 40 you will never encounter a physician who believes you are at risk of heart attack or stroke

This is absolutely not true. Only someone knowing nothing about healthcare could come to such a conclusion.

> guidelines that act like programs, and your local doctor is the interpreter.

Such reframing is irrational. You are reframing scientific facts into an almost completely empirical context. It doesn't work like that at all.

[yieldcrv]

Then the entire medical industry is failing at communicating that

The relatability of OP’s shared experience has us wanting to replace most medical professionals with genAI language models as soon as the regulations allow

[rscho]

> replace most medical professionals with genAI language models as soon as the regulations allow

Understandable, I guess. But not feasible now, nor in the foreseeable future. The problem is not even "AI" performance. The real problem is that the useful data isn't available to machines, because it's mostly acquired through meeting patients in person. It's gonna take lots of money to make machines that can compensate for that.

[yieldcrv]

Multimodal language models have already been good at accepting imaging input and noticing things that professionals overlook

I don't see how a meeting patient in person requirement is an issue. They can listen to the patient, have a context window large enough to analyze their medical history and environmental factors, look at charts, and diagnostics of tissues

and still have a much greater EQ, ability to affirm, and have empathy more than the dismissive high IQ doctor ever will

humans are going to chose that because smart humans don't have those attributes

[rscho]

It is said that "90% of diagnosis is made on patient history". That's the whole problem for machines. We'll need machines able to converse and integrate patient appearance, behaviour etc. as well as humans, and reliably derive the appropriate conclusions from that before we get efficient medical AI. We'll see how fast progress can be made, but from what I see from chatGPT and the like, I seriously doubt the current AI wave will achieve acceptable results in real, everyday medicine. IMO, procedural medicine where lots of multimodal info is always available and the environment relatively fixed, such as (simple) surgery, is a better candidate for (reliable) automation in the near term. Something like prosthetic orthopedics, maybe ?

[mquander]

Isn't it dramatically easier to provide more useful history to machines?

If I'm providing history to a doctor I am pretty much trying to jam the history into a two minute explanation, and they are trying to remember our previous interactions based on short summarized notes that they made without my help.

If I'm providing history to a machine I can take my time to tell the machine as much as I want every time. I can send it whole spreadsheets of symptom logging and tell it my whole life story.

[JumpCrisscross]

> We'll need machines able to converse and integrate patient appearance, behaviour etc. as well as humans, and reliably derive the appropriate conclusions from that before we get efficient medical AI

This presupposes the problem of medical records having been solved.

[yieldcrv]

relevant today

https://www.nytimes.com/2024/11/17/health/chatgpt-ai-doctors...

[mannykannot]

> Then the entire medical industry is failing at communicating that.

Rebutting hypobolic extrapolations from literally one datum is still not something that the entire medical industry - or just my PCP and cardiologist, for that matter - should be prioritizing (unless they have a patient doing just that), even if the prevalence of such claims has increased over the last decade or so.

The afforementioned professionals had no reticence in taking my pre-40 symptoms of heart disease seriously, even though I did not present any of the correlates frequently associated with it.

[yieldcrv]

many demographics have well studied issues of being validated at all

It’s not hyperbolic, it’s a relatable shared experience, which are the words I used for a reason. as its not a single datum, while also avoids any attempt to quantify it at all

[mannykannot]

Ipnon's claim was explicitly stated to follow from just one datum, thus:

>The main calculator used in the US to calculate 10-year risk of cardiovascular incident literally cannot compute scores for people under 40. There are two consequences to this....

And the first claim:

> If you are under 40 you will never encounter a physician who believes you are at risk of heart attack or stroke.

If that's not hyperbolic, where's your evidence that it even just close to being the case?

[yieldcrv]

yes, the word “never” is hyperbolic, while the words “relatable shared experience” are not

moving on

[refurb]

> The second is that even if you get a heart attack or stroke due to their negligence they will never be liable because that calculator is considered the standard of care in malpractice law!

I think you misunderstand how the risk calculator is used.

Physicians are still expected to use their clinical judgement and information from patient conversation to determine the appropriate intervention.

If a 30 year old patient comes in with high blood pressure, but no existing cardiovascular disease (so the calculator could be used except for the age), it would clearly be malpractice for the doctor to say "sorry! you're too young to use the calculator so I'm going to give you a stamp of approval for health!"

[hombre_fatal]

Out of curiosity, how is a physician negligent if decades of exposure to hypertension/LDL/smoking/diabetes (the variables on that calculator) give you a heart attack or stroke?

By the time you're put on a statin, for example, you've already had decades of exposure due to your lifestyle.

Also, I don't believe the claim that physicians don't care about CVD risk in patients <40yo including high blood pressure and high cholesterol.

[zamadatix]

Flip the issue to something less polarizing and it should appear this is a very separate scenario from what GP is talking about (even if perhaps you still don't agree it should be malpractice for some reason):

1) You go in after feeling confused and have a headache after falling from a skateboard with no helmet. The ER sends you home not having checked anything or any notes to watch out for because they think you're too young to have problems from a fall (despite many young people having problems after a fall each year). At home you die because of a brain bleed.

vs.

2) You go in after feeling confused and have a headache after falling from a skateboard with no helmet. The ER runs some tests, sees the problem, and prescribes the best course of treatment given this information. Despite this you still die or have lasting effects on your brain.

Despite the doctors not fully remedying your problem in both situations only situation 1 involves negligence for a malpractice claim because the problem isn't the outcome, it's the quality of treatment not meeting the minimum levels. Flip the scenario specifics back and what GP is saying is that it isn't considered negligence to say "you're under 40, you're fine, go home" instead of "you could seriously be having a problem. We should put you on a statin and talk over the risks/symptoms of a heart attack" because the standard of care (sort of one measurement for what's a negligent treatment action) says the calculator defines the appropriate treatment and the calculator doesn't even work for those <40. What GP is not implying is doctors are negligent just because you still had a heart attack anyways.

[adastra22]

Any ER would check for a concussion in that circumstance, as I can attest from experience.

[zamadatix]

Almost certainly. That's why not doing so is used as a clear example of malpractice and negligence - the standard of care says to check for those kinds of issues given the situation and that's what nearly every doctor will therefore do.

[adastra22]

Concussion isn’t age related though, so the circumstance isn’t comparable.

[rcxdude]

Falling certainly carries more health risks as you're older, but young people aren't immune, and the same is true for heart attacks. That's the point of the analogy. The skater concussion scenario is obviously ridiculous to highlight how the heart attack scenario is also ridiculous.

[zamadatix]

(separating this out)

I agree with you heavily here: "Also, I don't believe the claim that physicians don't care about CVD risk in patients <40yo including high blood pressure and high cholesterol."

Seems odd over all. My physician, unprompted, wanted to put me on a statin when I was very healthy and in my early 30s just to lower my risk as my cholesterol numbers were trending up at the time. Whether or not this calculator actually works for those under 40, physicians certainly still prescribe statins, evaluate heart health risks, and communicate on the dangers of poor heart health to individuals all the time anyways.

[hgomersall]

Almost all ailments can be mitigated to some extent by lifestyle choices. Is anyone that doesn't make the best possible choices for the particular ailment responsible for their situation?

[hombre_fatal]

The question in this context is whether they are less responsible for their lifestyle choices than their physician.

We're talking about the variables in the calculator: blood pressure, cholesterol, smoking, and diabetes.

Which one of those is the physician more responsible for than the patient?

[hansvm]

What happens if the doctor says the tool is likely wrong and gives a reasonable (according to their peers) reason why? Does the court blindly accept some algorithm over hard-earned experience?

[rscho]

No, typically a court would summon an expert on the topic for testimony. Such an expert, as most any doc, would understand the limits of guidelines/calculators/etc. and judge accordingly. A typical clinical presentation resulting in a missed diagnosis would not fly at all under this process. But an atypical presentation in a very low probability context (young patient, no risk factors) might get through. Also, contrary to popular belief docs absolutely do not cover for each other in court.

[thrw42A8N]

> When was the last time you found a bug that could be attributed to the interpreter rather than the programmer?

On the other hand, when was the last time you used a custom one-off interpreter?