Hacker News Reader

In defense of doctors, they are ideally supposed to practice based on evidence. That is the whole point of Western medicine in good and bad.

As a physician you might see people in your work that report these dreams and take it as a data point if it is very common. But what about people who see such dreams that don’t report them, or who aren’t even sick and it was just a dream, and most of all, who are sick and see such a dream but don’t die? What is the real statistical correlation between those dreams and death?

Any good doctor needs to be very skeptical about everything until there is properly gathered and assessed statistical evidence. It’s the opposite of being arrogant to require extraordinary evidence for extraordinary claims.

This is not a statement to dismiss end of life dreams. I think it sounds like this is a real phenomenon.

I disagree that a good doctor needs to be skeptical of everything until they properly gathered evidence. That is more a description of what a rigorous scientist should do.

There is a school of thought in medicine among some doctors (at least in Central and Northern Europe) that many patients know what’s wrong with them and one can go a long way toward a diagnosis by listening to and trusting a patient. Tests are used to confirm the diagnosis if possible, but they are well-known to be less reliable than the patients’ own experience (pains and other symptoms, for example). As an ex-medic myself, I strongly believe this is a more correct way to practice medicine, at least until significant advances are made in testing.

That is not to say that we don’t have highly accurate tests that will clearly indicate conditions (blood tests for IgGs, IgMs, BG, CRP, organ function, BP, ECGs, etc). But many conditions won’t show up reliably in common examinations and tests.

One of my old and wise doctor colleagues from a long time ago used to say that we live in the Stone Age of medicine — most of our tests and exams have very low specificity and we must treat a lot of people by what they tell us and our own subjective experience. He used to say that future doctors will see us as benevolent cave men who were constantly failed by our tools, unable to effectively remove illness and suffering, only really able to effectively listen and try to help, sometimes by just trying therapies until something hopefully sticks. I agree with them.

There is nothing worse than a distrusting doctor who dismisses the patients symptoms to instead blindly and arrogantly applies a schematic based on assumptions that our testing and examinations have very good specificity. That is just not the case for most diseases and violates the benevolence principle considered intrinsic in medicine by many. In my opinion, this is only acceptable for new doctors (like those still in training and under supervision). Otherwise, this behaviour is just malicious.

The science of medicine is very different from practicing medicine. The consequences of malpractice are deadly, and the time to treat a patient correctly is often limited. Scientists work in a much less constrained environment. Applying rigorous scientific method has relatively few negative externalities.

> There is a school of thought in medicine among some doctors (at least in Central and Northern Europe) that many patients know what’s wrong with them and one can go a long way toward a diagnosis by listening to and trusting a patient. Tests are used to confirm the diagnosis if possible, but they are well-known to be less reliable than the patients’ own experience (pains and other symptoms, for example). As an ex-medic myself, I strongly believe this is a more correct way to practice medicine

What evidence do you have to "strongly believe" this? It's quite something, to state that the patient does a better job diagnosing himself than the doctor does. In that case, there should be some evidence to that effect, to show that this is indeed the case? Otherwise, saying "I strongly believe" or "school of thought" is just a way of saying "I have a hunch".

> There is nothing worse than a distrusting doctor who dismisses the patients symptoms to instead blindly and arrogantly applies a schematic based on assumptions that our testing and examinations have very good specificity

What on earth are you talking about? Medical diagnoses are made using a variety of sources of information, including of course symptoms! What do you mean exactly "dismisses symptoms to arrogantly apply a testing scheme"? Maybe I'm misunderstanding.

Yes, possibly misunderstanding or perhaps I did not communicate clearly enough. My position is not extreme and speaks of the relative minority of medics who suffer from medical arrogance.

> to state that the patient does a better job diagnosing himself than the doctor does

This is not what I stated. I stated that listening to and trusting the patient helps arrive at a diagnosis more reliably than only doing tests. Sometimes it can even help arrive at a diagnosis more reliably than doing tests (for example, fungal infections can be seen or felt by patients more reliably than their cultures grow in the lab, and most doctors diagnose without a culture test).

> Medical diagnoses are made using a variety of sources of information, including of course symptoms!

Yes, but too often the diagnoses are made following algorithms or guidelines that don't suit many patients. A doctor is often required to follow the algorithms (and perhaps for a good reason), but should also know when they are not applicable to an individual patient.

My position is not extreme, although it's not mainstream either. There is a large body of research talking about medical arrogance specifically manifesting as doctors ignoring the patients. Likewise, many people in the field (at least in some regions like the UK) have experience dealing with colleagues who swear by algorithms (or worse — their own ideas) and are skeptical of patients who don't fit within them. This seems to be much less common in other regions. My family works in the medical field in Central Europe where, in my opinion, very few medics have issues with medical arrogance. I cannot comment on the US where I assume a good number of readers of this text are from, although academic literature indicates it's a global problem.

Would you like to make bonds with people that will soon die over and over again? I think many people misunderstand the kind of stress and mental strain that many doctors are subjected to regularly. Ironically, people who call for doctors to be more empathetic, often lack empathy themselves.

Also medicine is very broad field, it's probably hard to stay up to date in every new study. Especially that academic research is filled with less than ideal studies, so not only you need to read and understand them properly, you also need to make sure that source is trustworthy.

That stress doesn't come from empathy, it comes from treating death as something to be feared and not talked about.

In other cultures death is not such an icky subject, and making bonds doesn't mean generating attachment that will lead to stress.

I'd have some empathy for doctors. They are doing what they are paid to do, which is extend life and improve its quality according to a given set of metrics.

Like most engineers, when there is a potential positive outcome that isn't captured in the metrics they are incentivized to improve, they shrug and turn their focus elsewhere. It doesn't mean they're happy about it, it's just not their job.

> it is sad to hear about yet another case where doctors are too arrogant to listen to their patients and try to understand

It's not 'doctors', it's 'people'. The width and breadth of the world is a greater challenge to our understanding than most of of are even able to comprehend. I suspect.

Very true. I was specifically talking about medical arrogance as a phenomenon, but of course, arrogance and choosing to remain close-minded is common in people.

Almost everyone could benefit from being more receptive, observing, and open to new ideas. The most open-minded people I ever met spoke most of how much more observant and receptive they would like to be.

> And it disappoints me greatly that the medical community shuns this phenomenon

The medical community is a joke as a whole. They even brush off side effects because they have never heard about them before. They are as unscientific as you can go.

Nowhere in hard science world do people act like that.

> The medical community is a joke as a whole. They even brush off side effects because they have never heard about them before. They are as unscientific as you can go.

I've had lackluster medical care before, but this is an extreme position. A lot of health professionals are dealing with life and death decisions on an hourly basis. I can understand how under those circumstances you'd be biased towards conservative and practical methods. Do what you know works; you don't want someone to lose their life, or have some horrible complication, because you think it'd be cool to try something different.

The complaint isn't about any particular treatment but rather about a lack of basic respect for patients. I once had a doctor tell me I was lying because studies show that only 10% of patients had that side effect. There are systems that are supposed to help find previously unnoticed side effects but I wonder how many doctors are actually using them when some have such strong reactions to known and not even that uncommon side effects. Of course, patients can also incorectly attribute something to a medication and doctors need to take that into account as well but repeated challenge gives a better idea. Some particularly strong effects, like that prompted the doctor's comment in my case, are rather obvious when they being shortly after starting the medication and stop shortly after the medication stops. Patients need to be ready to decline treatment if doctors aren't listening or there can be major, even deadly, results.

> The medical community is a joke

I've been reading "The Medical Detectives" and it seems like there used to be a stronger drive to seek understanding of the unheard.

We have made a system that has no room for seeking understanding. It needs to be fast, affordable, and without mistakes otherwise you’ll get sued, so everyone simply follows protocols.

I have respect for doctors and their skills, but I don’t associate the guys actually running around in a hospital with hard science. They are factory workers, like programmers that produce widgets on a tight deadline. They have a metric ton of shit to handle under enormous stress.

I agree with the idea that medical doctors are not scientists, not even engineers. Yet I think it's impossible to do medicine as if it was a science: Most person is different from the next because their life events, and biology and medicine are incredibly hard.

For example we do not have models of human physiology, even if it looks something that could be computerized (there are efforts: dr Guyton's heritage, BioGears, etc).

Another thing is that we only had recently tooling to interrogate what's going on in our body: MRI and ultrasound. Yet no medical doctors (GP/family doctor) use them. At best they use blood analysis which gives an indirect knowledge. But if the doctor does not ask for the right analysis, whole health developments stay unknown until it's too late.

And many family doctors work with feeling more than with medical standardized practices: It's common that old family doctors say that they know what brings a patient as soon as they enter into their office. This is because of these "gut feelings" that we still have half of cancer cases that are discovered when they are metastasized (too late to be treated by oncologists).

Ok, I'll state the reverse opinion in the same stark way as you did: why should they? Their job is helping people who still want to live and can be helped. If someone is terminally ill and has made peace with the thought that they are going to die soon, there's nothing they can do for them anymore...

> Their job is helping people who still want to live and can be helped.

By this logic pain management is also unnecessary, because the patients won't (generally) die of pain.

It is necessary because understanding the process (1) may improve the quality of (remaining) lives of the patients, and (2) may actually help prolong lives, similar to the placebo effect.