
The Lawlessness of Medicine - Petiver
https://lareviewofbooks.org/review/the-lawlessness-of-medicine
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jepper
Very interesting article, his previous book 'The emperor of all maladies' is
also highly recommended. A lot of medicine is not level III evidence or better
backed.

As both a doctor (surgical attending) and programmer medicine feels not just
like debugging a very complex non linear machine. Patient psychology is one of
the hardest parts of the job. Is the stomach pain caused by a psychical
problem or can it be functional? The use of protocols (part of the science)
can help in catching non typical presentations of illnesses, especially if the
patient is not adequate in presentation (drunk, very young, old, trauma etc).

But sometimes medicine comes down to an art, when you have the feeling
something does not add up, you have to dig. The same with (older) attendings
with very attuned diagnostic skills due to lots of experience that can help
solve non-obvious cases.

~~~
cantrevealname
> medicine feels not just like debugging a very complex non linear machine

One way in which medicine is _not_ like debugging is the hours spent by a
physician vs a programmer. I (as a programmer) have sometimes spent 100 hours
tracking down a bug whereas I've never seen a physician spend more than a few
minutes trying to diagnose an illness.

Even with a gravely ill person, my experience has been that an attending
physician has never spent more than about 15 minutes on the diagnosis (or to
be a bit more generous, let's say several 15-minute re-evaluations as new
information came to light, such as blood test results).

It's a strange contrast. I considered my bugs to be serious bugs, and it was
worth 100 hours to diagnose it correctly. But my bugs are _nothing_ compared
to a human life. Why is our medical system OK with quick diagnosis? Does it
all come down to money or would more time available to the physician make no
difference because [medicine is art not science / some other reason]?

~~~
Angostura
The analogy is not apt. A closer analogy is not a programmer - the doctor is
in IT support ... and is dealing with a unique combination of bespoke hardware
and software for each case ... and has no makers documentation available.

~~~
clavalle
I wouldn't say bespoke (which implies written from the ground up from
scratch), but with possibly different environment and other configuration
variables and, occasionally, slightly different shared library files.

And while there is no official documentation available, there is plenty of
good guesses from hordes of brilliant reverse engineers.

Still, there are only a handful of error codes that are thrown, and you have
to make your first guesses from those and the logging is pretty terrible when
you do decide to dig a bit deeper.

And inserting your own code into the spaghetti mess is a bit of a crapshoot.

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jrapdx3
To quote the article: "Mukherjee’s laws of medicine are laws of uncertainty,
imprecision, and incompleteness. ...".

I don't know if these ideas constitute science "laws", but of course the
practice of medicine _is_ bounded by such factors. Then again what discipline
of any importance is not also similarly constrained? A common theme on HN is
the inevitability of software flaws, the uncertainties and corner cases
inherent in programming tools, like compilers, render satisfactory outcomes a
matter of probability, not at all unlike medical diagnosis and treatment.

Nothing new, medicine has been regarded in the last century or so as an art,
with a basis in science to the extent it exists. Truth is that a great many
phenomena have received little or no study, yet unstudied problems still show
up in the office every day and must somehow be addressed.

Good practitioners welcome scientific contribution and eager to employ
"evidence-based" procedures. Trouble is there's not much guidance forthcoming,
leaving those in the front lines doing what they can with the inadequate tools
in the toolbox.

It's worth adding that a substantial part of the probabilistic nature of the
work is attributable to the limitless variability of human illness. I've long
expressed the idea in a terse form: _The reality is no two people ever have
exactly the same disease_. The subtle differences are what make diagnosis and
treatment a constant challenge.

Put another way, abstraction is at once a powerful benefit and potential
source of error. Declaring a patient's condition falls into a particular
diagnosis lends a valuable clue. However such categorization may easily blind
us to the small, crucially important distinctions among sufferers with the
same diagnosis. We can easily be fooled by our own cleverness. Point is that
the intuition, the talent, of a fine practitioner will always defy
"explanations", and that makes it an art.

Edit: punctuation

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drchiu
What's worse is that modern day society expects physicians to be able to act
with some certainty. And when outcomes don't turn out the way everybody wishes
it would have, the target of scapegoating is the physician.

If you saw a person falling in front of a car, and you stopped to help him but
in the process stepped on the man's glasses, would you believe it to be fair
for the person who fell to blame you for the broken glasses?

~~~
harryjo
Yes, if you also got the credit for saving him from the car!

~~~
crpatino
And in a world where stepping on someone's glasses can bankrupt a well to do
family, that pettiness of yours and all that think as you do causes people to
die under the tires of a car... because would be helpers do not think they can
afford to do what is right.

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forgotpwagain
I will note that Siddhartha Mukherjee is also the author the _The Emperor of
All Maladies_, perhaps the greatest popular science book on cancer that is
scientifically and historically accurate and very engaging. I highly recommend
it (and will be picking up this book on the basis of Dr. Mukherjee's previous
work).

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mathattack
Interesting. For a while I've felt that Medicine isn't the science it's
cracked up to be - or at least our knowledge of the state of the art is never
as certain as presented by science. It seems to have many false paths of
thought similar to economics.

In the spirit of confirmation bias, I recently listened to a great podcast
relevant to the topic [0] which discusses why this is. It's more than just
lazy statistics.

[0]
[http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.htm...](http://www.econtalk.org/archives/2016/02/adam_cifu_on_en.html)

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polskibus
I can't scroll down linked article on android 5.1 chrome. Although what I've
read on the first page corresponds to my observations regarding medicine.

~~~
unixhero
You just have to clever up!

I managed to scroll down by invoking the Android text selector and be dragging
the selector block downwards.

Android-CURRENT on Huawei Nexus 6P here :)

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raverbashing
Very interest article (yeah, it scrolls for me). And it mirrors some of my
concerns with only basing yourself on EBM

Most studies are flat. They are concerned with "condition X and drug Y". They
go to a finer granularity usually when it's obvious (like treatment A works ok
but it is obviously a worse choice if patient has condition B). Getting too
deep in conditions is a slow process

Added to that the elements of diagnostics, which more often than not is a
"Plato's Cave" view of the patient's condition

"The first law is that a strong intuition is more powerful than a weak test.
By this, he means that common things occur commonly and uncommon things,
uncommonly... “If you hear thundering hoofbeats, think horses, not zebras —
unless you happen to be in Africa.”"

Bayesian thinking!

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moobsen
AFAIK, the most important law of medicine is "First, do no harm." The rest is
basically the details.

[https://en.wikipedia.org/wiki/Primum_non_nocere](https://en.wikipedia.org/wiki/Primum_non_nocere)

~~~
JoeAltmaier
Yet doctors routinely do harm - chemotherapy, amputations etc. Its part of
many therapies to make a patient hurt. So that's a noble goal, but modern
medicine left it behind a century ago.

~~~
nisa
These things are not taken lightly and are done to reduce more harm or to
avoid death. What's the alternative?

~~~
JoeAltmaier
The point is, "Do no harm" is sophomoric. Harm is, sometimes, the way to do a
greater good. Save a life. Restore function. Remove cancer.

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jerryhuang100
technically i think it's called stochastic systems biology

