Yeah, my dad, a family practice physician for 20 years, would confirm this. His monthly overhead costs (in a tightly run physicians' group) are mind blowing and he has working hours and a sleep schedule that would stupify this 25 year old. He could work a quarter of the hours and make more money just doing ER work, but feels an obligation to his patient base. But there are many other doctors making that choice or choosing lucrative niche specialties, and who can blame them? There's almost no economic and lifestyle incentive to become a general practitioner anymore.
Also, any time you have a complicated system that no one believes in, people are going to try to game it. So you have some doctors billing Medicare these huge sums for a patient coming in with a runny nose, and this further discourages the honest doctors.
Most of the routine coding, billing, scheduling, and ordering paperwork is done by clerical staff. It's still inefficient, but most physicians aren't doing it themselves.
A lot of the paperwork (or computer work now) that physicians do is for documenting procedures. While that may take up a significant percentage of time (don't know if it's +/- 25%), it's crucial for patient care to have a complete and accurate medical chart.
They have a problem, we have an opportunity guys. Help automatise their paperwork and procedures! Nice big market, and clients with deep pockets. Do it right, and it'll spread virally, as they'll recommend your product to their collegues.
Now, I could not tell you in what form and how this automatisation would work. Some standardizing (of data sharing etc) would help too.
There are dozens, maybe hundreds, of companies already doing this. If you have a good idea then go ahead and try, but you'll find that the sales cycle is slow, competition is fierce, and the pockets aren't all that deep.
There are a variety of existing standards for data sharing from organizations like HL7, HITSP, IHE, ANSI, NCPDP, etc. The standards work but many vendors don't fully support them yet. And sharing healthcare data means you also have to enable your customers to comply with HIPAA privacy regulations as well as (sometimes) more restrictive state rules.
We've traveled this road fairly extensively as well. You will almost certainly find that you will have countless ideas on how to improve things. The better the idea, and the more it will help, the less likely it is that you will be allowed to do it.
Implementing good ideas requires change. I can't think of many fields where change is more resisted than medicine.
I've worked as an ER nurse for 15 years. I make it a habit to ask MD's that I know whether they would become a doctor if they had to do it all over again, and the vast majority tell me, "No". Adjusted for inflation, MD's salaries haven't gone up for over 20 years, in fact, they've decreased over the past 10 years: http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrp...
And, if Bush's medicare cuts go through and aren't postponed, many of the good doctors are going to be leaving 12-15 years of schooling behind and looking for a different career.
If they want they can come and work in the British NHS. A good GP here can get £100,000 a year. Of course you'll have to put up with the MRI taking weeks unless it's an emergency but it seems better then what that doctor suffered.
I think the biggest difference here is that although people in the UK moan a lot about the National Health Service they do respect the doctors and staff and value their input to society. Who doesn't benefit from feeling respected and valued?
ahh, but there are a lot of openings for GP's. Our medical students all want to be brain surgeons and don't seem to realise that without GP's most people would be dead before needing a brain surgeon.
"For me it's an endless amount of work that I can never get through to do it properly".
Hands up anybody who's prepared to admit that this doesn't apply to their job, and they have plenty of time to do everything expected of them to their complete satisfaction.
There are some young approaches to solving this problem. One I just discovered today is Qliance, a low-cost version of boutique care, dubbed "direct primary care."
No insurance needed or accepted (thus no coding or paperwork), ~$50 a month, same or next-day appointments, 24hr access to care, they take their own xrays for free and dispense their own medicine at cost, &c.
Aside from making workloads managable (800 patients instead of 2-3000), the really interesting part is how this does away with the perverse incentives of insurance payments (which reward procedures rather than health, and which turns primary care into 10 minute referral-fests, rather than actual care), as well as sets up other good incentives, which reward the doctors for keeping the patient healthy (healthy patients don't need to spend a bunch of time in your office) and so on. His talk is really interesting: http://health.scribemedia.org/2008/01/21/garrison-bliss-pion...
Maybe we need to redefine the problem. Some of the suggestions below were about automating the paperwork. Why not automate the treatment? I mean consider how unscalable it is to have a doctor, an actual person, see each patient. At most they can get through one patient every 15 minutes.
A doctor normally looks at a patient, asks them a few questions to rule out certain conditions and then prescribes a pill or requests a test for more information.
Sounds like the perfect kind of job that software can do if it knew the parameters.
The hard part is training the software, so you'd need doctors to perform treatments in a way that a computer can understand it (codified in some way) and then you need patients to report back on whether or not that treatment worked.
There's your business opportunity and a real opportunity to help people, both the doctors and the patients.
All the AI needs to do to be medically useful is obey the samurai principle: meet/exceed the effectiveness of a doctor on some subset of patients, and `raise GoSeeARealDoctorException` on the rest.
I'm sure regulators/politicians/medical establishment won't like it. But the technical problem isn't all that bad (and has actually been solved by machine learning for a few use cases).
Out of the frying pan, into... another frying pan.
I have friends who worked for McKinsey, BCG, etc. My observation: High pressure, long hours, continuous travel which eventually drives you crazy. (Travel sounds like fun, until you realize that business travel consists of the insides of hundreds of airports, limos, hotel rooms, and conference rooms and not much else. And it really is continuous -- four days out of every week, except for the lucky folks who make it into the coveted Wall Street office where the commute is only a few blocks. Ever wonder why every ad at every airport seems to be targeted at management consultants? Wonder no more...)
Lots and lots and lots of diplomacy and office politics (which is your primary task). You'll wear out a lot of ties.
Not to mention the first-order problem: There is a right time and a wrong time to get that job. The time right after you get your MBA is a good time. Thanks to a fad (which, I believe, began in the nineties) for hiring fresh new Ph.D.s, the time right after you get your Ph.D. is a good time. I'm not sure that there are many other good times. I'm guessing that "right after you burn out on medicine" is not a good time.
Over half of doctors are glorified con-artists. The MO of modern American medicine is to sucker in trusting patients and write prescriptions and perform procedures at great cost that empirically do not work. The doctors are feeling frustrated because the jig is up. There are too many of them and society can't afford the con game anymore.
I downvoted because there are a lot of assertions here without sources or context.
My anecdotal experience, where my wife is in the doctor's office routinely due to Hashimoto's disease, is that your mileage may vary. We went to an immunologist who sat on his hands and waited for several months for her thyroid to get enough out of whack before he ordered more testing. We've had several incompetent doctors who failed to diagnose conditions that harmed her health and the health of our son. On the other hand, since we've moved and had to find new doctors, we've gotten some really helpful doctors who really know their business and have been clearing up longstanding immune problems.
The right doctors have really been great for us, the wrong doctors have really been bad.
The first close citation I found for your argument was here:
There was a study that most doctors have high standards, but they would fail to report colleagues who didn't meet those standards. However, they appear to claim that reporting would not solve the problem, just lead to its own set of headaches.
I would say that America needs to follow the money to get to the bottom of this problem. The prices of medical care just aren't commensurate with the costs anymore. Ease the financial pressure and the whole system will probably improve.
> there are a lot of assertions here without sources or context.
I don't have time to build the full case. The nutshell version is that modern medicine is dominated by pharmaceuticals. Doctors are largely in the pill dispensing business. Problem is, the pills don't work. Spend more than fifteen minutes reading about the cholesterol and statin racket for just one example, and this is a huge billion dollar thing. It's a big chunk of what doctors do to earn a living. My familiarity with the business comes from the software side of pharma sales. For another example read about long term efficacy of many kinds of chemo and heart surgery. The stuff just doesn't really work, but it sure costs a lot.
Doctors are something like the fifth leading cause of death. Malpractice is rife.
Modern medicine is great for trauma, injuries, and various acute diseases. But the financial reality of health care is that most of the spending and most of what doctors do is about lifestyle diseases, and the treatments are useless. They give pills and order tons of tests for people who should really just be told that there's nothing to be done other than better diet and exercise, or maybe bed rest. They also blow millions on people who are simply in the process of dying, mostly of old age, and the treatments are empirically known to do nothing.
"Doctors are largely in the pill dispensing business."
You do realize that doctors don't make any more money based on medications they prescribe.
"Problem is, the pills don't work. ..... and the treatments are empirically known to do nothing."
I don't really want to get into a big discussion about it because I know I won't be able to convince you. But this is just wrong. Many pills do work. Modern medicine is based on the scientific method and millions on dollars are spent on studies to prove that therapies work. Strnagely enough, insurance companies are part of the gatekeepers for this, since they don't want to pay out of their pockets to provide expensive care for things that don't work.
On the other hand, much of "natural" medicine and homeopathic medicine are based in anectodal evidence and not on any large scale scientific evidence.
"Strnagely enough, insurance companies are part of the gatekeepers for this, since they don't want to pay out of their pockets to provide expensive care for things that don't work."
Consider the economics here. If something is not expensive, you don't need insurance. So it's in the insurance companies' interests to inflate the prices so more people will need health insurance and can't pay for procedures out of pocket. The insurance companies just have to raise their premiums to compensate, and the larger the amounts of money passing through their hands, the easier it is for them to keep some of it.
I'm not attacking insurance companies, just pointing out that it's not entirely logical to assume that their interests are aligned with yours.
I'm not saying they are the only gatekeeper. But point is, pharmaceudical companies can't just create a medication and claim it "does xyz" and expect that people will pay for it. These medications are reviewed before being "covered" by insurance companies or medicare (goverenment), so it's not a free for all, as implied in the original poster's comment.
> Modern medicine is based on the scientific method and millions on dollars are spent on studies to prove that therapies work.
Sure. Take Ambien, for example. The studies show it works! People who take it fall asleep a whole 15 minutes sooner than placebo! For thousands of dollars and unquantified long term consequences you can have something pathetically less effective than lifestyle changes or some cognitive therapy sessions, so ask your doctor about Ambien.
Same for the cholesterol statins. They work! They really do lower serum cholesterol, just as advertised. However, they have absolutely no affect on mortality rates in the typically prescribed case, and are implicated in serious neurological disease...
This kind of nonsense is pervasive in the medical industrial complex. Doctors, for the most part, dispense treatments pushed on them. But the stuff is largely a waste of money.
With a whole lot of these cancer therapies you statistically buy an extra year of life. But the person who took the therapies felt like shit for four years and blew all their savings. The person who just let it be died a year earlier but spent a lot more time feeling ok and saved a lot of money. You can just go on and on with stuff like this. The medical industrial complex is deeply dysfunctional, and at the end of the day there are way too many doctors and they do too much. This is why health care spending and number of doctors per capita is uncorrelated to lifespan and health across regions of the US.
The Heart Protection Study (HPS) randomly assigned 20,536 subjects to simvastatin (40 mg/day) or placebo
After an average follow-up of 5.5 years, the following significant benefits with simvastatin were observed:
- A 13 percent reduction in all-cause mortality (12.9 versus 14.7 percent for placebo).
- An 18 percent reduction in deaths from heart disease or related blood vessel disease (5.7 versus 6.9 percent).
- A 24 percent reduction in major cardiovascular events (19.8 versus 25.2 percent)
- A 25 percent reduction in the first event rate for stroke (4.3 versus 5.7 percent) reflecting a 28 percent decrease in ischemic strokes and no reduction in hemorrhagic strokes
- Among 3982 diabetics without prior cardiovascular disease, a 28 percent reduction in the incidence of MI and stroke (14 versus 18.7 percent).
This study supports my position. 12.9 vs 14.7. From taking my statins I get a measly 1.8% lower chance of dying over a five year period, and that's a shaky assertion. It costs a fortune, I'm impotent, and my short term memory is screwed up, but hey, the doc says to take it for that 1.8%. And I suspect the 1.8% is misleading. The profile of the people who died in both groups was probably distinctly identifiable, so in effect the vast majority probably got no benefit.
And I think I've seen this methodologically refuted elsewhere. Some studies have definitely got the opposite result.
Dude, I've worked as an ER/Critical care nurse for years. I push a drug, a person's heart rate changes. I tweak a drug on an IV pump, a person's blood pressure comes out of shock and normalizes. The idea that pharmacology doesn't help people is quite simply wrong.
Sure, the protocol for Advanced Cardiac Life support changes every 2 years, because some therapies that we use to thing were very effective, are proven to be less effective than new ones. But, there is a strong self-corrective factor in Medicine. The ideal isn't to do what the pharma companies push the doctors to do. The ideal is to do whatever the best science says increases lifespan, quality of life and decreases morbidity and mortality.
At times, studies are funded by pharma companies, and the research is tainted. Current best practices are a moving target, because the science changes. But, over all, good medical practice is a big plus.
Sure there are drugs that have great promise, are pushed through FDA approval and then are found to have bad side effects and/or not as effective as once thought... (e.g. Vioxx, Celebrex... both recalled several years after approval).
But, for every drug that isn't effective, or has bad complications, there are dozens that do work. And, many more are found to have other beneficial uses. For example, mucomyst is a drug that was developed to help break up mucous plugs in people's lungs. Then, is was found to work as the antidote for one of the most common and toxic poisonings: tylenol. It's also used to protect people's kidney's during IV contrast injections.
I'm sorry but the anti-pharma, anti-vaccination stuff that flies around the internet is one of the clearest examples of FUD I've seen, and it's very harmful. I've seen a number of people die because they didn't trust medicine and they didn't trust doctors. Please, check what you are saying before someone gets permanently hurt by your ideas.
Key words are ER and Critical Care. That stuff works great and makes progress all the time. It's also somewhat irrelevant to the bulk of medical practice and health care costs, which pertain to chronic conditions and lifestyle disease.
If people don't manage their chronic diseases with medication, where do they end up? The ER.
If a diabetic doesn't take insulin or their anti-high-blood-sugar pills, where do they end up? The ER in a diabetic coma. A daily dose of insulin is like $1 a day. An ER visit/ICU hospitalization for a diabetic coma is around $20-50k depending on the severity.
If an asthmatic doesn't manage their chronic condition with the appropriate inhalers, where do they end up? The ER. IF they let it go too long, they end up on life support in the ICU.
Pneumonia used to be a leading cause of death, now it's not. Why? Antibiotics and oxygen therapy. People used to get polio all the time. I haven't seen an active case of polio every in my 15 year nursing career. Why? The polio vaccine.
The incidence of tetanus has dropped from 600,000 deaths in '92 to less than 150,000 deaths world wide. Why? The tetanus vaccine. Ref: http://www.emedicine.com/emerg/topic574.htm
Please, stop saying the pharmacology doesn't work. It does. It saves lives. Are there problems with the system? Sure. But please stop spreading FUD about "Big Pharma".
I have zero doubt that this is true. I have been around a lot of those medical errors, and I have seen people who have been killed by medical errors and malpractice. It's tragic.
But, just because there are problems, that doesn't mean that the system doesn't work.
In the article that you posted, they mentioned 10's of millions of unnecessary antibiotics. The reason that antibiotics are prescribed for viral infections is twofold. And, it's primarily because people want them. If I take my child who has been sick for 1 week to the ER, spend 3 hours waiting in line for a 5-10 minute visit with an ER doc. I want to go home with a prescription in hand. If not, I'm going to be very angry. So, it's easier for the MD to prescribe an antibiotic than deal with the 5-10 minute conversation convincing the parents that it's only 2008 and we haven't found a cure for the common cold yet.
As for unnecessary medical procedures... That pretty much speaks to 95% of plastic surgery cases and 80% of dermatology practices.
Our society also has very high expectations of the medical community. We used to go to a shaman, priest or pastor when our family was dying and looked for answers or expected miracles. Now, we take then in a ambulance to the hospital and expect answers and miracles from our doctors and medical systems.
Doctors feel those expectations and generally work very hard in very difficult circumstances. They also are trying to make a decent living to pay for the 12-15 years of schooling they suffered through. So, the average MD will work 70-110 hours a week. When you work that much, you're bound to make mistakes.
There's no doubt about it, there are a lot of problems with the system, but that doesn't mean that we should throw the baby out with the bath water.
Tips to getting better health care:
#1 Bar none, go to the rich people's hospital. Go to the neighborhood with the most expensive homes, and find a doctor in that neighborhood. You get much better medical care in those areas because that's where the good doctors go to practice. After working in 35 different hospitals in 15 years, I settled on working at an upper class/upper middle class hospital in Silicon Valley. That was deliberate. I can give better care here than any where else I've ever worked.
it's 1.8% percentage points which is not the same as 1.8% lower chance. It's a 13% lower chance. And that's just from dying. It prevented many others from having a heart attack or stroke which can be pretty bad to.
You can dismiss it if you like, but what these numbers mean in more practical terms is this:
Over 5 years on treatment, it will prevent up to 1 person out of 10 from dying, having a stroke, or heart attack.
And there may be a negative study here or there, but there are many more positive studies. It's like flipping a coin 100 times in a row. There will be times when you get 70 heads, 30 tails, and times you will get 30 heads, and 70 tails. If you do it enough, it will average around 50% heads and tails. This is the "true" result or chance over time of getting heads or tails.
If you do a single study, you might get a negative result (no improvement), if you do another study you might get a really positive result (huge improvement). If you do it enough, the results with trend towards the "true" result... which for statins is that it saves a significant number of lives and prevents heart attacks and strokes in certain patients.
Semantics. I change my odds by 1.8% in the naive assumption that these numbers are applicable to myself at face value. If you like these odds I would like to sell you some lottery tickets.
Your thinking is fundamentally flawed. 1.8 people out of 100 are prevented from dying, and not for free: there are side effects and financial costs. How many died in year six as opposed to year five is also unclear. We're talking about drugs they want to keep people on for the rest of their lives.
The cumulative arithmetic of how many escaped cardiovascular "events" and death cannot be computed clearly from the numbers presented, as you seem to allude.
I agree that the cost is not free. The point being is that these medications do do something. They aren't sugar pills.
You're first assertion was that these medications don't actually do anything. I simply am pointing out they do do something.
It comes at a cost of $$, possible side effects, sure. But if you are arguing that point, then you have to concede that if the price is low enough or the side effects are low enough, then it's worth it.
If it's not personally worth it to you to take the statin because you have side effects from it... that's fine. don't take it. But you can't use it as a blanket to say all medications don't do anything, just because you had a bad experience with one or don't agree with the cost/benefit analysis.
Personally, I'd say 1.8% over five years is nothing, and as I mentioned I've seen the abstract read closer to 0% or -X%. Think of it as 0.36% per year. Expect big lawsuits next decade about the side effects.
> you have to concede that if the price is low enough or the side effects are low enough, then it's worth it.
Not quite so simple, because there are lifestyle treatments that do work and are generally not pursued. The drug options are pursued at the opportunity cost of much more efficacious, much simpler, much less profitable options.
Again, I believe you simply don't understand percentages, or statistics.
The numbers were statistically significant, which means the differences were not likely related to random chance.
The statin prevented 1079 people from having a stroke, dying, or having a heart attack. It helped 10% of the people in a non-trivial way in this study.
(and lifestyle changes are typically pursued alongside these medical treatments. Certainly in these studies, of course your individual doctor's mileage may vary.)
I understand statistics just fine, asshole. You're saying I should bank with XYZ Bank because their savings account interest rate is 100% higher than my current bank! Or, .5% vs 1%. I'm saying the interest rates are .5% and 1% respectively.
As for the 10 out of 100 total winners claim, it looks fudged up to me on quickly scanning the abstract. I'd have to use a calculator and read the study. That cute little bit about a compliance adjustment smells like fudge. And, as I've said, there are other studies with other conclusions.
1) Your continued comments are way off topic. In what way do they relate to doctors being overworked? None that I can see.
2) You really don't seem to have a good grasp of what the statistics are telling you. Take the statins example. As others have tried to explain to you quite politely, the statistical improvement of statins vs placebo are both significant, and even impressive. Your response? 'Asshole'. Nice work.
Nice try, but your argument doesn't hold up for society at large.
It doesn't matter to you as an individual if you are prescribed heart medicine when you need it. However, it truly does save lives in society. How do you propose we scale back the system of medicine? Should doctors no longer prescribe statins?
You have some time now to find those opposing drug study citations. Your claims interest me and I'd like to subscribe to your newsletter, but the rubber will start hitting the road for me if this conversation progresses from accusations to evidence.
Here's an example of the kind of thing that interests me: a recent meta-study of FDA trials of SSRIs (antidepressants) showed little to no benefit over placebo, below statistical significance in some important cases. So there's a fair chance that most people shouldn't get SSRIs because they just don't work.
"Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication."
You have mischaracterized modern medicine. However, preventable medical errors were recently estimated to cause somewhere between 44K - 98K deaths per year in the US. For anyone interested in the details I highly recommend reading the Institute of Medicine report "To Err is Human". http://www.nap.edu/openbook.php?record_id=9728&page=1
There are good potential business opportunities in building automation to reduce errors, however it's still tough to get funding and find customers since the reimbursement system generally isn't structured to pay for error prevention. There was one positive step recently when CMS set a new policy to not pay for fixing preventable care problems. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=...
Spoken like a person who has never had to answer the question "why are you an engineer when the big money, the prestige, and the long-term career prospects are all in medicine or law"?
Sometimes it's useful to remember that other fields have Dilberts, too.
But this is hacker news. This is screaming business opportunity. If you can create a service to remove the hassle of running a practice, you're golden.
Also, any time you have a complicated system that no one believes in, people are going to try to game it. So you have some doctors billing Medicare these huge sums for a patient coming in with a runny nose, and this further discourages the honest doctors.