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Comment by scarmig | Hacker News Reader

My issue with doctors:

Recently, my dad was sick with a pretty bad cough. Like, so bad that he couldn't speak without coughing. He fainted twice from minute long coughing fits, one of those times hitting his head his head on the stove on the way down, leaving a deep cut and blood everywhere.

He went to at least three different doctors. He got a scan of his chest. Everything looked clear, and all of the doctors were stumped. Things were pretty bad.

I mentioned this to a UCSF resident friend, and her immediate response was "Oh, is he on <some blood pressure medication I forget the name of>?" I was like, uh, let me see. Called my mom, she checked, and, lo and behold, he was on it. So his doctors took him off it and within a week he was better.

This coughing wasn't some obscure side effect of the medication she knew through sheer brilliance: it's a side effect that's been widely known since the 1970's. Hell, it was on the drug's Wikipedia page.

So there's a couple morals you could take from this. One would be, wow, doctors are smart to be able to diagnose an issue based on a single symptom and some reasonable assumptions about a patient's background! The other is that the median doctor is pretty worthless; spending tens of thousands of dollars gives you no guarantee you'll see someone competent; and that a medical system that relies on you grabbing drinks with a UCSF resident to get good results is fundamentally broken.

Machine learning and expert systems don't have to be as awesome as the best doctors to be valuable. They don't need to be better than competent doctors, even. They just need to provide a bare level of competence to provide a huge amount of value.

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I just want to add something really important onto this.

ALWAYS READ EVERYTHING YOU CAN ABOUT DRUGS YOU ARE PRESCRIBED!

Sorry for all caps, but it is super important. Not that your dad is in the wrong, lots of people have justified (to a degree) trust in their doctors. However doctors are people and just by that alone aren't perfect.

A few years ago my doctor prescribed me an antibiotic for an ongoing illness I had. I read the entire pamphlet for it and did some reading online about it. All before taking it. Turns out it can cause seizures if it interacts with polypropylene glycol, one of the main ingredients in e-cig juice, which I use daily. I had told my doctor I use an e-cig.

Really I cannot stress how important it is to be knowledgeable about the drugs you are taking.

i agree with your advice. but on japan for example drugs are given ouT of their package with no info whatsoever about side effects and all. just like candies. what do you do with that?

Interesting... So you just have to trust your doctor, no matter what? Does doctor explain the reasoning behind giving you the pills?

hardly. consultation including prescription is five minutes tops.

This! I view doctors more and more like any other service provider. Their goals (removing symptoms / being on time for next appointment / staying within budget / maybe even prescribing drugs I get commission on) are not necessarily aligned with mine: identifying and removing the root cause for disease. So the decisions I make are my own, but I take the input from doctors and try to do as much research as possible. Needless to say, I don't take prescription drugs unless strictly necessary.

Once you view your GP as a mechanic, you can make much better decisions. Sure, their "cars" are more complex, but the role they play is similar. If you want your body to function well, you are responsible for it, not the doctors. They just help you out.

I 100% agree with this. Doctors in America are hopelessly bad for what they charge.

The system is built on rent seeking behavior. If I don't treat it immediately then the patient will come back again and I can charge him/her a subscription.

Health care in America is very inefficient. Mostly because of insurance lobbying and govt that can't make a firm long term decision.

I would love to see most common problems be self diagniosable with kits and AI.

Especially if you're taking multiple types of medicine, know their interactions. There may be a specific sequence of consumption that you should use otherwise side effects get amplified, e.g., NSAIDs.

>ALWAYS READ EVERYTHING YOU CAN ABOUT DRUGS YOU ARE PRESCRIBED!

I'm not trying to undermine your point entirely, but there is a flip side.

I can't tell you how many times I have seen a patient start a medication, then come back to the office within 48 hours because they coincidentally have every side effect that is listed in the pharmacy's information sheet or that they looked up online. The vast majority of these side effects are benign, present with next to no pertinent physical exam findings, and can't be definitively tied to the new med (like upset stomach, fatigue, headache, etc.).

Then they will start listing that medication as one of their "allergies", and if the nurse/doctor documenting doesn't dutifully probe what type of "allergic reaction" they had, they may end up not being prescribed that med in the future when it really is the drug of choice. A little nausea is a small price to pay if it kills a potentially life-threatening infection.

Also, I'm skeptical about the seizure risk. The thing about side effects is that they are supposed to be stratified according to risk. Doctors are typically aware of these risks, but patients aren't. So if your drug is listed as causing "headache, nausea, and seizures", there may have only been one patient out of millions who had a seizure while 50% experienced headache, yet the handout probably won't tell you that.

But even if it is a notable risk, I would be surprised if the propylene glycol you inhale from an e-cig could accumulate to a high enough level in the bloodstream to cause drug interactions, although I admit adequate research on the subject is lacking.

My advice would be trust your doctor first. If you don't trust your doctor, start seeing a doctor that you do trust. Then if you have a significant adverse reaction to a medication, talk to your doctor about it. Quite often they know something that you are not going to find by spending a few minutes on the internet.

As a side note, a good history includes asking about many habits. A lot of healthcare providers are guilty of simply asking "Do you smoke, drink, or use drugs?", but ideally the smoking aspect should be phrased as "Do you use any tobacco or nicotine products?". Patients usually won't read your mind and volunteer that kind of information. They will tend to give yes/no answers, so direct and specific questions are important.

> yet the handout probably won't tell you that.

That seems like a major problem. Is there any reason that more detailed information can't be included? Mathematical literacy may be a problem, but that doesn't mean that there aren't millions upon millions of mathematically and scientifically literate consumers who could use this information effectively.

You would probably have to ask a pharmacist, but from the clinical side I can tell you most prepared health information that we can give to patients has to be very bare bones and comprehensible to essentially everyone at or above an 8th grade education level- I assume because it is considered too resource intensive by the publishers to produce multiple versions of the same information, and people with higher education typically have the initiative/means to ask their doctor the right questions or research the information themselves.

I'm not trying to justify any of this, but that's how it is.

Not sure if it will be helpful in the future, but I can tell you that descriptors used with side effects follow a standard convention:

    very common: > 10% 
    common: 1%-10%
    uncommon: 0.1% - 1% 
    rare: 0.01% - 0.1% 
    very rare: < 0.01%

But you will probably never know the exact origin of these figures (like how many patients were studied, what populations were included, how tightly the study was controlled, whether adverse effects were self-reported, etc.) without doing some intense searching. And even if you did, I doubt it would have a significant impact on your healthcare. I don't want to go on a tangent about the nuances of pharmacology in clinical medicine, so I'll just circle back to my point that you should trust your doctor, or else find a new one that you do trust.

> there may have only been one patient out of millions who had a seizure while 50% experienced headache, yet the handout probably won't tell you that.

Odd, here in Norway that's exactly the kind of information I expect to see on a leaflet inside the packet, not only on prescription drugs but also over the counter pain killers like paracetamol. Roughly translated from the Norwegian it says:

Rare side effects (more than one in ten thousand but fewer than one in one thousand patients) include: over sensitivity, allergic skin reaction/rash, reduced white blood count, anaemia, disturbed liver function. Very rare side effects include serious skin reactions. Liver function can be affected by paracetamol and alcohol abuse.

That's quite a lot you've taken away from one anecdote.

ACE-inhibitors are well-known to cause a cough but not like the one you're describing.

If I was to guess I'd say he had a respiratory tract infection that magically disappeared (as they do) not long after ceasing the medication. This is a common type of scenario where lay people get confused about correlation and causation, and is one of the reasons you need doctors to help you.

Even if it was the medication, like I said, this sounds like a somewhat unusual case.

You'll probably spend the rest of your life thinking the doctors didn't know what they were talking about, but in my experience with doctors (I have a lot of that since I'm a doctor myself), even the "median" ones are far better at diagnosing things than lay people.

I think that a median doctor + a statistical classification scheme > a median doctor alone, though.

Sure. And most of us would be super keen to use that. In fact, ED doctors in particular use heaps of things like that. Maybe instead of rule systems we will eventually use deep learning algorithms.

I don't know - if you're at all in a profession that requires problem solving, it can be quite jarring to work with a doctor.

For any given complaint, most will just tell you that your test results are in the normal range (don't get me started on this "normal range") and tell you there's nothing they can do.

I live in the bay area and have had a few GPs over the years, some from well known institutions.

Doctor's seem to put in the minimal amount of effort to get you out of their office in the allotted 20 minutes so that they can move on to the next patient.

I have multiple anecdotes similar to OP's - times where if it weren't for my insisting or my own inkling to visit a specialist I just would never have been helped.

Are there goood GP's? I'm sure there are - but to casually dismiss OP's statement is a bit ironic - since casually dismissing is part of the biggest problems as far as my own experience with doctors.

Your problem with doctors sounds like it's their time constraint. Why don't you pay a bit more to get a longer consult? You want them to work magic in 20 minutes?

I responded to OP's statement. Dismissing is quite different.

Why don't the doctors just tell him that they need more time to address his concerns properly, rather than dismissing his concerns?

I don't know. Maybe they do? Maybe OP needs a different doctor who is more aligned with what he/she wants.

Won't happen. Unlike engineers, doctors are trained to come up with a diagnosis given whatever subset of information can be presented to them and understood by them in the time allowed. The main source of their information is not even the patient, but prevalence (i.e. prior probabilities). It's a 80/20 sort of system, really more like 95/5.

It's a lot like YC office hours actually. Though doctors have less time than YC partners. And doctors get paid per appointment.

In general, it's not useful to think of doctors as engineers. The line doctors work is much more tech support - lots of similar highly repeatable cases, with a well understood script. The ones that are more like engineers are doing research in research hospitals and writing that script. They still see some patients as part of their work, but appointment reimbursements are not a profit center for them, but part of their research.

When making an appointment, my GP's assistant explicitly asks whether you've got multiple complaints, and if so, to list them; before explaining that in that case, they can reserve more time.

Then again, my previous GP said he had 7 minutes per consultation.

(FWIW, I’m in the Netherlands).

It's not possible to pay for a longer consult, in the same way it's not possible to pay for a 3 Michelin star meal in a McDonalds.

This is not meant to sounds harsh, all I am saying that from any business you can't buy a product they aren't in the business of selling.

I guess GPs where you are practice differently to GPs where I am. I can't imagine why they wouldn't book a double consult. How do they do more complex procedures and sort out patients with complex health problems?

Comparing this business model to McDonalds is a bit ridiculous. Maybe compare to a lawyer booking double time, or thousands of other professionals. But don't make the unnecessary jump to a fast food chain.

Spend more time than allocated on complex cases, then run late and short on others. More typical of specialists, but GPs do it too. Beyond that, incrementally, 1 appointment/billing code and a new test/intervention at a time. Until the patient gets better, worse or gives up.

Are you in US? Is double consult something insurance/government pays for twice for you? Or are you are talking about a different billing code? Or self-pay?

Australia. We have different billing codes for different length of time and different complexity of concern/procedure. We book double/triple/etc. appointments when necessary.

Doctors still often go over time.

Interesting. In US there are also different billing codes like that. But it's not something a patient has input on. However, it's safe to expect a provider to chose the maximum code that can be reimbursed at any given time by default.

So given that, a patient is likely getting the most expensive product a given doctor will deliver already. To get a better product simple options are specialists (much higher reimbursements, selection bias for more complex cases) and specialists at major teaching hospitals (even more of the above).

There are effective ways for a patient to hack the system by doing lots of work themselves (e.g. by maintaining his own clinical summary) but they are beyond what most patients will do.

Patients don't really have anything to do with choosing item numbers. They just may request a longer appointment or a specific procedure or test.

Las tdoctors visit I had I wanted to go through a list of 6 issues. I scheduled the longest available time slot, 45 minutes. I wasn't sure how long it would take, but assumed I'd be able to take as much time as I needed within those 45 minutes.

The doctor, after number 3 in my list and less than 15 minutes into the appointment said "Are you done?" After item 4 a couple minutes later he said "Is that it?" In a condescending manner.

Needless to say, I was pissed.

But, the thing is, it's not the doctors fault. He's working in a system that values throughput over all else...and this is Kaiser, a vertically integrated provider where you would think that would be less of an issue. So he was late to my appointment and saw my long appointment as a way to get back on schedule to ensure he saw the 40 patients he had to see that day.

The whole system is broken.

That's an unfortunate experience you had. Patients with lists can be a bit of a trial but at least you had the foresight to book a longer appointment. It's a shame the doctor saw it as a way to get back on schedule.

My father used to work for Kaiser - if he saw < 20 patients a day there would be some clearing of throats from management.

in Japan if you get more than 5 mIns with a doctor it is your lucky day.

> even the "median" ones are far better at diagnosing things than lay people

We aren't comparing doctors to "lay people" - we're comparing them to machine learning algorithms. I'd prefer the machine to many of the arrogant, but mediocre, doctors I've seen in my life.

Actually, OP was comparing doctors to his lay friend, who diagnosed the cough.

Edit: It seems "UCSF resident friend" is American for doctor. I suppose my statement was actually out of context then.

This response makes me want to coin a new term: "doctor-splaining."

You're looking for "docsplaining"

Yeah, that's better.

A recent MD friend of mine mentioned that the standards in medical school are much higher today than 20 or 30 years ago. While this is pretty anecdotal, you may have better luck with doctors who graduated more recently. Perhaps someone with experience from medical school can comment.

Separate from that, I've had similar experiences. The median doctor I've interacted with isn't able to put in effort to really understand an individual case, and it's very easy to get overlooked or ignored. I've run into a few exceptions but that is the general rule. Source: wife had pregnancy with complications, young children.

The downside is that at least in my experience the newer doctors seem to be docbots. Lousy bedside manner.

I've had the dubious honor of spending quality time in a few hospitals with sick relatives in the last year. The nurses rock, and PAs and NPs seem to do what residents used to do.

The residents in particular seem to be clueless. With electronic records, they can't look at the chart as easily and aren't situationally aware.

It seems that at any given program either the residents are amazing and the fellows are mediocre of vice versa.

It's a common fallacy to want an older, experienced physician vs. a resident or fellow. There are exceptions like specialized surgical procedures. Generally speaking though, when physicians leave the academic environment they rarely get better. Residents and fellows (and physicians who stay in academia) spend a huge amount of time on education - it's built into every day they're at work. Things like case conferences, morning reports, and Morbidity and Mortality reviews.

When you enter private practice it is completely up to you to stay educated and current. Sure, you may attend SGIM once a year and read monthly journals, but that is nothing compared to the structured learning environment they left behind.

I will take a good resident at a county hospital over a private hospitalist any day. Even at exceptional Tier one hospitals the level of dumb shot that happens with lazy private physicians can be jaw dropping.

The private hospitalist is going to order some labs and consults, round on you once a day (maybe) and that's about it.

A good resident will discuss your case at length with their interns, co-residents, fellows, and attendings.

Were you seen in a hospital or a private practice? If it was a hospital you almost certainly primarily interacted with graduates of the last 5 years since you're mostly seeing residents.

Fwiw, "putting in effort" is somewhat relative. Do you mean they were lazy, or spread too thin?

The counterissue to standards being higher (which might or might not be true) is that programs are ramming students through at a faster rate. They're reducing and compressing course and theory and pushing them out into clinical settings more. You could argue that this exposes them to real-world learning faster, but my impression is that it's driven mostly by just getting extra free help in the clinic. I think once you exit the classroom, too, you're at as much of a risk of unscientific idiosyncracies of supervisors as you are likely to benefit from real-world learning.

A this point, in a lot of schools, PAs and MDs get about the same amount of in-class training, for example (especially when you consider that PA prereqs are often stricter than MD prereqs in terms of prior coursework and experience). A PA with 2 years of experience is at about the same experience as an MD just out of school. The discrepancies with specialists (e.g., optometrists, dentists, psychologists, and so forth) is even greater.

I don't think MDs are incompetent, but I think our healthcare model is basically wrong, in that people just aren't able to juggle everything in their heads, regardless of how smart they are, and someone focused on their problem, with access to the internet, just might be able to get more traction than the person trying to remember 1 out of 10000 things in their head. I think this is also why there's been a push toward specialists: it's just easier that way, even if the problem isn't that specialized, because the specialists only have to remember 1 out of 20 things.

The basic healthcare model, with MDs at the top, followed immediately by PAs and nurses, needs to change, to be more decentralized. There's a role for those training backgrounds, to be sure, but many of the same tasks could be accomplished in different ways, and many things are maybe done more efficiently and less expensively through different routes (by relying more on pharmacists, for example, or expanding training and practice for optometrists, psychologists, and so forth).

Maybe if a pharmacist had been consulted, for example--maybe if there was less of an expectation that you start with an MD, or rely on an MD to provide all the answers, or expect them to know everything--the side effect of that med would have been confirmed earlier.

This is the one silver lining that I might hope for in a renewed healthcare debate, which is a restructuring of care systems to increase competition and decrease costs. So far everything has focused on how to pay. That's not to say I agree with moving away from a single-payer system, or that the current government will lead anywhere productive, or that I've seen anything innovative from them in that area, but it's something that hasn't been done yet.

> the median doctor is pretty worthless

This seems fairly disrespectful. I suppose you mean that the median doctor isn't perfect, but do you have any idea how many hours residents put in? You might think carefully before calling the median one worthless, and ask whether they're really, truly wasting their lives in the service of others.

Less emotionally, I find it hard to believe that half of doctors proved essentially no benefit.

> it's a side effect that's been widely known since the 1970's

Guess how many side effects have been widely known since the 1970's?

For clarity: I am 100% in favor of thinking critically about a doctor's advice, having received contradictory diagnoses before.

> Guess how many side effects have been widely known since the 1970's?

Does this make it fine not to expect a doctor to inspect the list of known side effects for drugs his patients are taking?

I've heard this very story a few times already, perhaps the sources of data widely accepted by doctors are not up to par with what non-doctors consider as accurate, in some cases anyway.

Without knowing this specific case, I can't say for sure. But my broader point is that the knowledge base required of doctors is so huge that even if it's not excusable, it is understandable. Like online community moderation, it's really easy to point to cases where doctors got it wrong and assume it's all for naught.

Absolutely the accuracy of doctors should be improved, but the bar is not "are you as good as a UCSF resident?" (one of the best programs nationally) but "are you better than nothing?"

It just seems crazy to me to suggest that the median doctor, i.e. at least half, is worthless.

yeah, arrogant comment that was. I presume the guy always does his work at 100% or more, flawless, checking every detail and aspect, thinking 10 minutes before saying anything... We all have our tiny and bigger faults, yet somehow when it comes to health we expect impossible.

I have similar crappy experiences like most people here, and tended to hate all medical personnel uniformly. Then I started dating a young doctor - still can't wrap my head around how overworked over-stressed and underpaid piece of shit work that is.

Bear in mind that we're talking about biggest university hospital in Switzerland. Working ridiculous amount of hours (normal shift can be 10-13 hours, overtime unpaid), night shifts that will just mess you up mentally, crazy and dangerous patients, drug addicts, very real danger of contracting stuff like HIV or hepatititis C by single tiny mistake, or actually killing somebody by overlooking some tiny fact about N-th patient that night. You can end your career for life and end up in jail and/or with lifelong debt by one mistake. ONE. Even after directly saving life of 500 other people.

Compared to my comfy corporate job, where I earn much more, did get mistake or two in production over last 5 years (nothing critical like making loss, but still), well... We should be thankful that anybody clever is actually still doing that job. Most of them could earn more and have actually a life someplace else. Blame how system is setup much more than individuals forced to exist in it.

Incidentally, the question of "Do younger or older physicians produce better outcomes?" recently came up on the Freakonomics podcast (they were doing a 3-episode focus on the medical system). [1; 12/14/16]

Or, if you want to search the transcript for it, "So, given a choice between two doctors, let’s say — one fresh out of medical school and the other with fifteen years’ experience, which one do you go for?"

It's a good listen or read.

Tl;dl: Anupam Jena [2], "And we can basically see what happens if a patient happens to be treated by a doctor who is 20 years out of residency versus 5 years out of residency. And what we find is that if you happen to be treated by a doctor who is 10 years or 15 years out of residency, your mortality within thirty days of being hospitalized is higher." [Note: surgeons were one of the specializations that did not follow this correlation]

Side note: the medical profession is really terrible at keeping statistics on outcomes, outside of actual trials.

[1] http://freakonomics.com/podcast/bad-medicine-part-3-death-di...

[2] https://www.ncbi.nlm.nih.gov/pubmed/?term=Jena+AB%5BAuthor%5...

Well, I don't think this is surprising, really. Those doctors are closer temporally to their training than the old docs. This is also why "Are you smarter than a fifth grader?" is actually harder than people think, because all those kids just learned last week what the capital of West Virginia is. Surgery seems to be a logical exception, since at the end of the day, I suppose it's more like being a car mechanic than a trivia competitor, and having a body of experience and "tricks of the trade" is more valuable than trying to compete with knowing more than WebMD and Wikipedia. I can't wait to pass the torch of diagnostics over to computers. People are generally lazy and they get comfortable too quickly for my taste, including doctors. I bet if you found some kind of situation in which doctors were kept on their toes, and constantly retraining their knowledge base, you'd find that the mortality rate doesn't go up.

It's not doctors. I am working on software for the OR right now and I had never taken a biology course. The amount of stuff you need to know is IMPOSSIBLE. No, it is literally impossible. The human body is beyond ridiculously complicated and this is why most doctors pattern match for everything they've seen before.

This is why, if I were an MD, I would be latching on to ML as quickly as I possibly could. There is a TON of money to be made here, sadly, I do not have the domain expertise to make it, though I am picking it up pretty quickly.

You didn't say whether the medication was declared at the initial admission. Nonetheless the thing I took away most from your remark is a reminder to be aware of side-effects. Or more broadly, a reminder that patients are participants in their own treatment, and that the existence of doctors doesn't excuse us from responsibility toward ourselves & those we care for.

>"Oh, is he on <some blood pressure medication I forget the name of>?"

I'll bet the farm it was lisinopril, or another ACE inhibitor. The ACEI cough is notorious enough that any 1st year medical student probably should have been able to piece this together.

The problem is not that those doctors were ignorant. It's more likely that they did not ask the right questions to get a proper history. You should ask every patient to list their medical problems and medications unless it is a routine follow-up when nothing has changed.

Something else that can happen is patient ignorance (and I am not insinuating your dad was guilty of this, or making a value judgment on people who are).

Often times you can't get a proper past medical history or medication list unless the patient brings all of their prescription bottles to the office. E.g.:

>"What medications are you on?"

>"Well, I'm on a sugar pill, a water pill, a cholesterol pill, a stomach pill, and some allergy medicines."

>"Ok, do you know the name of that sugar pill?"

>"It's a little white pill. I think it starts with an 'F'. No wait, I'm thinking of my water pill."

>"Do you have any medical problems?"

>"No."

>[glances at meds list] "Ok, so why do you take metformin, hydrochlorothiazide, atorvastatin, omeprazole, cetirizine..."

Was it Lisinopril? A cough is a recognized side effect of it, but I think something as severe as you are describing would be fairly rare?

While I think you might be overreacting a bit here, I have a similar story. I had an irritated, gunky eye for the better part of a year. Was bounced around multiple doctors, including one specialist, and had all sorts of really annoying treatments I was supposed to do. Finally got bounced to a specialist at a major teaching hospital. Took him five minutes to correctly diagnose me, and the major part of the fix involved instantly stopping all of the things recommended by the other doctors. (The rest of the fix was simply to make sure my eye was protected while sleeping.)

So yeah, I think there is a lot of value that might be added by an expert system that is familiar with the slightly more exotic things that can go wrong with your health.

Angiotensin receptor blockers can give you a cough. Almost all drugs have side effects. You got to read the drug information yourself and watch for known side effects. Start one new medicine at a time so you know which one is giving new side effects. By the way, reducing salt intake is amazing for lowering blood pressure.

In the doctors's defense, most people know that blood pressure medication may cause coughing. At least most people with hypertension.

Your dad's case is like complaining about constant nosebleeds while taking Aspirin every day. It's a bit obvious, to be honest.

Given the symptoms, discontinuing an ace inhibitor is one of the very first things you would try.

Atenolol? I'm not a doctor but I'm reasonably sure it's this.

Not this. ACE inhibitors tend to cause a cough. You tend to get this side effect pretty quickly. It doesn't just occur randomly months or years after starting the drugs unless of course something else changes in your health.

Really happy you wrote this anecdote because it illustrates a point that physicians are arguing about a lot right now--how to measure quality care. Is it readmission rates, is it 30-day mortality, is it getting all the required screening exams for each patient... we don't know. In the US, the CMS is trying to mandate many of these and it's really hard to measure quality of care.

For example, I am a radiologist. Probably 90% of my cases are mundane and are either normal or have 'easy' pathology that I can readily detect and quickly report. Another 9% is a mixed bag of things that take a lot more time--something I need to reference or think a bit more about or possibly show a colleague. And then there's the 1% that is truly a 'make' or 'break' case. My sub-specialty training and experience can really shine in these situations and I can easily dispense a diagnosis or make a 'tough call' where another might equivocate or defer to more imaging or a follow-up. I like to think I'm not being paid for that 90%... I'm being paid for the other 9+1% That's where I truly add value in the system. But how would I measure my 'success' rate when even the best eventually make mistakes given a long enough time and there is often not a gold standard for diagnosis or even long term follow-up/resolution to many of the tough cases I've seen.

Studies have been done where experts review a sampling of cases and that's essentially what we do now for quality control--we randomly review a few prior exams for a case we are reading and then submit feedback based on our opinion on the same case. In these studies, trained radiologists do very well and make clinically significant mistakes only rarely.

But here's the problem. Let's say we use machine learning to interpret a scan, something like a CT of the chest to look for a pulmonary embolus. On that scan, the machine may see an incidental pulmonary nodule. Well that's fine, we have good data on how to follow-up on those and what to recommend. Well, what about an anterior mediastinal lesion? Now it's not as clear. The differential is wide and dependent on age, sex, symptoms, history, etc. Let's say we build that logic tree, let the machine learn from 1000 anterior mediastinal mass cases with tissue diagnosis. Well guess what, we do those studies all the time and it turns out that NOTHING is 100% sensitive AND 100% specific. You have to sacrifice one for the other... it's a balance. So, you would need to build ROC curves for every possible finding on every scan and decide that 1% of the time you will miss a cancer to save having to biopsy an extra 20 people... or maybe you want to miss cancer only 0.1% of the time, but that means you'll have to biopsy an extra 200 people and one will have to be hospitalized from complications. You think they will be happy knowing you made that decision? Guess what, we are already doing that with Mammography. The screening guidelines that the different societies and agencies argue about are this very rationale... how many women should be allowed to die to prevent those extra biopsies, false positive workups and all the things that come with that. I welcome machine learning into medicine. Guess what, it's destined to be mired in the same ethical dilemmas we face everyday.

I have a feeling I'll make it to retirement.

Yes, much better to make ad-hoc decisions of additional tests versus missing disease, without the benefit of a double-checked system giving you and the patient the likelihoods of complications.

I appreciate the sarcastic comment, but I don't think you understand the implication of a system like that. Even if you have more data, it doesn't better inform a patient's decision process.

For example, let's say you could--you can't--but let's say you could without a shadow of a doubt predict that the pulmonary nodule in your lung is not a cancer with 98% certainty. Well if you are 40, that's not that good actually.... that means 2 out of 100 people in a very productive time of their lives may have a cancer go completely ignored! So should I tell every patient in my report, "There is a 2% chance that this is malignant, but I won't recommend biopsy because there are chances of complications from that and we can save a lot of money by letting a few slip through the cracks--it will cost the healthcare system too much. Thanks for your understanding."

Remember, statistics predict population outcomes... not individual outcomes. I can tell someone that something very rare might happen.. but guess what, when it happens... the idea that it was a rare possibility doesn't assuage any negative feelings about it.

There is no right answer. Some people are illiterate! Even educated people don't understand statistics... how am I going to quantify that kind of risk/benefit analysis in a way that ensures a patient truly understands the implications. What if that risk were 1%, or what if the patient was 70 years old? Should either of those affect my recommendation? Who am I to decide who should be recommended one thing vs another... it's a value judgement! But if I leave it solely to the patient, a lot of times they will ask me, "What would you do?" Probably the most common thing asked after a long discussion like that. The answer is, "I don't know."

Bottom line: We can do 'strong' recommendations for things that are well studied like breast cancer and pulmonary nodules, but we don't have data to support recommendations in many other areas of everyday practice. A machine learning system would need data that just isn't available yet to make recommendations.

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