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Comment by nradov | Hacker News Reader

There is a saying in medical diagnosis: "When you hear hoofbeats behind you, don't expect to see a zebra". https://secure.wikimedia.org/wikipedia/en/wiki/Zebra_%28medi... Most patients have common problems that are fairly easy for experienced physicians to diagnose. So there is no point to entering a bunch of data into Watson just to get back the same answer you already know. But it could certainly be helpful for those rare edge cases where the physician can't figure out the "zebra", or where the patient hasn't responded as expected to treatment.

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I think this is backwards. (After thoroughly testing of course) I'd rather see Watson be the first-tier of diagnosis, backed up by a doctor when Watson isn't so sure of an answer, as opposed to Watson just helping befuddled doctors. This could really bring down medical costs at scale.

And also possibly make it harder for doctors to, say, recommend a more expensive procedure because their hospital gets paid more.

Actually, this seems like the perfect opportunity for pharma companies to "help" in creating the database.

That's actually what they are already doing when pitching new drugs to doctors. Now they only have to convince the system designers and not thousands of practicing doctors.

In the end, the power is going to be with the payors, who are plenty savvy themselves, not the pharma companies.

Drugs are a relatively small part (10-15%) of the overall cost of healthcare.

Most new drugs today win on marketing, rather than efficacy. Once you have a system like watson, it's rather trivial to do the expected value calculation of "This treatment has an X% chance of working, and costs Y. The competing treatment has X'%, and costs Y'."

As long as that data is available to patients (and it should be), I'm with the parent poster, this will make it harder to pad treatments.

The customers for the software are the hospitals that people go to, not the insurance companies or the patients. I guarantee you that the hospitals will prefer whatever option results in the best possible financial outcomes for themselves.

Well then who is going to do the clinical observation, coding, and data entry? That work doesn't get done for free and in most cases it would actually take the healthcare providers more time to do.

There's (going to be) an app for that! Input data -> output diagnoses!

Ha ha. Seriously, clinical data entry is not quick or easy (outside a few limited special cases) regardless of how well you design that mythical app. Even perfect speech recognition would only get you part of the way there, and we aren't likely to get that any time soon.

I really don't think perfect speech recognition is that far away. 10 years and we're gonna have something that can work. 10 years and we'll have an advanced Google Goggles that can help with diagnosis. Ask the question "What are the limits of human input?" Nothing besides touch, taste, hear, see and smell, and we're getting closer and closer to being able to input that data and process it as humans would.

"Even perfect speech recognition would only get you part of the way there, and we aren't likely to get that any time soon."

We're working on it, though.

http://www.mmodal.com

Most of the time, there is still a transcriptionist in the loop. Or the doctor has to make his own edits.

I know, we use your service. :-) It works well for increasing the productivity of our human transcriptionists but it doesn't really solve the automated diagnosis data entry problem that others were asking about.

and a Mobile Diagnostics X-Prize to incentivise you to get there: http://www.technologyreview.com/biomedicine/37596/?p1=A4

Do you need to spend 7 or 8 years training someone to do that? If I'm not mistaken, that's already largely done by nurses and patient care technicians.

You are mistaken. In most cases that's not done at all by anyone. Most of the data entry done by medical coders (not programmers, the other kind of coders) is for billing and insurance claims purposes. That claims data isn't detailed enough to be useful for diagnosis. And in most cases it is done hours or days later, not immediately at the point of care where the doctor is expected to make a diagnosis and decide on the course of treatment.

> And in most cases it is done hours or days later, not immediately at the point of care where the doctor is expected to make a diagnosis and decide on the course of treatment.

So does that mean it's not important to the doctor's job? Or would having this information right away allow doctors to do their jobs better? If so, why isn't it done that way right now?

Here is a list of the most common diagnoses from a few years ago. http://www.hcup-us.ahrq.gov/reports/natstats/commdx/table2a.... Doctors already do quite well diagnosing those in almost all cases so there isn't much room to improve on the diagnostic side. Once the doctor takes the patient history, observes the symptoms, and reviews the lab results then the diagnosis is usually fairly obvious (to an experienced professional). If the doctor had to enter all her detailed observations into a computer it would just slow the process down and increase costs.

> If the doctor had to enter all her detailed observations into a computer it would just slow the process down and increase costs.

On the other hand, paying someone working for/requiring much less money/training than the doctor (say, a BS & $20 or $30/hour) to enter the data would lower the overall costs, would it not?

No that really wouldn't lower overall costs because it wouldn't immediately add much value in most cases. There would be some long term value later since that additional coded clinical data could be mined for clinical research to determine which treatments are most effective. But no one is willing to pay an additional $10 (or whatever) per patient encounter to get that data.

If there wasn't so much bureaucratic red tape surrounding the healthcare industry, that would be a great opportunity for an enterpreneur. Correcting the smallest inefficiencies can dramatically increase profit.

I know this might sound a tad heretical, but if Watson gets to be as good as or better than a doctor, do we really need doctors anymore?

The theoretical upper bound on Watson's ability is a lot higher than the theoretical upper bound on a doctor's, since it can make inferences based on a vastly larger data set.

For emerging diseases, advanced malingering, etc, you definitely need real life actual breathing human beings. Otherwise, sure, physicians are just as theoretically replaceable as any information-as-a-service workers might be.

Edit: I didn't realize this was even a controversial statement to make. First, to be clear, when I'm in the hospital and say "doctor" I'm usually thinking non-surgeon, as I am here. Second, you will always need supervision of the machines, just not 1-to-1 supervision. Not every interaction brings up ethical questions, for example. Sometimes someone really just has a viral URI.

We'd still need surgeons until the robots are good enough. We'd need radiologists until they can add decent computer vision. Ditto for pathologists and other vision-intensive specialties. Orthopods are very hands-on and collect information through channels other than words. So there's a suite spot in the spectrum of doctors for something like Watson. I'd wonder about the ability to ask questions and ferret out socially-obvious problems like broken arms from abuse if Watson were a first provider.

Presumably you'd couple something like Watson with a world-savvy human physician assistant that acts as its eyes, ears, and touch.

To the extent that abuse is a medical diagnosis, it would be trivial for a computer to make that presumptive diagnosis. In fact, if Watson is truly performing at the level of an M2, it probably already can.

Actually, I'd think the first signs of abuse would be the most difficult things for a computer to diagnose. Excuses are given, nobody says anything about violence, the person slipped, but the non-verbal cues might raise a red flag.

I'm not sure how much common sense world knowledge would be in Watson. "Hey doc, I got a pain in my chest while watching the football game vs Cal at Memorial Stadium." The DDX might include angina despite the computer being unlikely to know about a fan's emotions or environment of a football game.

For diagnosis maybe not, but we will still need surgeons, unless IBM comes up with a really good autonomous robot that can perform surgery.

Watson may be able to recommend you get surgery, but he won't be able to perform the surgery himself. He's only moving in on one aspect of medicine. Matching symptoms to diagnoses is the thing that machines are most clearly suited for in the entire medical profession, because of the vast volume of possible measurements and diagnoses, and because humans' various cognitive biases don't work well with the probabilistic nature of the work. That's still a rather narrow range of work. Humans will remain superior at performing medical work for quite a while. And until true Strong AI, humans will also remain superior for quite a large amount of gathering information that Watson requires, especially psychological measurements, and for making decisions that involve quality-of-life and other ethical considerations beyond just probability of success.

tl;dr Watson can, and will, exceed doctor's capability for a certain, somewhat narrow, range of their function. Doctors will still be necessary for the other things that they do.

Watson may not be able to perform surgery, but with "telesurgery" becoming a reality, maybe we can offshore it and still save 80%.

I've always wondered about this. What happens when the network goes down in the middle of open-heart surgery?

"And until true Strong AI"

Watson seems like a significant step in that direction.

http://www.intuitivesurgical.com/products/ Amazing, 3D vision robots. Very graceful translation of hand movements into the robots arms. Very nice product. Currently only for laparoscopic intra-abdominal surgery. Not yet automated. They have DaVinci assisted cardiac surgery programs developing in some parts of the country.

Robot assisted airway manipulation http://www.anesthesia-analgesia.org/content/111/4/929.abstra...

This robot could intubate you. DaVinci could operate on you.

Can't sue a computer.

Legally, someone has to be responsible for the healthcare provided to the patient. The patient shoulders some of it, true, assuming they're basically competent adults and not severely impaired. (That's why powers of attorney exist, and why physicians are empowered to 'fire' non-compliant patients.) However, the MD is the one who has had the training and who is legally authorized to exercise medical judgement (as opposed to nursing judgement, and no, I'm not going to even try to get into where the arbitrary line between them falls), so the MD is the one who ultimately decides the treatment strategy, which may involve referrals to other MDs, who also must be legally capable of exercising medical judgement.

So, legally, there has to be someone to sanction (threaten with malpractice lawsuits and loss of licensure, among other things) and it's probably better for everyone involved if that person has personal contact with the patient.

You can sue the creator of the computer, or the owner of the computer.

You can sue anyone for anything, but unless the computer system is certified by the FDA as a "Medical Device" then you're unlikely to win a judgment. It would be like suing the publisher of a diagnosis textbook that contained incorrect information. That's the reason that clinical decision support vendors typically design their systems to just show possibilities rather than explicitly making a diagnostic recommendation. It's ultimately still up to the doctor and so the doctor bears all of the legal responsibility.

Yes, but the comment I was replying to was within the context of all doctors being replaced by computers, and his point was that it couldn't happen because there needs to be a person to blame. Well, if you get rid of the people (except those creating the computers), then it is still possible to sue the computer owner and/or creator.

Watson isn't a replacement for the physician. It's a physician's extender, a tool that allows a physician to "see" more patients in a day and provide diagnostic results in a more timely manner. The physician will still be the one responsible for the final judgment call.

BTW, it would have been nice if the journalist had bothered to consistently spell the doctor's name correctly (it's Siegel, not Siegal).

This is one of my favorite sayings, so I feel compelled to minorly correct it here. The full saying is "When you hear hoofbeats in Texas, think horses not zebras." The "in Texas" is a key piece of context, as there are some places where zebras might well be more common than horses. The point being that one should suspect and rule out the most common differential diagnoses first.

I read your statement to assume that entering data into Watson is going to take longer than "entering" that same data into your GP. How did data entry for Jeopardy work?

This would mean that the main issue in adoption of Dr Watson (Hmmm, haven't I heard that name before?) would be the data entry - obviously a pain point in many digital services. If an effective answer is found, and I would suspect that this should soon happen, then the argument becomes more a matter of whether you prefer a subjective opinion from your GP (based on his/her current thought processes / focus) or an objective one from a digital process.

I think I'd prefer the digital process, once the main issues are ironed out.

Iirc, Watson used voice input.

incorrect, watson was fed a text of the question over ethernet right after Trebek finished reading the question.

Also incorrect, Watson was fed the question as soon as it was revealed. He didn’t – just like the humans – have to wait until Trebek finished to read the question.

Don't hold your breath. This has been an area of active work by many of us for decades. We have some systems that work reasonably well for a few limited cases but the general case of clinical data entry won't be solved any time soon. It's a genuinely hard problem that those without experience in the domain tend to underestimate.

Doctors have only a few minutes for most patient encounters. They simply have no extra time to do data entry. You can delegate some of that work to clerical staff or allied health but there are limits to what they can do, and they don't work for free either.

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