Comment by pak | Hacker News Reader

Comment by pak | Hacker News Reader

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Disclosure: I'm currently attending medical school in New York.

It seems incredibly irresponsible for a doctor to prescribe things based on an internet conversation without a physical exam. You can't auscultate (listen to with a stethoscope), visually inspect, run labs, do basic imaging, etc. over an anonymous internet forum, which are basic facilities that anybody should expect a doctor in the US to utilize. It is plainly evident, once you become involved in clinical encounters, that you discover things on exam that the patient didn't know about, forgot to tell you, or wouldn't be able to find themselves. These findings are often critical for diagnosis. Telling the patient to take a certain drug without that data is dangerous and irresponsible.

You could certainly offer general "advice", but this will never be a substitute for seeing a doctor. Perhaps interfaces with video and sound are able to up the bandwidth of internet medicine but currently there is still too wide of a gap between that and actually laying hands on the patient.

I was not surprised to find that this is exactly what the linked document of related policies by state medical boards states for New York (http://www.fsmb.org/pdf/InternetPrescribing-law&policylangua...):

Section 80.63 of the controlled substance regulations requires a practitioner to physically examine a patient prior to initially prescribing a controlled substance. Issuing a prescription for a controlled substance solely on the basis of a questionnaire or other medical history submitted to a practitioner over the Internet does not meet the requirement of a physical examination or establish a legitimate practitioner-patient relationship and is not a valid prescription.

I cannot find anything controversial about that. I am all for forums linking doctors to talk to more patients, even for payment, but keep the "MD" out of the name because this is not a true substitute for seeing a doctor.

Beyond cost, seeing a doctor is an annoyingly long and cumbersome process. If it were convenient, affordable, and of reasonable quality, more people would likely utilize the service- improving health, earlier detection, etc.

How many old farmers have you seen drag themselves into clinic with their 2-year bone pain that turns out to be multiple myeloma? Would they have come to attention sooner if a virtual visit took 10 mins on their computer, rather than a full day in the city?

Hard to quantify, but I do believe there is a role for a "drive thru" option here. Not every symptom needs the full weight of an academic medical center. Every day in the community there are doctors prescribing based on only a conversation, and there's ample conditions when this is fully appropriate. When a simple answer isn't possible, referrals will undoubtedly be made. The biggest issue is establishing trust.

I think attempts like this are symptoms of something really badly broken. It obviously isn't a good solution, but for anyone to even be thinking of seriously implementing it speaks volumes.

Yes, but it is a symptom of the medical system being badly broken or a symptom of how we think about these kinds of problems being badly broken...?

Come to think of it, it's both!

If you take the concept of business and profit out of medical services and try instead to have a culture of medicine as public service, then ideas such as confidentiality and care become more commonplace.

I am not meaning this as a particularly anti-capitalist view, but I think there are areas of human existence where profit making should be excluded. For certain things, like fire departments, that battle was won long ago, and thankfully we are not in the days of ancient Rome where you would have to argue prices with Marcus Crassus before your house fire was put out. http://en.wikipedia.org/wiki/History_of_firefighting#Rome

> You could certainly offer general "advice", but this will never be a substitute for seeing a doctor.

No, and I don't think anyone is arguing that. But surely its better than doing nothing, which is the alternative for people who can't afford to visit a doctor?

The increasing inequality in access to care is something that concerns me greatly because I see it all the time (I work for a free clinic that supports local residents without insurance) and I fear that it contributes to growing frustration and distrust of the American healthcare system. It is this very frustration that fuels desperate solutions like CoinMD, sketchily marketed natural remedies and insurance supplements, political bickering over healthcare.gov and the ACA, medical tourism, semi-legal internet stores for prescription drugs, ... it goes on and on.

As a commenter below put it so well, all of these responses are "a symptom of how we think about these kinds of problems being badly broken..."

Furthermore, I disagree that something is necessarily better than nothing. Wrong or incomplete advice can be much worse than no advice. Telling somebody it sounds like they have the common cold while missing out on the possibility of tuberculosis because the doc can't do a chest XRay, a PPD (skin test), run cultures, or listen to the lungs, is downright dangerous to that person and the people that they come in contact with. If a doctor then recommends the wrong drug to somebody based on incomplete information, the long term outcome can reduce or end a life.

This is why (1) medicine is already so heavily regulated (2) malpractice is such a prevalent concern among doctors and (3) it would only confuse healthcare consumers to endorse a second tier of medical care where the advice they receive might be "less right" than that of the first tier.

Here are some reasonable parallels to the dilemma you bring up:

- Plenty of people in the US can't afford to buy a car. Is it surely better to let them all buy cheaper used cars from foreign countries with crappy brakes, no seatbelts and no airbags?

- Plenty of people can't afford to buy meat as often as they'd like. Is it surely better to let them buy cheaper meat from unknown sources which hasn't been USDA approved?

The reality is that there is already, and will always be, wide variation in quality between providers and institutions. No one should expect perfection from an online service, or anywhere for that matter.

It is this kind of thinking, the fear of missing that 0.01% chance of something serious, the fear of colleagues low opinions, the fear of lawyers and persecution- that perpetuates the current culture of doing as much as possible regardless of probability, adverse events or complications of those actions. You can't cough in an ER these days without getting radiated. You can't be a little short of breath without getting a chest CT. Surely there is a line to draw.

I agree with your overall premise that there should be a minimum quality level and regulations on any service. But I am not convinced that an online doctor (or even Watson) would be any more of a 'quack' than seeing a nurse practitioner/PA in a tiny clinic in suburbia.

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