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Comment by atwood22 | Hacker News Reader

> Many of the conditions that vets see don’t have specific drugs associated with them (or even high quality studies), so vets often have to get creative.

> If I want to market to doctors, I’m best served by having high-profile researchers in that specific indication and high profile studies. Ideally, I’d also get a change to the treatment protocols, too. If I want to market to vets, I’m best served by having well-known speakers (who don’t necessarily specialize in that indication) and well-run (not high-profile) studies.

> There's something sad about what American physicians have become.

Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy. It's not like the "good ol' days" where doctors had carte blanche to do whatever they want. If you want to market a product without scientific evidence that it works, go ahead, just don't do it when people's lives are on the line.

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The problem with that perspective is that it essentially dooms every "life on the line" with a condition which can not be established with "scientific evidence"

For a simple example, the multitude of young lives lost to cancer because "scientific evidence" does not support screening before age 50. That perspective seeks to minimize and mischaracterize early warning symptoms because of public health probabilities.

Are you implying that more active screening would cause more good than harm, and that the scientific evidence that shows otherwise is mistaken? What makes you think the evidence is wrong?

Screening is a very complicated topic and being overly aggressive with screening can really hurt patients. https://www.youtube.com/watch?v=yNzQ_sLGIuA

Or do you simply not support using scientific evidence and/or harm reduction to guide medical policy? What do you propose should be used instead in that case?

I think the point is that not all cases are cut and dry. There are many for which evidence is inconclusive; and for those having a blanket regulation is worse than letting the patient and the doctor select a choice that the patient prefers.

Then they chose a poor example to illustrate their point, since anyone is free to book a cancer screening even if they are younger than the recommended age, if they so prefer.

You can try and book anything you like, but the doctor/technologist is under no obligation to actually run the screening test for you, and if they do there is not requirement that your insurance pay for it. So you can have a full body MRI reference done, but it will cost many k$ out of pocket, if you can get someone to do it for you.

Your video seems good and I don't know if he is an authority but his description he makes clear that he is not an authority.. but it's about asymptomatic screening, while my point was about continuous symptom minimization and mischaracterization.

There are also some obvious mistakes in his overessentialization of the statistics, which imply that early detection never results in a nonfatal prognosis.

A cost-benefit analysis can have different answers when applied to an individual vs. a population. That something is rare isn’t much comfort when you’re the one in a million rarity.

There is no problem with screening literally all the time, provided that the goal of screening isn't to immediately trigger a response from a single sample, but rather just to gather time-series sample points which can later be fed into predictive models to trigger alerting. (Where those "predictive models" can just be, y'know, your GP's eyes at your yearly checkup, as they flip through a series of your CT scans as a little flip-book.)

> There is no problem with screening literally all the time,

I have no opinion on the matter but this is disputed for some screening methods, which supposedly can increase the the risk with statistical significance. I don't believe that they ever nailed down the cause though, but I'm not a medical professional so I am not really well read on the topic.

Yes, but that's not a problem with screening as a concept, that's a problem with those screening methods. We accept "destructive testing" in medical screening (e.g. biopsies; x-ray fluroscopy with both radiation and carcinogenic chemical tracers; etc.) because we haven't structured medical screening in such a way as to incentivize investment into "non-destructive testing."

The medical establishment doesn't care about the potential for harm from repeated use of methods on patients†, precisely because we think of them as things that only need to be done rarely. There's been no need to optimize for "low cumulative impact" in screening methods, because there's currently no incentive to do screening often enough for it to matter.

Let me put it this way: the state of the art in MRI technology (reducing required size + cost per machine to enable more frequent + "trivial" use) is being pushed forward economically almost entirely by demand from Operations Research in the aerospace industry, rather than by demand from hospitals wanting to have more MRI-machine capacity per patient. That's ridiculous.

† The freshest example of this on my own mind isn't diagnostic per se. Have you ever noticed that dentists don't tell you to close your eyes — nor give you UV-blocking wraparound goggles — despite shining a UV light directly at your face for 30 seconds at a time to harden UV bonding resin they've used? They know it'll hurt their eyes if they stare at it all day — which is why the UV lights they use have circles of UV-blocking backscatter guards, to allow them to look at your face without reflected UV light hitting their eyes. But there's no concern for what they're doing to you, because you're only getting a few cumulative minutes of concentrated dental UV per year, vs. their cumulative hours of exposure.

So multiple doses of CT scan-level radiation are not a risk of harm. Got it.

Planning screening strategies is a very specialized job. There are good reasons to that.

This analysis assumes there is no harm from false positives in screening tests. This is obviously false even if the only side effects are cost and stress induced by say a false cancer diagnosis.

> "scientific evidence" does not support screening before age 50

There is a difference between science has no idea and science suggests it would be harmful (in aggregate). My understanding is that cancer screening is more the latter not the former.

As the meme goes:

> Being an old-timey doctor would rule, just drunk as hell like “yeah u got ghosts in your blood, you should do cocaine about it”

> Yes, we have an expectation today that medical procedures be backed by scientific evidence of efficacy.

Statistical evidence of efficacy, you mean. Doctors today are much less "scientific", insofar as they're less willing to work with a patient to try to experimentally derive an intervention that will work uniquely well for that patient. Instead, modern doctors try to fit the patient into a coarse-grained statistical mold, and then apply the flowcharts of rote treatments that are "proven" to work for people who were labelled as fitting that mold according to some arm of a trial. They persist in this, even when it can be seen that the individual patient isn't responding.

A doctor who's actually practicing medicine as science would, for example, run a patient up the current DSMV flowchart for treatment of depression, rather than down it — first determining, as the most important step, whether the most hard-line treatment will do anything at all for the patient; before then finding the weakest treatment that will still have a useful effect.

Also, a doctor practicing medicine as science would be doing a lot less "try this because it has no side-effects, regardless of whether you're likely to be a responder to it", and a lot more measurement to "cleave the problem-space at the joints."

(Yes, ER doctors can't afford time to measure. Most doctors are not ER doctors.)

I'm glad somebody is making the distinction between scientific experimentalism and executing a protocol based on scientific research.

I've worked in medicine as an experimental phycisist (radiology, imaging), and I found so-called evidence based medicine anything but. Evidence based is used to cement existing methods over new ones into protocols that are very, very slow to evolve.

If doctors did science on each patient (which would open up a huge can of legal liability worms), you'd pay ten times as much for healthcare.

This is just the trolley problem from ethics.

A doctor who follows those course grained recommendations derived from statistical evidence will provide the best outcomes to the most patients in aggregate.

A doctor who tries to uniquely discover the best outcome for each individual as they come through, may provide the best outcome for any given individual. But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.

When initially presented with the trolley problem, most people side with the saving the group over the individual. It's funny how quickly their minds change when they realise that in a healthcare context, they are never the group, they are always the individual.

Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.

In fact, near as I can tell. In the US, there is so much fear from doctors of misdiagnosing and starting patients on the wrong treatment plan, that they order too many measurements. Overall reducing the quality of care. The time needed to take measurements, as well as the risks of measurements are not negligible factors in healthcare outcomes.

> But overall the deviation from the statistically recommended procedure will lead to worse outcomes in aggregate. It has to, because if it lead to better outcomes, the doctors 'personalized' process should become the statistically validated process with time.

Yes, but not for the reasons you're implying.

Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.

But "number of doctors per patient" is only a bottleneck because we make it one, with medieval-guild-like limited-acceptance-per-year medical-bar licensing.

(And the medical bar does what it does, IIRC, because doctors really like being paid as much as they are; and having a more efficient market for doctors would mean doctors would be paid less. Even if it'd also mean that e.g. hospital doctors could work 8-hour shifts rather than 24-hour shifts.)

There's also the fact that flowchart-based diagnosis is liability-minimizing from a medical-malpractice-insurance perspective. With the flowchart, a hospital being sued can always use the defense that the doctor took the lowest-risk, best-practice next step they possibly could at each juncture. (Mind you, it's the best practice because it's the lowest-liability-risk — not for any other reason.)

> Measurement in medicine is also in many cases not particularly quantitative. E.g., fatigue, pain, cognitive dysfunction etc. So taking more measurements doesn't necessarily give you any useful information.

You only need quantitative instruments if your goal is to aggregate data to achieve statistical significance. An individual patient can be evaluated perfectly well ("clinical significance") with qualitative instruments. There are tons of objective-yet-qualitative instruments — e.g. observation of signs (rather than symptoms) of a syndrome, where there's no clear weightings to give to any given sign, but where one can always track each sign "dimension" of the syndrome separately, and then observe whether a given intervention improves outcomes along the "dimensions" you're tracking.

>Yes, but not for the reasons you're implying.

Following the impersonal process leads to better outcomes in aggregate because it's less labor-intensive; and so doctors end up seeing more patients; and so more patients end up being seen.

If the personalized process performs better on medical outcomes. Then over time doctors should be pushed to include more personalized steps in their treatment plans. I actually think that in many cases, personalized steps are already included in treatment plans that contain many branching paths.

It's also quantitatively true that in some cases (I believe most cases, but I don't have a good data set in front of me), a well validated flowchart leads to much better diagnoses and healthcare outcomes.

A good example: When a standardized checklist for the diagnosis of a heart attack was first introduced, doctors were upset about it, claiming that it took away professional judgement from clinical assessments.

Over time though, the checklist proved itself to be much more effective at diagnosing heart attacks than the vast majority of doctors. And most people who were having a heart attack were diagnosed correctly.

Of course some people will still be misdiagnosed (and unfortunately the misdiagnosed ones often fall into minority groups). But the statistically validated processes are not aiming for perfect. They're aiming for better than a human can do, most of the time.

And research will improve the flowcharts over time.

It also means that we can begin to think about delegating routine assessments where outcomes are very well understood to nurses, leaving doctors free to think about more complicated cases.

... and then we have dentists. With the treatment variability of x10 in price and procedures 'needed'.

My understanding is the price variability in dentistry is much less then for various other medical procedures. I have been told it because much of dental work is non inssured but I am just relying what I have heard.

Who are you or some nameless fed to tell me I can’t take drugs of choice? That’s insanely authoritarian.

The government routinely legislates public health issues.

Yes, an the government in the west is very totalitarian by historic views.

Recall the United States declared independence over 1/4 the taxes we have today and “no representation”.

Now, I can’t buy antibiotics for myself (but I can for my fish or cow) over the counter. Wtf world is this.

you are angry that antibiotics are restricted? You know why that is, right?

Antibiotic use in food-producing animals is regulated by the FDA.

That's not responsive. Nobody is asking what does happen, they're asking why it should happen on this specific issue. I can make you pray in school and call it public health.

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