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Comment by smitherfield | Hacker News Reader

The "Yelp for drugs" pull quote is missing the second part: "with MD star ratings." i.e. only medical doctors would be able to review/rate. Which IMO is a reasonable and interesting idea worth exploring.

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Imagine the little perverse incentives that companies offer to leave a Yelp rating (rate us and get some free breadsticks! or whatever), but with pharmaceuticals (leave us a five star rating and get a new car, or a new medical device, or whatever). That sounds really, really bad, and it would require a lot of regulation and oversight to make sure ratings weren't being manipulated. I suspect those two things will be in short supply in the incoming administration.

Doctors, like lawyers, accountants, pharmacists and so on have professional associations with existing and quite strict ethics regulations about this sort of thing.

That hasn't stopped "buying expensive stuff for doctors to sway them" from being a thing, even now!

http://www.wsj.com/articles/SB100014241278873246951045784145...

I didn't say the existing rules were perfect, I'm just noting they exist. You can also say that a "Yelp for drugs" wouldn't change the existing incentives.

FWIW, the doctors I know take ethics very seriously; they take great pains not to be seen as accepting gifts, they treat pharma company claims with a great deal of reasonable skepticism, they always prefer non-drug and OTC treatment to prescriptions, and generics to branded drugs. A few bad apples do not spoil the tree.

Then why do we regularly see stories about doctors engaging in epically fraudulent billing practices, taking illegal kickbacks from drug manufacturers, prescribing unneeded drugs and so on? Have you heard of the opiate crisis? Because if so you cannot but be aware of how much of it is driven by prescription rather than black market drug sales. Not to put too fine a point on it, the drug market in the US is a total shitshow, and taking your comment at face value requires ignoring a mountain of evidence.

Please don't insult our intelligence with your argument from ignorance. If you actually believe what you wrote above, then you are massively under-informed and should pay more attention to the news.

You seem to be a very angry person.

We see stories about that because we are a country of 330 million people and there will be some subset of any [group of people] who do bad things in such a large population. The vast majority of doctors are highly ethical.

As for opiates, I'm afraid I don't quite fit into your strawman; I think doctors should be banned from prescribing them on an outpatient basis to anyone but patients with a terminal prognosis. Chronic pain is awful, but opiate addiction is still worse. Since the action (and addictive mechanism) of opiates causes the pain to worsen over time, it's not an appropriate treatment.

The main reason for overprescription of opiates is not some evil doctor conspiracy, it's because doctors, like everyone, have a very hard time telling people "no." And there's no group of people more skilled at emotional manipulation than junkies.

Overprescription of opiates is also a cause for "junkies", not just a consequence of their skills in emotional manipulation.

It's a feedback loop. I suspect the ur-cause of the current epidemic is higher rates of depression related to an aging population and chronic un- and underemployment.

You wouldn't be saying that as a chronic pain sufferer. They are the only thing that makes my life livable. With them, I'm a competent member of society. Without... well, I'd be dead, thus negating my entire social and economic investments by society. Seems pretty stupid.

You think FDA employees are immune from this type of thing? How do we go about finding the angels needed to staff this agency?

No, but those elaborate FDA approval procedures are designed to reduce the risk of corrupting human influence much like any other scientific protocol that aspires to reproducibility.

[...] only medical doctors would be able to review/rate. Which IMO is a reasonable and interesting idea worth exploring.

This is still an incredibly bad idea, for the entire reason we have medical science. One physician, no matter how principled and rigorous, won't have enough data. This "data" comes by way of raw number of patients, information collected about each of those patients (general and relevant to a specific drug study), how that data was collected (i.e. good experimental methodology).

Worse, even if good data were magically available, random physicians won't have the background in experimental science and statistical methods to analyze that data meaningfully. Even trained research scientists often have problems with this stuff. Add to that the already extant risks of conflict of interest from physicians receiving kickbacks from big pharma... sheesh.

So yeah, Yelp Anecdata FTW! Welcome to the tyranny of the snake-oil salesmen!

Do we really want pharmaceutical medicine, which already has major systemic problems, to degenerate to the level of "audiophile" arguments on web forums?

Oh because people who have MDs are incorruptible? Be realistic, lots of doctors take illegal kickbacks from pharmaceutical companies. As a Euro I can't believe that pharma companies are still allowed to advertise direct to consumers on television. They claim first amendment protection, but advertising is not the press and commercial speech should not be subject to the same legal protections as that of individuals.

Are the people at the FDA incorruptible?

No. Do FDA trials involve elaborate administrative procedures designed to overcome that problem? Yes, and most of the time they work OK. Go on, tell me how easy it is to rig an FDA trial.

I don't know precisely how easy it is to "rig" an FDA trial, and I don't know precisely how easy it would be to "buy" enough MD reviews to get a good "Yelp" rating for an unsafe treatment. I suspect both are quite possible given enough money, but I don't know which would be easier.

A responsible MD wouldn't rate a drug without basing their rating on a review of the research. Seems redundant to me.

Pharma corrupting MDs has been routine for quite some time. The restriction doesn't do anything but focus the target of manipulation to exact the population Pharma has spent the most effort learning how to manipulate.

Are you saying that because only doctors would be able to give ratings, those ratings would be more credible? I agree that __should__ be the case, but it wouldn't/isn't (http://jnci.oxfordjournals.org/content/99/15/1148.full). I cannot find the source, but I once read that there was a very small minority of doctors in the country subscribing the most brand-name drugs simply because of perks offered by drug companies.

Just because doctors have to deal with moral hazards (and sometimes fail) doesn't mean that non-doctors are more reliable sources for information about pharmaceuticals. This should be some form of cognitive bias (maybe it is and I just don't know the name for it): someone thinks something is a black and white issue, and has settled on "white" (ex.: doctors always give the most unbiased information about pharmaceuticals). Then, that person learns of a gray area in what was previously thought to be black and white (ex.: pharmaceutical companies aggressively market to doctors). Then, the cognitive bias: rather than revising their opinion about the binary, black and white nature of their belief, they keep believing it's all binary, but the evidence of the gray area causes them to flip their opinion from "white" to "black" (ex.: because pharmaceutical companies market to doctors, doctors are now considered altogether unreliable). When the reality is that even a potentially compromised doctor is most likely (not always, just most likely, but we have no way of identifying the exceptions) going to be a better source of pharmaceutical information than the collective wisdom of the rest of humanity.

Why would you replace research into its effects with a star rating from MDs based on what? Their gut feeling? Them testing it in the wild with no controls? These are human lives we're gambling with now.

Which is ridiculous, Pharmacists are often far more knowledgeable about medication, and even then crowdsourcing reviews for medicine is a crapshoot.

Try it, test it, see if it works.

OK, you be the first guinea pig. Or you can nominate one of your family members if you'd prefer.

Has it never occurred to you that we have already tried this approach in the past before the FDA was set up? OK Yelp didn't exist then but but the medical community's endorsement has long been used as a marketing tool - 'more doctors smoke camels.'

Why do you think the FDA was set up in the first place? Because some communists decided they needed a way to keep sick people in worse health for longer, or because the general public was sick of the uncertainties that inhere in patent medicines and the like?

You could do that, of course. But you should absolutely not depend on it.

And drugs don't work like restaurants, of course

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