It seems that health care professionals don't have a nuanced problem solving attitude. They make a diagnosis, see how this diagnosis fits into a preconceived treatment bin, then just solve from that position without understanding what's different, what's unique to each case. And, in their defense, they probably just don't have the time for that extra work. That's where I see technology as most useful....how to automate and make more efficient the redundant parts so professionals can concentrate on the important, unique parts to each patient's diagnosis.

I come from a long line of docs, though I'm a software dev. Let me tell you that the vast majority of patients can easily be sorted into these pre-formed category bins. Rare conditions are rare by definition. Most of medicine is dreary repetition.

This ought to be highlighted, before people start an echo chamber of "doctor's don't know what they're doing!" that ultimately undermines everyone (guess what argument the anti-vaxxers use).

A string of anecdotes of "I double-checked and it turned out the doctor was wrong" remains less than a trickle compared to the flood of patients doctors have to deal with, and a tiny fraction of the hypochondriacs they must deal with. Our medical system is broken enough without adding doubts on the competence of its medical professionals.

By all means, people should double-check what the doctors say, but realize the much worse consequences of sowing doubt.

There are some useful questions patients can ask.

"What happens if we do nothing? If we do watchful waiting?"

"What happens if I don't take these meds?"

"How likely is that bad event? Tell me in terms of numbers per 10,000 people rather than percentages".

Another useful one is to ask him to explain his reasoning.

If he can't justify his decisions, then he's probably using instinct which is unreliable in the case of rare diseases, or he doesn't know how to diagnose known diseases which means he's incompetent.

Some people are offended when you challenge them for reasons for their advice, but I think that's because they aren't confident in it themselves or feel superior. Doctors shouldn't be in either of those positions and should be willing to tell you how they came to their conclusions.

Whilst on the whole I agree with you, the amount of doctors I know that would react (quite strongly) negatively to that is quite high, so anyone who takes your advice should be prepared. The most common response I've seen to your question was the doctor reminding the patient "there is always something called a second opinion", a couple of times though I noticed them taking the time to explain it.

Why is "numbers per 10,000 people" meaningfully different than taking the percentage and multiplying it by 100?

Doctors and patients do not know what you mean when you say "your risk has gone up 50%". When you say "in a group of ten thousand people we would expect 4 to experience this thing. But in a group of 10,000 people who eat peas we expect about 6 people to experience this thing".

Gerd Gigerenzer has a book explainin it better than I do.

This highlights the importance of a second and third opinion as well.

As the joke goes, "what do you call the guy that graduated last in his class at medical school? Doctor."

Doctor's aren't machines, they're more like mechanics, they see a symptom, use their knowledge to make an educated guess essentially, and then work from there. If their knowledge is soft it's likely an incorrect diagnoses could just be exacerbated by incorrect treatment.

Get another opinion, and then another, the next problem is deciding on siding with consensus or outlier.

It's exactly this attitude that turns me off of a lot of doctors. It dehumanizes the experience of being a patient. First you are put in a bin, then the doctor basically runs you through a check list.

It's really unfortunate that nearly 100% of the bins are disease or a disorder. A typical interaction with a doctor involves finding out which disease bin you should be in, and then putting you in there. Once you're there, they're not concerned with making you healthier, or looking at the variety of options that could improve your life. They're just concerned with doing the standard operating procedure for dealing with the disease. Instead of being a person, the patient becomes a checklist.

Many doctors don't even see you. They see the bin you're in, and the many potential bins you could potentially be in.

What if half the bins were about great physical health? And what if the doctors worked just as hard to get you into one of those, as they do "treating" the diseases you might have?

Ugghhh. It makes me sad thinking about how far we are from that world.

I think it is not so much the doctor that is at fault, as the system of checks and measurements that make up modern health care. The boxes are there for the convenience of management, insurance, etc, as much as it is for the doctors.

Or rare variant of common issues. Got told a story by a relative in the health care profession about a patient that complained about pains. But their location etc didn't match anything fitting the the age etc. Eventually they discovered that it was a heart condition...

There's a similarity of sorts here to airline pilots. What separates the decent ones from the great ones is how they handle the rare cases. There's enough dreary repetition that it's easy to be unprepared when it counts the most.

> Most of medicine is dreary repetition.

Hence why we can automate away most of the problems with it.

Yes, which is also why The Checklist Manifesto was so successful.

I agree with you and also believe this extends to the majority of professions. Even within software development, there are a significant number of people that will only solve the immediate problem in front of them in a stepwise manner, rather than using lateral thinking to evaluate if the problem should be solved in the way that's most familiar to them, or to look at it from a different perspective and solve another problem entirely (e.g. the root cause).

To be fair, the majority of problems are probably addressable without thinking differently. So people get into habit/routine and that's their "job"; thinking otherwise is not a day-to-day operation. To your point, automating the redundant/repetitive problems should allow for creative problem solving where machines don't yet excel.

A lot of school administrators have PhDs, but get one to tell you how they learned about some really cool experimental results at some conference (probably publicized by someone trying to sell them something, incidentally, but that's another problem) and are trying to reproduce them at their school(s).

You'll be in for a treat.

A "treat".

Fun bonus anecdote:

One of my wife's principals was convinced the prayer jar she provided for the staff was effective because over half of the prayers the prior year had been answered. When she told me that story it damn near broke my brain.

>One of my wife's principals was convinced the prayer jar she provided for the staff was effective because over half of the prayers the prior year had been answered.

Depending on the prior probability of the prayers that were answered (and those that weren't), 51% could be plenty to support the efficacy of the prayer jar.

I know, the problem is that she was evidently entirely unaware that without knowing something about the probability of "answered prayers" absent the prayer jar, the simple "over half of all wishes came true" was entirely meaningless. Without more information any number could, potentially, support either conclusion (did/did-not work). This wasn't said in jest, either, if you're wondering (I did).

This depends also on the person having the organizational position and time to do said thinking.

Couldn't this be argued of people in all professions, including software engineering? There are some who just don't care; people who just follow the process and procedure and aren't interested in the bigger picture.

While I agree that technology and automation can help, in addition we should find ways to help professionals move beyond their routines.

but software engineers 'pretty much' make at most in the early 6 figures and doctors 'pretty much' start there. i'd love to give customers max 15 minutes to tell me how they want their website only to tell them this is what they are going to get because its the standard of care.

why should a doctor care? they get paid weather you live or die. what happens to you basically has no bearing on their career. a doctor i know worked on a guy who was having chest pains but was 'diagnosed' with COPD. he was to be sent home, but that doctor refused to because of patient history: all 5 of his brothers died of a heart attack before 60. what would have happened to anyone there had he been sent home? nothing, just another heart attack death.

at least they got things right on brother #6 though.

in short, doctors have little incentive to pick up their game. the supply of doctors is kept short purposefully to ensure they make money++. Only way out of this mess is technology when people can finally take their health back into their own hands.

They'll rue the day they purposefully restricted the available supply of skilled physicians through limitations on residency programs when those pesky technology engineers perfect the doc-in-a-box.

Even worse is when some of those guys open source it and give away the software and hardware schematics, just because they hate giving $30 co-pays and dealing with deductibles, just to get an antibiotic prescription for a viral infection.

Don't make professional problem solvers see you as a problem, or you might just get solved.

Your post is a gold mine of potential points to attack but I'll save it and just focus on this:

>the supply of doctors is kept short purposefully to ensure they make money++

No. It's costly to train them, and it's hard for an average person to afford.

It's somewhat less depressing than that, from a personal point of view, at least. Most interventions carry with them pretty significant risk. Therefore the choice is not between "do nothing and see what happens, or do something with zero risk and see if it helps", but rather "do nothing and see what happens, or do something really high risk and see if it does more harm than good."

Iatrogenic disease (harm caused by interventions) is by some measures the leading cause of death in the US, outstripping heart disease and standing at more than ten times the rate of death by automobile.

Under those circumstances, not doing anything until something horrible happens is not a bad policy, and the people engaged in it are not expressing cynical indifference so much as a due awareness of the real risks involved in almost any intervention.

Which is, admittedly, kind of depressing, but for quite different reasons. Either way, technology and patient empowerment are likely to help.

You have a source for those measures?

http://www.avaresearch.com/ava-main-website/files/2010040106... puts it on #3, after heart disease and cancer. So, it may be an exaggeration, but not a huge one and certainly not an inexcusable one. It is fairly common to remember that something is way more common (or way rarer) than one would think, and then overestimate the number when trying to produce it later.

http://en.m.wikipedia.org/wiki/Iatrogenesis#Incidence_and_im... has more links, which I didn't read.

Even if true, I don't know what to make of such a statement - needless interventions for ALL diseases/causes may kill a lot more than any ONE single, narrowly defined disease/cause - that says more about the classification/definition system than interventions... it's only if interventions on any ONE disease kill a significant proportion vs the disease itself that that intervention / interventions are truly dangerous...

The problem is that it's not just "needless interventions" that can backfire. Even in situations where an intervention could unquestionably help, there's still plenty of ways for it to go wrong. The most obvious is human error -- a well-intentioned intervention that's disastrously mis-executed -- but that's just the beginning of the list, not the end.

What you have to remember is that for the vast majority of human history, medical interventions of all kinds were at least as likely to hurt the patient as they were to help them, because of our crude understanding of how the body works and how disease is communicated.

A textbook example is Oliver Wendell Holmes Sr.'s classic 1843 study of puerperal fever (http://en.wikipedia.org/wiki/Oliver_Wendell_Holmes,_Sr.#Medi...). It showed how doctors who were doing a completely routine intervention -- general examinations of the health of newborn babies -- were actually picking up that infection from babies who had it and then spreading it to others who did not, because they didn't sterilize their instruments and change their clothing between examinations.

This seems obvious to us today, but at the time it was quite shocking, because in thousands of years of medicine doctors had never sterilized their instruments or clothing when moving from one patient to another. It never occurred to them, because none of the prevailing theories of how diseases spread called for it. So untold numbers of newborns sickened and died because of well-meaning, completely uncontroversial interventions by their doctors.

Today doctors obviously do understand the role of germs in spreading disease better, and they have much improved medical technologies and practices available to them, which has helped reduce the risks of those types of interventions. But millennia of these types of unpleasant discoveries has given medicine as a profession a healthy regard for the possibility that what they think they know even today could be incomplete or flat-out wrong.

> Today doctors obviously do understand the role of germs in spreading disease better

And yet study after study of hospital acquired infections show that simple hand washing between patient examinations is abysmally irregular (between 10 and 50%.)

I'm a doctor and former software programmer, so let me offer a counterpoint:

I would disagree with your statement that medical people have a fatalistic passive attitude. In this case the decision is between 1) watching and waiting to see if the tumor grows and 2) acting immediately to take it out. The tumor in question is a meningioma, a relatively common tumor of the skull (meninges, to be precise) whose natural behavior is unpredictable (some are essentially benign, others are highly malignant). Sometimes high-risk features can be identified on MRI imaging (brain invasion, areas of tissue necrosis, rapid growth) and these will always be treated with intervention. I work at UCSF, one of the top neurosurgery programs in the world, and I can guarantee you the radiologists don't make the mistake on sizing tumors mentioned here (well maybe they do, but it is out of carelessness rather than a problem with there software. it is not hard to find anatomic landmarks to ensure you are measuring at the same level). I would argue that a small meningioma without worrisome features should definitely not be operated on because the risks of surgery are not negligible! These surgeries are no joke, they are extraordinarily complex and they are mucking around next to structures which can cause significant morbidity, neurologic deficits, and even death sometimes if they nick the wrong artery.

It is well accepted practice and backed by evidence (see the WHO:tumors of the CNS publication) that the best way to decrease overall morbidity is by watching and waiting with these types of meningiomas. This is because MOST meningiomas are low-risk/benign (they are often found incidentally during autopsies for other reasons) and the risk of adverse surgical outcomes would be high if you subjected each of these people to invasive procedures when the incidence of high grade meningiomas is low. It is a population based strategy and unfortunately on an individual level you can't predict the outcome, but that is unfortunately a problem with this data. Fortunately lots of new technologies are emerging that can tease out individual differences (the so-called personalized medicine technologies)

That being said the new techniques to map out anatomy to aid surgeons is very cool! And to be fair, it sounds like the patient in this article did not get great care and that some of the doctors were not following the standard of care (1 year between imaging is definitely too long).

I understand your rationale for the "wait and watch" option, and agree fully with it.

> "well maybe they do, but it is out of carelessness rather than a problem with there software."

I think this statement precisely illustrates the point that the parent commentator has with much of the medical community. Think about what the "carelessness" of a radiologist that you're talking so flippantly about means for a family – the anguish, sleepless nights, and feeling of morbidity and helplessness.

I may be overreacting here, but I would be extremely worried if a radiologist can be careless and ruin a year or more of someone's life, possibly forcing them into opting for a highly risky surgery. If you think there is a chance that your radiologists are not measuring things properly, wouldn't it be beneficial to start a double-checking procedure of some kind whereby each MRI is checked by 2 radiologists and a doctor (or something of the kind)?

Agreed, carelessness can cause serious issues. I see it sometimes but overall I would say most doctors (I in a tertiary care academic facility so obviously there is a bias) take their job quite seriously and understand the gravity of decisions they make.

It's proabably a waste of resources and time to have a 2-check method as protocol (doctors are already overworked). Often times it is present informally (radiologists/pathologists will often have their colleagus review problematic cases for agreement and neurologists and surgeons will frequently review the films)

What everyone should do is realize you can always get a second opinion and have another expert review the material.

On the point of 2 radiologists checking, as a routine that would be too uneconomical, so if you wanted 2 people check you'd have to get a second opinion. Most likely on your own cash, since (as far as I am aware) everywhere medicine is in more demand than supply.

However you can be assured before an actual surgery, the same films will be reviewed by many doctors. Meaning that a mistake falling through everyone's mind is less likely.

I do agree with your point that sometimes a mistake can have a large impact on people. It's one of the challenges of medicine I'm not sure anyone has a solution to. On the flip side there would be many who are properly told the correct analysis, but i guess sometimes you get unlucky and a human error is made.

Welcome to modern society. Likely the radiologist etc see so many people that caring about each and every one would result in a early retirement for exhaustion or similar.

That was the most succinct summary of the attitude i've seen many times amongst doctors. I'm saving that :D

It's always funny when someone thinks they're the center of attention... yes in a perfect world I'd remember everything and care only about you but if I do that I won't be finished my job. After a while I've noticed even as a student (and certainly picked up that a few doctors) that if you try care on a more personal level about every person, you'll be knocked down more and it'll be harder to function. Hence why I think a middle ground or even lack of care is what you see.

A more charitable explanation would mention how the prime directive of their profession is "first, do no harm": (http://en.wikipedia.org/wiki/Primum_non_nocere)

I think the other reply covers it a lot, but I find posts like yours to be very demeaning. You're essentially doing the same as someone who doesn't understand programming making declarations of how programs should be made. There is a lot going on behind the scenes and modern medicine is based on evidence, so please take the arm-chair commentary away

Like most professions, I am sure there are doctors who are like you describe as well as many others at they opposite end of the spectrum. Its wrong to generalize them all to be like this.