
Why Doctors Reject Tools That Make Their Jobs Easier - dsr12
https://blogs.scientificamerican.com/observations/why-doctors-reject-tools-that-make-their-jobs-easier/
======
Fomite
An alternative headline is "Tool Makers Make Tools That Don't Help Doctors". I
know a ton of colleagues who flinch every time someone mentions that this'll
just hook into the EMR system, because they know everything will be broken and
tedious for years before another vendor comes along.

At a conference I was at recently, I'm nigh positive "Decision Support Tool"
was a dirty word.

~~~
jrumbut
One of the problems I see here, and would love to find a way to solve it, is
that software is best developed interatively. I see a lot of software that has
some cool ideas, it just needs some tweaks to get rid of ridiculously annoying
flaws, or needs to put some more control in the user's hands.

Unfortunately, and inevitably, a little tweak in medical software may as well
be a tweak on a satellite in space.

Like I said, changes need to be prevented from making the software bad, but
the difficulty of making changes also makes the software bad. I don't know
what the solution is, but I would like to see this aspect addressed more
explicitly.

~~~
zdragnar
Safety first, full stop, no exceptions.

Until correctness can be done easily in accessible programming languages with
a decent developer pool, iteration in this space, along with other life-
critical spaces such as trains, planes (and wouldn't automobiles be nice too?)
is sadly a long, manual process compared to web development.

Edit: to expand a bit on correctness, think Coq but with the ease of Java or
Typescript. Even Rust's safety isn't yet formally proven; that's not a knock
on rust, but a demonstration of just how hard it is to do.

~~~
conanbatt
> Safety first, full stop, no exceptions.

And here you are, cutting-edg hospitals running 2012 versions of modern
software, and paying millions of dollars for the privilege.

The direction has to be exactly the opposite, by giving the patient
increasingly more control over his own health.

~~~
Fomite
Having seen several talks from some patient advocates recently, I'm skeptical
that's a good idea.

~~~
conanbatt
I think health services are some of the most misunderstood by the population
above everything else.

------
carleverett
The article talks about thermometers being rejected by some doctors who
thought fevers were more qualitative... they're not wrong. Different people
have different average body temperatures, so a fever for one person might not
be a fever for another person [1].

Obviously it's not smart for a doctor to reject the idea of knowing internal
body temperatures at least to have as a data point, but those doctors weren't
COMPLETELY off base.

[https://www.webmd.com/first-aid/normal-body-
temperature](https://www.webmd.com/first-aid/normal-body-temperature)

~~~
chapium
Wouldn’t it be useful to have a tool like a thermometer to establish a
baseline value?

~~~
arama471
if they've already got the fever then it's a bit late for that

~~~
derefr
Seems like it'd make sense to go into your doctor at some point when you're
perfectly healthy and let them measure a bunch of baseline values to put in
your medical file.

~~~
Swizec
It's like my bird's vet said once: If you start measuring, you're gonna find
stuff. The more you dig, the more you find. Does it mean your bird is sick? Eh
look at him, does he look like a sick bird?

My girlfriend can be very ... concerned. We spent $1000 in vet bills before a
real avian expert was like "Guys, he's fine. Look how happy he is. He just
loves the attention."

Apparently one of his tests for vet interns is to tell them "This bird is
sick. Figure it out". Then he gives them a perfectly healthy bird. Their bias
always makes them find something. Caused by their tests half the time because
they're stressing the bird.

~~~
throwaway287391
> Apparently one of his tests for vet interns is to tell them "This bird is
> sick. Figure it out". Then he gives them a perfectly healthy bird. Their
> bias always makes them find something.

Seems like the "bias" in that case is likely due to an authority figure
intentionally misleading them in the context of a "test", where one naturally
assumes they're not being deceived by the very premise of said test? If an
actual bird owner came in as a client and said the same (or if the test
explicitly told them to assume this is the situation), the interns might very
well still realize the client is wrong.

~~~
ALittleLight
I'm not a vet, but if I were and someone said "This bird is sick." I hope the
first question I'd ask is "Why do you think so?" Not to doubt the person but
to figure out what the presenting symptoms were.

~~~
watwut
It is not abstract general someone. It is very concretely more experience
professional and teacher whose judgement you trust more then your own. And no,
if you dont go much out of way to be approachable or have reason to be afraid
of him, no matter how small, they will not ask more. Because most interns know
they are beginners and don't know yet.

------
DrNuke
The industry is annoyingly conservative but whizzkids pretending to have a
better opinion about how to cure _insert desease_ from isolated, mechanistic,
non-standard observations of few markers are dangerous.

~~~
Fomite
Yeah - I work a lot in healthcare associated infections, and a good 80% of the
stuff I read about "We're from Silicon Valley and we're here to help..." just
ends with me going "They're going to kill people."

~~~
cf498
I think this is something that isnt that present in our profession as it
should be. If you are an electrical engineer, it is clear and present, that
your products might kill someone if you screw up. The same goes for a
mechanical engineer. And it will be your responsibility. If you screw up and
should have known better, you might even go to jail for negligence.

We on the other hand have the Therac-25.

We claim to be on a level of engineering fields. We should also act that way.

~~~
Someone
Therac-25 was thirty years ago, and still is the go to example. That made me
wonder. If you compare, for example,
[https://en.wikipedia.org/wiki/List_of_bridge_failures#2000–p...](https://en.wikipedia.org/wiki/List_of_bridge_failures#2000–present)
or
[https://en.wikipedia.org/wiki/List_of_structural_failures_an...](https://en.wikipedia.org/wiki/List_of_structural_failures_and_collapses#2010–present)
with
[https://en.wikipedia.org/wiki/List_of_software_bugs](https://en.wikipedia.org/wiki/List_of_software_bugs),
software doesn’t look that deadly.

~~~
jcranmer
People generally don't attribute failures to software bugs if there is
anything else that contributes to failure. The list in particular is missing
the loads of accidents caused by bad UI; incidents of "I was just following
the GPS's/autopilot's directions" that result in death are missing (such as
the KAL 007 airliner incident).

------
megy
> From the thermometer’s invention onward, physicians have
> feared—incorrectly—that new technology would make their jobs obsolete

Is that true, or are doctors incredibly risk averse since they have seen what
can happen when something goes wrong, and that is death.

~~~
ivanmaeder
I've also read that physicians can be overconfident in their own abilities:

[https://www.ncbi.nlm.nih.gov/pubmed/18440350](https://www.ncbi.nlm.nih.gov/pubmed/18440350)

> … argue that physicians in general underappreciate the likelihood that their
> diagnoses are wrong and that this tendency to overconfidence…

More on the combination of algorithms and humans:

[https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_...](https://en.wikipedia.org/wiki/Paul_E._Meehl#Clinical_versus_statistical_prediction)

> Meta-analyses comparing clinical and mechanical prediction efficiency have
> supported Meehl's (1954) conclusion that mechanical data combination and
> prediction outperforms clinical combination and prediction.

------
anon4lol
As someone who has had several CT scans (and paid for CT scans), the idea that
a CT scan is better than a physician feeling your abdomen is absolutely
ridiculous. Pumping contrast agents into everyone who has pain is a very bad
idea. Moreover, enforcing decisions by algorithmic rules is problematic,
especially considering who might be making those decisions.

~~~
DrJaws
Plus radiation. Every CT scan increases your odds of cancer.

Also, mammography or even colonoscopies have been proved for most of the
population to do more harm than good. cochrane is full of meta-studies about
it.

The medical industry is very shady.

~~~
08-15
> Every CT scan increases your odds of cancer.

There is no evidence for that statement. More specifically, there is no
evidence that a single radiation dose below 100mSv is harmful at all, but
plenty of evidence (Taiwanese radioactive apartment buildings, nuclear navy
worker study) that it isn't. Muller made it up for political reasons.

~~~
ItsMe000001
There is evidence:

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660619/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660619/)

> _Title: Cancer risk in 680 000 people exposed to computed tomography scans
> in childhood or adolescence: data linkage study of 11 million Australians_

> _Conclusions: The increased incidence of cancer after CT scan exposure in
> this cohort was mostly due to irradiation. Because the cancer excess was
> still continuing at the end of follow-up, the eventual lifetime risk from CT
> scans cannot yet be determined. Radiation doses from contemporary CT scans
> are likely to be lower than those in 1985-2005, but some increase in cancer
> risk is still likely from current scans. Future CT scans should be limited
> to situations where there is a definite clinical indication, with every scan
> optimised to provide a diagnostic CT image at the lowest possible radiation
> dose._

And about _" a single radiation dose"_: As soon as you get a CT the chances
that you will have only a single one in your life are greatly reduced, because
you just had that one. So it still is better if the count remains at zero, or
your precondition can easily be invalidated.

~~~
08-15
The problem with that study is that "people who take a CT scan" is not exactly
an unbiased sample of the general population.

Now compare this to

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2477708/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2477708/)

> only a single one in your life

"A single dose" as in "a discrete event". Another single dose the next month
is (probably) harmless again. Cells react to radiation with repair mechanisms,
and once that activity subsides, the event is over.

Radiation exposure isn't linearly cumulative. The argument that it is was made
before we even knew the structure of DNA! Today, we know better.

~~~
ItsMe000001
I also recommend at least the "Conclusion" section of this document, selected
as an example, not as the one definite document:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611719/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611719/)
It is a good read overall too. You make it sound as if it does not matter.
Apparently that is not the general medical opinion.

I also don't see what the problem with the selection of people is supposed to
be. Those selected are more likely to not be able to repair DNA damage? I
think this particular selection makes no difference for the purpose.

Overall, OP said "there is no evidence" and it seems that yes, there is. What
you think of that evidence is not the question, OP had said there isn't any.
When I look at the actual recommendations it seems that most medical people
don't think so, after all, the recommendation still is to limit the radiation
exposure, not just for the frequently exposed (radiation workers) but also for
those one-time patients.

Even on a per-event basis reducing the amounts of radiation was and is a major
design goal for the devices. Does not look like those who are involved in all
of this think there is no problem.

~~~
08-15
> Overall, OP said "there is no evidence" and it seems that yes, there is.

This is evidence for a correlation between the number of CT scans and cancer
incidence. To jump to the conclusion that the cancer is caused by the
radiation from the CT requires a leap of faith.

The funny thing is, if an epidemiological study shows that low dose ionizing
radiation is beneficial (radioactive apartment buildings, nuclear navy
workers), it's dismissed by a completely ad-hoc "healthy worker effect" or
"healthy student effect". But in a study of people who received a CT scan,
where you should expect a "sick people effect" (healthy people don't get CT
scans), you "don't see a problem".

------
bsder
Part of the issue is that the _doctor_ is on the hook if the _tool_ fouls up.

Consequently, having an extremely skeptical viewpoint on tools is perfectly
rational.

I can also tell you from discussions with doctors that one of the problems is
that the intersection of GUI programmer, competent engineer, and medical
domain knowledge is either a null set or a single person. (For example: EEG
analysis seems to be a natural fit for ML/AI--enormous amounts of data with
events only sporadically scattered in it--yet there is nobody capable of
handling the intersection of talents required.)

~~~
rpcastagna
It reminds me of _Moneyball_ ; in it, the author points out that the
statisticians were frustrated by their inability to get traction within the
MLB, but their pitch essentially boiled down to "you guys don't listen to
statistics, you should listen to these new ones we just developed," which left
unsaid that the statisticians made up new quantifiers _because the old ones
were ineffective._ The MLB had the lived experience of those statistics being
ineffective, so they knew Bill James et al were right about that, but the idea
that the answer was _more numbers_ that didn't make a lot of intuitive sense
was a hard sell.

I would also add that my perception from working at a major east coast
hospital has actually been that hospital IT clamps down on new tools more than
anyone because of HIPAA requirements, etc, that the doctors ignore/don't care
about as much as they should. It's a complicated, layered system.

------
noonespecial
The number one thing you can do to get doctors to use your new tool is find a
way so that they don't have to enter patient data _again_.

The fear they have isn't that they'll be replaced on the job. The fear they
have is that they will be required by some policy to enter yet another copy of
the same data into yet another "time saving" system.

------
rpcastagna
Healthcare industry insiders joke:

Any theory of the current state of medicine that involves a cardio-thoracic
surgeon feeling like they are _not_ completely irreplaceable, one-in-a-
trillion geniuses/minor deities, put here on this planet to spare us lesser
mortals (as scheduling allows) seems... improbable.

------
Mbioguy
"They thoughtlessly order tests and thoughtlessly obey the results."

Hacker News, come on. You're better than this.

Taking it from the top: The obvious take is that the new tools this is
referring to is EMR and things like Watson. Will return to this in a moment.

Subjective and objective data both a play a role in medicine. The eye of an
experienced person can often see in a blink what would be missed by someone
looking only at numbers in a chart. Gestalt, or the fast system of Kahneman,
is invaluable when time is a serious concern. But noone starts out that way.
The slower, methodical plod of consciously using bayesian thinking is how the
art is learned. Hear hoofbeats, think horses, not zebras... trying to weigh
all available data and attempting to chart a course that gives patients the
best outcomes at the most reasonable costs. Nowadays additional hoops must be
jumped through: laws constrain, institutions have policies that must be
followed, and most of all care is dictated by what is allowed by the insurance
company. Rather than an invisible hand, this is an invisible supervisor
robbing much autonomy and initiative from a sense of worthwhile work.
Furthermore the ever-present fear of litigation pushes towards a course with
more testing than might be suggested by treatment and diagnosis alone: how
would this course be defended if things go wrong, as they will for a certain
number? All of these things individually stood to reason, but we as a society
must keep in mind the cumulative weight of it all. Emergent phenomena isn't
just a thing of programs and physics, it's a thing of human systems like
healthcare.

Back to the article. A happy picture is painted of modern CT scans, yet it
neglects the downsides. In 1980 the average per capita dose of radiation was
3.0 mSv, with 0.5 coming from medical imaging. It is now 5.5 mSv and rising,
with medical imaging alone exceeding 3.0 mSv. Medical imaging is now a larger
source of ionizing radiation than all other sources combined, with
particularly high risks for those in utero or pediatrics. Like any other test
or treatment, there is a risk/reward ratio. As technology improves, it is more
likely to be adopted, not because earlier physicians were anti-technology
Luddites, but because the improved technology changed that risk/reward ratio.
We are more likely to use imaging with less exposure, or better yet use a
modality without that risk.

Back to the Bayesian part of thinking... testing isn't perfect. I'd love to
see a test that is 100% sensitive and 100% specific. But there are inevitably
false positives and false negatives. Tools and tests need to be used in an
appropriate situation. For example: I have a test that is 99% sensitive.
Great! It'll catch someone with the disease, 99% of the time. So I can
thoughtlessly order tests and thoughtlessly obey the results, right? Wrong.
What happens if you use it to test for a rare disease that only 0.1% of the
population will have? It depends on how specific the test is. How many false
positives does it let in? If I test it on 1,000 folks indiscriminately, I'll
end up with a basket of folks, only one of which actually has the disease. How
many false positives got treated (and possibly harmed by that treatment)?
Mammograms work this way (which have fallen a little out of favor in younger
demographics without risk factors like the BRCAs), necessitating imaging and
invasive biopsies that, upon further collection of data and review, seem not
worthwhile for those under 40 and of questionable value under 50.

Tools are great! They need to be used appropriately though. Things have a
cost, not just financial but physical and temporal. Indiscriminate use of
tests and tools is the last thing anyone should want.

Nothing to add in a world of advancing technology? Bah. Most would love for
its promises to come to fruition. EMR for example. We were promised time
savings, with cross-talk between systems for better availability of data and
improved patient safety. Mostly what has happened is administrators now have
data used to push docs to see more and more patients (and spend less and less
time with any one of them), all the while the paperwork stacks up. Somehow the
paperwork never quite seemed to go away.

Maybe doctors don't reject tools that make their jobs easier. The article is
full of tools that were eventually adopted, after all. I can point to many in
development that have their ardent advocates, like point-of-care ultrasound
among many others. Maybe they don't like tools that were sold as making their
jobs easier but mostly don't, and instead benefit insurance companies and
conglomerate administrators.

~~~
derefr
> Mostly what has happened is administrators now have data used to push docs
> to see more and more patients (and spend fewer and fewer with any one of
> them), all the while the paperwork stacks up. Somehow they never quite
> seemed to go away.

Under capitalism, old companies (like hospitals) don't really tend to _adapt_
in response to market forces by actually changing anything as drastic as the
shape/relative scale of their internal bureaucracy.

It _looks_ like that happens from a 10,000ft view, but what's really happening
is that old companies are just dying, having been outcompeted by new small
companies that "grew up in" the market environment where the changes were "the
new normal." And then, eventually, the new, small companies acquire the big
old dying companies for their brand value—so the resulting merged company has
the appearance of the big old company having managed to turn over a new leaf.

When a company is only _slightly_ relatively unfit (due to e.g. serving a
market with inelastic demand, like medical care), it can take decades for
their relative unfitness to deplete their resources to the point that they'd
seek to be acquired. The current heavily-bureaucratic hospitals might be
actively dying _right now_ —it'll just take them another 50 years to become
all-the-way dead.

------
vinayms
> Too many doctors have resigned that they have nothing to add in a world of
> advanced technology. They thoughtlessly order tests and thoughtlessly obey
> the results.

Thoughtlessly obeying is undoubtedly a sign of incompetence; a doctor must
always use judgement based on patient's condition and not rely on a bunch of
numbers, a doctor told me in my teens. However, ordering tech based tests is
not thoughtless all the time, at least not with competent doctors. I mean, in
this age of self diagnosing based on googling, a doctor not ordering such
tests would be seen as incompetent, and even ignorant. Would a doctor risk his
reputation, and possibly livelihood, just to prove a point, even when his
spidey senses tells him there is nothing severe about the patient's condition
when the patient insists on it, directly or indirectly? Only a House would do
so. The writer is too eager to generalize for some reason.

------
tx21
Flashy article title clickbait.

Doctors are not fools. If a tool truly made their job easier, it would not be
rejected out of hand.

Job security for physicians is rarely the issue, there are plenty of sick
people.

~~~
pavlov
Surgical safety checklists were shown to lower 30-day post-operative mortality
by 22%:

[https://www.cardiovascularbusiness.com/topics/coronary-
inter...](https://www.cardiovascularbusiness.com/topics/coronary-intervention-
surgery/hospitals-using-surgical-safety-checklists-have-22-percent)

You'd imagine something as basic as checklists would be implemented as
standard procedure in modern medicine -- yet this study was in 2013, not 1963.
Most likely the majority of surgeons are still dragging their feet on this.
It's a very conservative field with lots of big egos.

~~~
gowld
Checklists make patient outcomes better; they don't make surgeons' work
easier.

~~~
onetimemanytime
I guess killing the patients as soon as the cut them open would be easier for
the doctor :), but their job us to heal patients. Anything that improves on
outcomes is good. The OP might have suggested that instead of new tools, just
use the old checklist system.

~~~
TeMPOraL
There's also trust issue. Doctors, who like everyone can be opinionated, had
to be convinced one-by-one that checklists actually work and are worth messing
up their work habits - unlike the many other things people are trying to sell
hospitals.

------
HeadsUpHigh
As a med student, using shinny new tech in medicine has become a dick
measuring contest. There is absolutely no fear of new tech, just professionals
rejecting useless unoriginal products that don't actually make our jobs
easier. Like the data fad that will just make us manually reenter data into a
new data silo for the benefits of other companies who will take no
responsibility to the stability required in the field. I absolutely resent
some of the interfaces we have to use but at least the CT/MRI reading software
doesn't crash. Anything new and shiny does though.

