This article was posted before several years ago. The whole premise is bumptious - "I can copy data out of a bunch of papers [which I am in no position to screen for quality or relevance], run a canned 'gold standard' analysis in R [the idea that there is one true way to generate valid data is ridiculous], and then go tell the professionals what they are doing wrong." He even brags that his meta-analysis for depression had more papers than the published one, as if this was a valid metric. The Cipriani meta-analysis he cites was publised in February 2018. His meta-analysis was done in July 2018, and had 324 more papers - what explains this difference, other than obviously sloppy methodology. A proper meta-analysis is a lot of work, researchers spend years on one meta-analysis. The whole concept is ill conceived, and the author is too caught up in themselves to even realise why.

Meta-analyses are a good idea, but the mere presence of a meta-analysis does not denote a useful undertaking. The literature is polluted with thousands of meta-analyses. As far as I can see this is mainly because there is software available which lets almost anyone do it, and once someone else has done a meta-analysis it is much easier to do another one because they have already found all the papers for you. The publication rate of meta-analyses far outstrips the publication rate of all papers, and shows some unusual geographic variation (Fig 2) [1].

[1] https://systematicreviewsjournal.biomedcentral.com/articles/...

With all the negative pushback this is getting, it’s making me think he was onto something. The exact same criticisms would apply to Airbnb, for example. “They have not the slightest idea how the hotel industry works. This is a very professional industry with a lot of legal hurdles...”

Just because people think an idea is bad is doesn't mean it's a billion dollar startup idea. Indeed, most ideas people think are bad are actually bad - it's only the few outliers that are actually successful. Even then I think there is a ton of mythologizing around this idea that the founders were able to see something nobody else did, usually to make the founders look like some sort of diamond-in-the-rough geniuses, when in reality what they built was just a natural evolution of tech that existed at the time (successful founders usually just execute better and faster than others).

I mean, despite all stuff I've heard on HN about how a lot of big VCs passed on AirBnB, when I first heard of it it seemed like a very natural evolution from sites like Couch Surfing and VRBO that had existed for years.

Well, Airbnb and Uber aren’t the best examples, are they? Their growth and “success” is fueled by either operating in a legal gray zone, or defying the local regulations all together. Many people all over the world think their lives were made much worse since Airbnb is negatively affecting the long-term rental market.

Point is, the effect of the company on the society can’t just be measured by market cap.

Back to the original article, the author was using statistical analysis to provide medical advice. Now, it’s incredibly easy to arrive to false conclusions with statistics. That’s why there’s regulations, peer reviews etc. What if the “Egyptian contractors” screwed the data up. Was the founder qualified to spot an issue?

Arguably one reason those two businesses were successful in areas with entrenched players and business practices was because they handle the money. If AirBnB was asking either travelers or hosts to pay $X to be on a recommendation site, probably very few people would. There's always a cheaper competitor when you're selling information. Because you book through AirBnB, for a service which is relatively expensive, they can skim off quite a lot of money in an opaque way.

I think they’re ideal examples. Market cap is pretty much everything. It affects the world more than morals do.

HN has drifted further and further from reality, which has been very strange to watch. The classic example was someone dismissing Dropbox when they first launched, but now it’s turned into dismissing billion dollar companies after they’ve clearly won.

Only the parent doesn't dismiss "billion dollar companies", they dismiss comparing them to shut down, non winning, companies like in TFA.

Ah yes, one failure = the idea is horrible. Another classic trope.

You’re constantly steering the conversation somewhere else, aren’t you?

The meta-analysis idea wasn’t terrible. It’s just that there’re many assumptions in a statistical sense, the founder might not be the right person to implement it and he might have targeted the wrong market. Some people are under the impression that everything can be solved just by build an app. However, some fields are much more complicated than your gig economy food delivery.

Also known as “having a conversation.” I’m not sure why you don’t see the bad faith in your words, but I have no interest in talking more. Goodnight.

Well, the idea was rejected by patients, advertising revenue, and doctors...

I also note the "weasel word" idea. This wasn't just an idea, but an implementation.

The same thing might make sense as a value-added feature in a more comprehensive health service (so the "idea" might be good when put in that use).

But as an idea for a service based entirely on it, it failed hard. What exactly twist do you have in mind to save it? Or are you just saying "we'll never be sure" with more words?

If you study a lot of history, you start to notice that old ideas are bad until they’re suddenly very good. Cannons sucked for a long time, till Napoleon showed they weren’t so bad.

I think posting haughty words is a lot easier than trying to make something work.

>If you study a lot of history, you start to notice that old ideas are bad until they’re suddenly very good.

Also the opposite: dumb ideas are tried again and again to no avail ever.

Adding as example of dumb ideas, people constantly trying to patent perpetual motion machines.

Nitpic on Napoleon, cannons were used centuries before him in sieges. People knew they were good all along.

Wasn't the someone who dismissed Dropbox when they first launched Steve Jobs?

How is that a "classic example" of drifting away from reality? "I don't think this startup business that doesn't seem likely to succeed will succeed" is a comment that looks funny in hindsight, that's all

> Their growth and “success” is fueled by either operating in a legal gray zone, or defying the local regulations all together.

We just got an impossible vaccine in under a year, I'm happy for all of medicine to spend a bit of time in a "legal gray zone" to see what might happen.

> Many people all over the world think their lives were made much worse since Airbnb is negatively affecting the long-term rental market.

Absolutely, just like the Luddites (Although they would be well off Luddites) their world is worse. But humanity has been made far better.

Aren't you falling for the survivorship bias trap? Sure, people have said that about Airbnb. But I think there are loads of that startups that failed because they didn't understand the industry they were in, or because of legal hurdles.

I think there's probably a lot more to be learned about business success by studying business failures. There's certainly a load more source material.

At least the last part seems to be right, doesn't it? As a user I love Airbnb, way cheaper and better than hotels, epsecially with a family.

Saying that there was a nuanced difference in what these two companies tried to accomplish would be a gross understatement.

Statistically speaking, isn't it sound to throw all the papers into the mulcher and see what comes out the other end? We do use the term "outliers" a lot in statistics, do we not? I understand that the quality might not be up to snuff for some, but won't the law of averages take care of that?

Have you ever used a mulcher to chop up some yard waste, only to accidentally put in some dog shit, and then the whole thing stinks to high heaven?

In all seriousness, with meta-analyses it's still "garbage in, garbage out". It only takes one or a few egregiously bad studies to throw off your results if that study has a large sample size but something fundamentally wrong with its methodology or implementation.

I've dealt with enough types of data that I feel super skeptical that you can just dump numbers from hundreds of studies into some data store programmatically, do statistical calculations, and get valid results. It's very difficult to believe that there aren't a ton of variations in how the data is gathered, filtered, and presented that need to be accounted for before any comparisons can be made. I'm not going to trust the law of averages to negate the effect of completely out of whack data when peoples' health is on the line.

This assumes all papers are of equal quality, peer-review and accuracy of results. Which we know they are not. Some studies should have more weight than others. Which has been mentioned in a previous comment; there is no 'right' answer, just a variety of ways to allocate different weights to papers based on various metrics.

You misinterpret the law of large numbers. What the law says is that if you have a large amount of samples, and assuming there's no pervasive bias in the samples, then any large enough sample (and often that's much smaller than you think - the classic example being election voters, with a group of only a few thousand representative voters being enough to predict the outcome of an election over a large country with millions of voters) will look identical to any other... that is, over a large enough sample, in the case of this article, the conclusion of many papers should converge to the same answer, with outliers being marked out as likely "bad" papers.

The only assumption you may reject here is that there's no systematic bias in the papers. Perhaps there is... or perhaps most papers are just very unreliable, in which case there should also be no convergence... but if you find convergence, there's a good chance the result is "real".

But the crucial bit here is the "large" in "large numbers". I expect that even for quite popular drugs the number of studies are maybe in the hundreds, which depending on statistics could well be quite a way from large enough. In particular if a significant fraction are crap studies.

You mean the Law of Large Numbers (LLN), not the Law of Averages, right? Both the Weak LLN and the Strong LLN presume all samples are independent and identically distributed. If we make a hierarchical model on the data of each paper, we can bind all the data into a single distribution, but assuming that each of these studies is independent is a _long_ shot. WLLN and SLLN _only_ apply to, roughly, sampling from the same process. Its scope is more applicable to things like sensor readings.

The Law of Large Numbers is an actual math theorem. The Law of Averages is a non-technical name for various informal reasoning strategies, some fallacious (like the gamblers fallacy), but mostly just types of estimation that are justified by more formal probability theory.

More generally, see "concentration of measure".

https://en.wikipedia.org/wiki/Concentration_of_measure

You get some numbers, they look good - fine, but at best it’s grounds for a proper study, at worst wildly misleading. You can easily fool yourself with statistics, and other people too.

For a good read about studies with solid statistics and bogus results, see [0].

[0] https://slatestarcodex.com/2014/04/28/the-control-group-is-o...

Based on the response he got, it was the right question, actually. People aren't Internet-style insecure in real-life, especially those who have high social cred (like doctors). Even accounting for the humorous exaggeration, the kind of question asked from a professional doctor is less likely to cause them to be offended and more likely for them to just tell you why not. They're not going to be "How dare you question my decades of experience?!". They'll answer like they did in the OP.

In The Mom Test, he suggests getting right to the core of a customer's pain points. This is just corollary to that.

Although do note that doctors are just humans, with all the same flaws. There's just a bias in the kinds of humans that tend obtain the title.

Yeah, I do clinical placements in hospitals as part of volunteer work, and doctors run the range from open and receptive to questions to incredibly arrogant and dismissive.

The fact that they agreed to talk to the OP probably means they aren't going to be immediately dismissive, but I'd hesitate to assign any supranormal human traits to doctors.

He had not the slightest idea of how doctors prescribe drugs.

The typical doctor has minimal training in evaluating medicines - that is not their job.

They defer to so-called opinion-leaders, who are the experts on particular diseases.

These people are the targets of drug companies' marketing - think scientific conferences in 5 star hotels in exotic locations.

The cost of influencing them would be millions.

So,the author was barking up the wrong tree.

That's not to say that he didn't have something, but had no idea how to market it.

This is so removed from reality to the point that it’s hilarious. Doctors evil. Doctors bad. Doctors corrupt. Doctors rich. That psychiatrist in the article sure must have been bribed to prescribe those 30-year-old drugs, right? There’s this thing called evidence-based medicine, go educate yourself.

I mean, there's a reason pharmaceutical companies in the US spend $20 billion a year marketing to physicians and it's not because it doesn't work. Doctors in the end are human and as capable of being influenced and biased and taking shortcuts as any other person. That doesn't mean they're evil, just human.

A big chunk of that $20B is on high cost ads to the general public, which doesn’t occur in many other parts of the world. It’s a backwards system when a patient is told to ask their doctor for a prescription to a medication by the company that manufactures said medication.

No, that $20 billion is ONLY for doctor marketing. There's an additional $10 billion on top of that spent on patient advertising/marketing.

edit: There's a whole industry around providing pharma companies better tools to influence doctors. I believe the industry name for this part of pharma companies is Medical Affairs so feel free to google the tooling being offered.

Yes, one of the few culture shocks when I lived in America was pharmaceutical advertising to the public. Another was constant political advertising on TV.

It is also a source of culture shock for Americans like me who visit friends and relatives that watch television. I mean, I watch netflix, but haven't ever had a cable subscription, and while I have a digital antena, I pretty much never use it. Visiting a home where the TV is on constantly is shocking, with all the ads and the viewpoints presented. It really shows how much the media fracturing is helping drive the political divide in the country too. I can't really imagine having those messages constantly pounded into my head.

I mean, you're just spewing insults at people instead of providing any numbers or facts. Clearly you don't want to have a discussion or educate anyone but just want to find reasons to insult people.

Nobody has to be evil or bad to read the white papers presented by their vendors rather than doing independent research. A doctor's job is not to figure out the best possible treatment for each patient, as nice as that sounds. It's to improve the life enough of enough people given the time available. If four drugs are approximately equivalent don't blame your doctor if you get the one that's only 90% as effective in your particular case.

Part of regulatory capture and the industrial complex, why medicines like MDMA and psychedelics have been illegal for decades due to them not being patentable - and being competition that most recent research shows is far more effective and without the "side" effects of many big pharma's drugs.

Far more effective? Source?

For a user named ketamine_ are you really questioning the well known efficacy of few-shot therapies for treatment resistant depression and PTSD?

Psychedelic-Assisted Psychotherapy: A Paradigm Shift in Psychiatric Research and Development: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041963/

Reviewing the Potential of Psychedelics for the Treatment of PTSD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311646/

etc.

> For a user named ketamine_ are you really questioning the well known efficacy of few-shot therapies for treatment resistant depression and PTSD?

Maybe they want to convince their friends?

Not all experts are cheerleaders.

I'm questioning your enthusiasm because I have experience and have read the research.

It is still early days. If one can end depression with an oral medication that isn't scheduled one is better off.

Some doctors use expert systems. They select symptoms and computer spits out possible list of treatments and then doctor picks one. If it doesn't work asks to come back and tries the next one. It's kind of like a human in today's self driving cars. Especially when it comes to mental health and anti-depressants. Essentially tests on production.

This isn't even close to how doctors prescribe medications. You don't prescribe meds without having a working diagnosis. Once you have that, you use the knowledge gained in med school and residency to pick the first line drug. If there are contraindications due to comorbidities (which there often are), you have to figure out what other meds you can use. You can consult online resources (e.g. UpToDate) to look up second, third, fourth line meds as well as advice on specific complicated scenarios.

Trial and error with prescription drugs without a diagnosis as you suggest is malpractice. Maybe you're specifically referring to psychiatry? That specialty is uniquely difficult since our understanding of psychiatric diseases is still murky. But even within psychiatry there are best practice guidelines on how to manage and treat different diseases.

You might be right for single-casual illnesses like a broken leg, CoVid-19, Tuberculosis, and others. But it's a whole other thing when it comes to more complex illnesses.

Having been for 18 months through different types of psychiatrists and clinics, I came out quite surprised in how "trial and error" this whole system is.

I'm writing this from Switzerland, where we have an (arguably) high quality health care system. But the amount of "OK, that didn't work, lets try this other drug". Or, now, 18 months later, "Oh well, we did the list once through. But who tells me that the MD prescribing the first drug did a correct analysis? Lets start the list from top again." Or, for a friend of mine, his girlfriend found a working cure like that: "Oh, this brochure describes your symptoms so clearly, and it's completely different from what you've been treated for these last 20 years. Let's try it!"

Spoiler alert for my case with the list: the top of the list was not better the second time around.

If you think this is cynical, well, I would like at least _one_ of these drugs to work. If you think the MDs are all useless: well, at some times I was glad they were there.

So, well, I think having a little less than random system might be helping. Let the MDs watch if it makes sense, enter the correct diagnosis, and catch the stupid errors data entry people can make. But i'd give it a try...

The closest thing to an expert system I've seen is clinical practice guidelines, which sometimes includes decision trees of indications/contraindications for administering certain medications for common and time-sensitive medical events, like cardiac arrest or exacerbation of breathing difficulty with COPD.

This is what I saw my doctors were doing. Also I saw cardiologist comparing my diagnosis using Google images.

Yeah, I believe your experience, and I think it highlights the issues we have with communication in medicine. While it may look like your doctor is just blindly Googling something, I would imagine they're probably using it as more of a reference source (at least that's what I often do). I regularly use radiopaedia.org just to look up a quick fact or find alternative examples of a diagnosis I'm working with.

It's like Googling coding questions and reading a StackOverflow thread. Obviously no programmer is solely relying on StackOverflow to do their job as no physician is solely relying on Google, UpToDate, or any other resource. They're simply quick references.

> Obviously no programmer is solely relying on StackOverflow to do their job

I've encountered a few people who were doing something very close to this. I really hope that doesn't happen in medicine too.

That's down to the (obvious) fact that job performance and working ethics is not equal but distributed among practitioners.

I think this is especially visible in software "engineering" with people joining the craft after a few weeks of boot camp. (think engineering vs programming)

However, we put doctors through an especially rigorous and long training and certification process to minimize the amount of unqualified practitioners.

Doctors are supposed to have a higher entry barrier than software developers. Does not mean that all of them are brilliant, of course.

Having software to show differential diagnoses, or using Google images because you know to search for, are not the smoking guns you think they are.

Hey remember when the opioid companies paid the clinic management(?) software companies to push opioids to people?

https://www.washingtonpost.com/nation/2020/01/28/opioid-kick...

The conversations are surely paraphrased and exaggerated—just look at the style of the rest of the article.

The position that doctors should be trying new things to improve their care sounds good but in practice most doctors are strongly biased towards the status quo and usually inaction is preferred to a slightly unknown action, even if that action has better expectancy.

I dunno. I think tech people have a tendency to assume they know for certain that they have a better solution, and their words/tone can reflect that in a way that can come off as very insulting to people who have been working in the space for literal decades.

Not everyone, and not all the time. But many people, and often enough that it's a stereotype. So I think it's worth considering, particularly when you're looking at a customer base who (by and large) really aren't used to being condescended to.

Even if you and I personally aren't offended in the slightest by what OP said on sales calls, it's possible a psychologist in the fourth decade of her career might take "Are you sure that's right?" differently than we would.

He struck me as completely oblivious to what was likely to have been a complete lack of interest.

His approach was never going to work, as doctors do not spend their time evaluating drugs in the way that he imagined.

It's a great example of "I'm going to make a pretty chart, and sell to.... $PROFESSION!"

It may have been a great product like you and others have said, he hasn't the faintest idea what physicians actually do day-to-day. He had apparently spent $40k over nearly a year before he talked to the first physician.

That's because his first plan was to sell to consumers. Only when that didn't work out he switched to physicians.

Like someone else said, he got greedy. Even if he had stuck to the WebMD model, he would have made a fortune. People like to Google symptoms before seeing a doctor, and although unethical, pharma companies would have gone head over heels to market in those spots.

I don’t think that was the point. The point was better healthcare doesn’t necessarily translate to more revenue. Healthcare is weird like that - you get paid a flat fee for visits. There might be an argument to be made that better prescriptions = happier patients = more retention, but it’s a stretch. If your practice is already booked full what’s the point?

This biz was clearly made for consumers but yea ads are tough - need a lot of eyeballs.

Better healthcare outcomes are of interest to health insurance companies and employers, not the healthcare providers. A reduction in overall claims over a patient's lifetime and better employee health are quantifiable financial results.

Healthcare providers hope for better outcomes I'm sure, but it's true there's not much financial incentive in most cases. Your comment sort of suggests the model for such a service should be on a per-use model, covered by an insurance company when a doctor uses it for their patient. That's a trickier model than subscriptions, but it may be viable.

Yeah I agree that’s the point of the article. I think what I wrote would still be a reason even if it is rationalised differently.

The argument that “patients won’t know the difference so I can just do whatever” must break down at some point (hopefully before malpractice) but I think an argument of “I’ll just keep doing what I did before, it’s worked fine so far” doesn’t encourage worsening treatment or paying for more experimentation.

As somebody said here, first line drug is prescribed since it’s know to work based on experience. Any experimentation puts too much unwanted responsibility on the doctor.

Right, and both doctors and patients don't want to run another experiment. If they are comfortable with a certain drug, that's a good enough indication its a good first step to getting better.

Psychiatrists are simply experimenting on each person they prescribe medications to. The status quo is indoctrination, and in this case, the psychiatrist wasn't even willing to use actual research based data to improve the treatment of their patients - even referencing that they won't make anymore money because the patient won't come back more often or refer more patients because of it. This is abhorrent unprofessional behaviour - but it's likely the attitude of 90%+ of the field.

Edit to add: if you think a practitioner putting their own revenue/profits above providing quality care, then something's wrong with you.

In medicine "quality care" is a binary attribute. Something either meets the quality threshold or it doesn't. And as the author found out, physicians do not spend their time researching medications. It's not their job, they're not trained in it, and most of them wouldn't be particularly good at it.

So I'm not sure why you would expect a psychiatrist to do something she's not trained to do to (maybe) increase an already acceptable metric some arbitrarily small amount higher.

I've seen this happen and the entire process of adding new drugs and waiting a week or more between visits seems cruel.

Lots of psychoactive medications take days or weeks to build up in the body to the point of effectiveness. They're finding out neat things about esketamine and psilocybin, but in general a large enough dose of a mood-altering drug to take immediate effect is a bad or at least very risky thing.

> I'll just prescribe what I normally do, since I'm comfortable with it

This is actually something that drives me absolutely nuts about doctors in the UK (I presume they are the same elsewhere) - inertia.

It's like doctors leave medical school with "best practices" about what they should prescribe - like they are glorified, human decision trees - and then across their 40-year career, they never read a paper, never read any new guidance, and general never change.

Inertia seems to be a particular problem in the NHS, where doctors have a set list they are willing to prescribe. Why? Because it's what they've prescribed previously, so they are "comfortable" with it. You can see there is a bit of a "chicken and egg problem" with other medications.

There is also the 'NHS approved medication' list that they can only prescribe from, which restricts whats available to you, and it takes years for something newish to make it onto that list (for reasons...)

If you want better options, the only choice in the UK is private healthcare.

But yeah, I do still agree with you - GPs don't seem to even be up-to speed on the latest info with regard to a patients condition - surely their industry requires on-going professional learning like the rest of us ?

None of this is true.

It's not technically true, but there is a lot of truth in it.

There are lists of recommended treatments, and there are many restrictions on prescription of medications, expensive ones in particular.

At a national level, NICE[0] (or SMC[1] in Scotland) decide what medicines the NHS will pay for, and for what conditions. They determine what medications are licensed for different treatments. They also set guidance on what treatments should be used for different conditions, what the 1st line, 2nd line, 3rd line treatments should be, and what treatments they think should not be used.

At a regional level, there are "formulary" groups, which take the national guidance, and make some tweaks - for example, for monetary reasons, they often increase the restrictions on expensive medications, making them harder to obtain. An example of those restrictions might be that the patient has to have been suffering for longer, the impact of the condition has to be more severe, or the patient must have tried several other (cheaper) medications first.

For expensive medications, it's often not as simple as a consultant saying "I want my patient to have this" - at a regional or hospital level, there are quotas/limits on how many patients per year will be treated with sich expensive medications, and there are comittees that meet regularly to decide who is worthy.

Now, if we put aside those expensive medications for moment: yes, technically consultants are free to use their experience, knowledge and judgement, and prescribe what they see fit (even unlicensed drugs) - but in reality, within the NHS it is uncommon to prescribe outwith the regional formulary guidance, or/and outwith licensed medication uses. There are a number of reasons for this:

1. Consultants take on individual liability when they prescribe unlicensed medicines, and individual hospitals fear legal risk too

2. Consultants will have their balls broken by their department head when they prescribe expensive medications - dept heads have budget responsibility, and in turn they will have their balls broken by the board

3. Consultants regularly meet with others from their department to discuss difficult/unusual cases, and have to justify their decisions to the panel

4. Perhaps it's the workload, but (IME) NHS consultants often have outdated knowledge. I swear some have never so much as read a journal article since they left medical school 30 years previous :( Again IME, private consultants seem to be much more confident to think out of the box with treatments; perhaps it's the commercial competition?

[0] https://www.nice.org.uk [1] https://www.scottishmedicines.org.uk

At it's core "modern medicine" is not actually a science. We've added a veneer of science, there's science at the edges, but at it's most basic form it remains an art from inception in the 19th century to today.

* Pharmaceuticals: science, mostly, but beware of "pseucutcals" like supplements and herbal remedies. Also beware of new ideas that cut into profits.

* Cutting-edge surgery: science

* Mental health: art, with a dose of science from big pharma

* General practice: mostly the art of laying on hands, distilled experience, a bit of research with your sales rep and whatever you took with you from medical school.

If this feels harsh, remember that, despite solid scientific evidence, it took over two decades for the conventional medical wisdom to move stomach ulcers from "caused by stress you need to relax" to "caused by helicobacter pylori we can treat it with a convenient antibiotic." Inertia is a helluva drug.

It's actually a very good sales question, I don't find it demeaning at all.

If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation.

It could come off as standoffish but when used correctly it's very effective because it gets the person on the other end to open up more and you try to get to the bottom of their objections.

I was ready to agree with you because question in the OP wasn't so bad, but "So you have perfect user retention then?" -- seriously? Yeah, that's being demeaning. Maybe being demeaning is a good sales technique, I dunno, but that's definitely being a jerk.

But "Are you sure increasing your user retention isn't worth something to you?" or something like that maybe.

It really depends on your tonality when you say it. In either case, saying "Are you sure increasing your user retention isn't worth something to you?" is just going to be met with another "No, we don't need it" from the other end.

"So you have perfect user retention then?" is a better question because you know for a fact that they can't have 100% user retention and they know that as well so it forces further dialogue.

i guess this is why I'm not a salesperson. If it works it works, but I'm having trouble accepting that it's not demeaning, which was the original contention. Because it's not really a question at all, it's a sarcastic question. Maybe being demeaning gets sales, sure.

Think of it more as being a pattern interrupt. They are saying no to you over and over, so by asking the question, "So you have perfect user retention then?" they can either say "No" instinctively which opens your sales pitch because they've now told you they have a user retention problem, or they stop and think about the question in which case you've successfully interrupted the pattern of no's that preceded the question and can further the discussion.

There are definitely better examples I could come up with, but now I'm stuck with this one because it's what I quickly typed out earlier.

Sales - like marketing - definitely does have an element of psych to it.

Anecdotally, it feels as though it leans on a lot on the targets level of politeness and decorum to want to continue the conversation. I favour polite but abrupt and seemingly heartless conversation enders for this reason.

"Hello sir, would you like to help a child keep eating for $2 a month?" "No, thank you!"

Back to this specific case, I guess the trick is to deliver your question almost rhetorically with both parties knowing that it leaves an answer that is common knowledge. Kinda like safe small talk about the weather.

Keeps the conversation going buying time for another hook to be deployed.

> Because it's not really a question at all, it's a sarcastic question

It's not sarcastic, it's serious and that's the point.

Obviously they don't have 100% retention, so this question might open them up to talk about their retention instead of saying "no, it's fine like it is".

It doesn't matter how good your retention currently is, if the product can boost it even by a couple of percent it would probably pay for itself many times over.

I think you could make the argument that saying "no, we don't need it" before even trying to understand the value prop is just as demeaning.

You seem to have an idiosyncratic definition of “demeaning”.

Agree with you on that.

Arg I HATE that angle ! It's like that sales calls.. "Do you like money ?".. if you say no thank you I"m busy... they like... oh so you don't like free money ?

beep beep beep

>If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation.

Assuming that I didn't initiate the call, if I tell some sales punk that I don't need their product and they come back at me with "So you have perfect user retention then?" my answer is going to be "fuck you" followed by ending the call.

Arrogance might work in used car sales but it's not a panacea for closing the deal.

I'm sure that happens occasionally as well.

I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement.

They will call the next person on their list, I'm sure it won't matter much.

Incoming spam is unwelcome in general, and I would not assume that this people are trying to help me.

>I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement.

Oh please. Not every product that's applicable to a given business would necessarily be beneficial to that business.

I get it, sales people have to drink the kool aid, but some humility is needed. Your product isn't right for everyone, and the sooner you understand that the sooner you can improve the quality of your lead generation.

If you have a vendetta against sales people you can just say that. We are talking about a completely hypothetical situation here, I don't see how you're now implying that the lead generation isn't good enough.

On HN, people hate cold emails. In real life, I've found that most people will respond or ignore. Like a tiny minority will act like you killed their mother, but that's life.

I know you know this, if you're in sales, but I, like many other engineers who read this forum was overly cautious when I first started speaking to people because I anticipated that 99/100 would be upset at having to talk to me.

The truth was that 99/100 were willing to speak to me and listening to HN and Reddit set me back farther than I expected until I unlearned that lesson.

So I'm saying this for the benefit of all those other engineers like me.

I guess that it is a selection bias.

People hating spam will complain about it, people not hating it will not bother with commenting.

And HN may have higher share of people more affected by spam (surveys send to emails scrapped from github and so on) and more likely to be able to find needed services - what makes beneficial cold calling even more rare.

And I guess that my reaction is unusual. I moved to another phone service after previous one cold called me offering a loan on bank service operating under their brand - and that was a sole reason.

Makes sense, you're typically not cold calling or emailing engineers which is presumably the majority of hacker news users

I don't have a vendetta. I used to work in sales. My first job out of school was cold-calling and I saw first hand what types of people tend to rise to the top in that environment.

I quit that job as soon as I could because I was sick of manipulating people or pressuring them into buying something they didn't want. At the end of the day that's all sales is. If your customer wants your product then by definition you don't have to sell them.

That makes a lot of sense then honestly. "Boiler rooms" are definitely not good environments.

>If your customer wants your product then by definition you don't have to sell them.

That's a misnomer, what if they don't know you exist? That's what sales and marketing are for, to inform people that could benefit from your product that it exists, essentially. Will their business implode if they don't buy your product? No, almost certainly not. But, they might derive a massive cost savings, time savings, increased employee satisfaction, or other efficiencies by using whatever you're selling and your job in sales is to get them to listen which is the hard part.

>That's a misnomer, what if they don't know you exist? That's what sales and marketing are for, to inform people that could benefit from your product that it exists, essentially.

This is a fiction that salespeople tell themselves to help them sleep at night. I use twitter not because someone from Twitter Sales sold it to me but because I sought it out of my own volition.

Only bad products need sales. Good products can thrive on marketing alone because people want good products.

We're talking about the context of a cold call here. It's extraordinary unlikely for something that is genuinely beneficial to me to come to my attention via a cold call. Maybe your product is actually good, but there's a wave of pushy salesmen trying to sell snake oil via these types of channels. At best, you've got a very tough job to make a sale to a business under those conditions. I don't know about the typical business, but that kind of talk isn't going to keep me on the line.

HN guidelines: “Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith.”.

I would presume that sentence is a quickly typed paraphrase. If you presume they are a competent salesperson, you can also presume that they say it less antagonistically in real life. Edit: Or perhaps they have found that antagonism is the most profitable solution for the business to turn around a “no” answer.

>HN guidelines

The comment to which I'm responding explicitly argues that the phrase, verbatim, is a good sales tactic.

you referred to the caller as a sales punk before he uttered the phrase, exposing your attitude. Just because you are biased against sales people and also have a thin skin when it comes to the slightest challenge in a question does not mean that the product would not be beneficial and worth it to you if you had a more open mind, nor does it mean that the sales technique on average is a failure.

i.e. when I read your comment it struck me as much more revealing about you than about the salesman, his technique, or his product.

People have argued that the tone and context in which it is being said will influence effectiveness. Verbatim has nothing to do with it but you keep ignoring that point.

It was indeed a fun read. As a pharmacist I had a similar 'idea' years ago and got two other pharmacists excited. We were sick of seeing prescribers not follow 'Evidence based medicine' and thought maybe something that took Cochrane Meta Analyses and UpToDate info in a nice interface would be amazing.

> I started babbling about network meta-analyses, statistical power, and p-values, but he cut me off.

> "Yeah okay that's great but nobody cares about this math crap. You need doctors."

So true. As an insider in healthcare I would probably have disregarded this for idealism.

It also sonds a lot like more than one tech / data scientist I met. Applying statistics and tch to a domain they have zero experience in. Kind of giving calculators to 1st grades and hope they know whether or not the results are correct.

> you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better.

That doesn't really capture the conversation though. Susan specifically said (as you quoted) that it was possible she would use the recommendations of the app. If she took a recommendation that means she agreed it was a better treatment. His question was not whether his algorithm was better than her default prescriptions - because they both agreed that was the case at least some of the time - it was whether it was better enough to be financially worthwhile.

Better didn't factor in for the doctor at any cost even free.

This tech could be used to replace the function of this doctor making them less useful.

You’d be surprised how many doctors neglect the state of the art in medicine... That’s also why second opinions are a thing. Medicine is a science and hence, an ever changing field.

I probably would be surprised if that's true considering that in most states in the US, doctors are required to complete between 20 and 50 hours of structured CME (continued medical education) annually as a prerequisite to relicensure, and every one I've spoken to took it pretty seriously.

They are not unaware of the new stuff. But it doesn’t enter their day to day until it’s reached critical mass or if they’ve identified a couple suitable patients to recommend it to. Eg. Advil’s not working for a patient’s headache so, tell patient to try Tylenol because I learned about it during CMEs. Advil remains default for a long while. In many cases, until this doctors kid replaces him in the practice. Their generation learned in med school that Tylenol should be default.

Are you a physician, work in medical education, or have some other sort of broader source of information than that of a patient? I've primarily had experience as a patient, but it certainly wasn't what you describe. Obviously anybody limited to a patient's perspective wouldn't have anything more than anecdotal data.

Though back in the day, I did support for a CD-ROM based CME product... It was simple software so most of the people who called were in their 70s and 80s and not very comfortable with technology. They all seemed pretty concerned with learning the new stuff.

I worked along side physicians for several years. I'm still in healthcare but more corporate. I have interacted with physicians as a clinician, business partner, and patient. They love to learn that's no doubt. But the OP content was about changing their prescription protocols based on some hacked together ML that has no traditional clout. That was never going to fly; not without some [insert specialty] doctor's endorsement or some medical journal nods.

When it comes to the business of healthcare, doctors are generally open to things that will make their jobs easier (they are money motivated creatures too). But, they don't necessarily like learning new things themselves. As a whole, they are rather resistant to change. It took a long time to incorporate any technology bedside (e-charts, etc).

As a patient, I/family has been referred to other doctors specifically because they were younger or knew their education differed in a meaningful way. The old guy knew his ways were outdated and we would benefit from the new ways. So he was aware of the new way, but wasn't practicing it.

A second opinion is a mainly a thing because different people have different approaches. And they can be both correct.

His writing style seems similar to Hunter Thompson’s - I wouldn’t read into it too deeply, exaggeration is the backbone. Personally I enjoy it.

As for the actual content, there’s a massive difference between customers dying to use your product and them telling you it’d be “neat”. People don’t buy “neat” products. This is why you talk money to them as soon as possible. No real surprise it didn’t work out for him, the incentives just aren’t there.

He could have prevented all this by reading the Mom Test - oh well, experience is the best teacher anyways.

And you back it up with proof but you hear I don't care about better treatment I care about prescribing what I feel works best and what pays best. Science be damned.

There in a nutshell is the problem with healthcare. Doctors care about different outcomes. Doctors have this image that they care about your best health outcome but they would always trade an extra dollar over any patient outcome as long as they are legally within guidelines.

As a developer. I went to school for a period of time. I have had a 20 year career of sucessful development jobs/projects.

If someone walked in without any experience but showed me a better way to develop a project through understandable datapoints I would listen and not ignore them because I was somehow all knowing. I may even buy. Why are Doctors different?

Note: psychologists cannot prescribe anything here (Eastern Europe), psychiatrists can.

I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. I personally learnt a lot about pharmacology due to my illness, and I know what kind of medications are should not be supposed to be prescribed which the doctor working at the ER at that moment may not. In any case, you could just point out the reasons, I believe.

For example: highly lipophilic beta-blockers are an issue in my case as I get anxious over its CNS side-effects that others may take it for performance anxiety, see: propranolol. The doctor prescribing me propranolol would be in the wrong. My own psychiatrist had no clue that lipophilic beta-blockers can cause all sorts of issues (CNS side-effects, such as brain fog) that lead to anxiety and even panic attacks for me. In my case, something like atenolol or even nebivolol would have worked better. Some doctors know this, some do not. I do not reasonably expect them to know everything though. It is sort of a detail that is not known because it is commonly prescribed to the elderly who do not report those CNS side-effects because they attribute them to their old age.

There were cases of metoprolol causing hallucinations[1]. The old person attributed it to having some kind of a super power of seeing the dead because their heart stopped for a few seconds and they were "dead". I am not sure if this is the article I posted, but there was such a case.

People who research their own specific illness may know better than some doctors, really.

Sorry if I was a tad off-topic.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295654/

> I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them.

If you're not comfortable with a medication's potential side effects I do think it's worth bringing it up (I'm not a doctor, just an occasional patient) but it really comes down to how it's phrased.

There's a very big difference between:

"Actually propranolol won't work for me because after Googling around I discovered one of the side effects makes me feel anxious, can we try atenolol or nebivolol based on what I read online?"

vs.

"I know Googling for medical advice is sketchy but I read one of the side effects of propranolol is brain fog and this really concerns me because my job remains that I stay sharp. I trust your diagnosis and I know just because a side effect is listed I'm not guaranteed to have it, but are there any other beta blockers that we can start with that don't have this side effect and will still work?

There's a lot of very carefully selected phrases in the 2nd way of saying the same statement.

- Admission that Googling for medical issues isn't usually a good idea on its own to take actionable advice on

- You bring up a valid concern about one of the side effects

- Saying "diagnosis" vs "advice" is respectful of their decision ("advice" and "opinion" are a bit demeaning because it discredits their decision)

- You call out that you know not all side effects will come true (you come off as someone who isn't just blindly Googling stuff, this raises your credibility)

- You name drop "beta blockers" which shows you've done a decent amount of research

- You let them take the reigns and offer alternative medication, giving them a chance to maybe pick the ones you've researched

- You close things out as being optimistic by saying "and will still work" rather than questioning their decision before they give it by saying "think it will work"

If I said the 2nd wording to a doctor and they denied my request without even discussing it then I'd leave and look for a 2nd opinion. Asking people questions without demeaning them is a great way to get an honest look at how someone operates.

You're offering reasonable practical advice, I think. But imagine if this were about consulting an auto mechanic. It's like "You can't just question them, you have to suck up!" It reminds me of a small Apple developer's open letter to Apple a while back, clearly very carefully worded, full of protestations about what a big longtime fan they were of Apple.

The difference in both cases is the gatekeeping.

Just because someone spends 30 years learning something does not mean they learned the right thing.

Just because you didn't have 30 years of learning doesn't mean you know better.

> Imagine walking into the office of someone who spent the last ~10 years at school and then potentially 20 years practicing their craft as a successful psychologist and then you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better.

As I understand it, this is exactly what new pharmaceutical sales reps are asked to do?

No, the sales rep is selling the outcome of the knowledge of the medical experts within the company.

In the same way the author was selling the outcome of the knowledge of their algorithm.

The author was selling the outcome of the knowledge of many expert medical researchers, as summarised by the author's algorithm.

As opposed to the sales rep and the medical experts within the sales rep's company, neither the author nor his algorithm have any obvious direct incentive to recommend one medication over another.

It's not hard to get a doctor's attention when he knows you will provide him with golf days and holidays, if he plays his cards right.

At least in the UK, sandwiches are the most that pharma reps can use to bribe doctors with... Which is not to say they aren't effective (you'll get butts in chairs at least, no guarantee they will pay any attention to you though).

Damned bribery and corruption act. I could really do with some free holidays and lavish parties. Now it's all branded mugs and that's your lot. Someone offered us free beer and we had to refuse. Oh, the humanity!

If you are to proud to visit stackoverflow or Google to search for best practices you're not a very good developer. Sounds like the same rule should apply to a doctor or psychiatrist.

Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended?

(Sorry if that came out a bit edgy. But this hole story irks me. It's frustrating when value can't be delivered because of cash flow issues.)

Doctors do have curated platforms where they can lookup information, and also have diagnosis tools / checklists in them.

Agree

> Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended?

It's very hard to understand their thinking without being yourself a patient or doctor.

TLDR: You need to spend 1K hours as a doctor, or shadowing, or something similar.

When you are responsible for people with psychosis your perspective changes. Can't play nosql games with people's lives.

One has to be accepting that medical professionals are not superhuman and don't have magic bullets for chronic illness. But I don't know where you are coming from with such a pompous statement about being "responsible" for psychosis. The minimum "responsibility" that I can imagine being taken for a patient who has a crisis would be to move a regular appointment up after (or before) they land in the ER, and in the healthcare system I'm familiar with, it doesn't appear to happen. Are you used to something different? Or maybe you have a different idea of responsibility?

It's nothing special, just a job. But people are perplexed and they can't imagine why doctors are like that. I said you have to do the hours to understand, nothing special.