
Ask HN: What will medicine look like in 10 years? - adammichaelc
I recently decided to become a doctor and there seems to be a lot of pessimism surrounding the field with the recent government interventions and what-not. But I'm more optimistic and can see technology playing a powerful role in disrupting old systems and creating a new paradigm of personalized-to-the-DNA treatments, tri-quarter-ish diagnosis tools, re-growth of organs and damaged tissues, and integrative medicine (whole-body treat-the-cause instead of the symptom). These things may not come in 10 years, but perhaps some will.<p>Am I naive and too optimistic? What does HN think about the future of medicine?
======
lkrubner
The current trend, as I understand it, is to reduce the independence of
doctors. This is happening on 2 fronts:

1.) The FDA is imposing stricter limits on how doctors prescribe.

2.) The insurance companies are imposing limits on what doctors can do.

The trend has been developing for several decades, but it only came into clear
focus during the 1990s, when the HMOs first gained prominence. Doctors have
lost a great deal of independence compared to what they had 100 years ago, or
even 50 years ago.

#1 has at least 2 parts:

a.) The War On Drugs: this has lead to limits on how aggressively doctors can
manage pain. Too aggressive and the doctor comes under scrutiny.

b.) The widening powers of the FDA. Over the last 50 years the FDA has become
a general clearing house for all new technologies that effect health. Whereas
its focus was once on drugs, it now has substantial say over every kind of
medial procedure, including such things as pacemakers.

A simple model of the contending forces might include these main actors:

1.) patients

2.) doctors

3.) government

4.) hospitals

5.) patient insurance companies

6.) doctor liability insurance companies

A simple model would simply assert that each of these is trying to lower their
risk, partly by moving the risk onto one of the other players. (A more
complicated model would have trial lawyers as their own element, but here the
trial lawyers are assumed to be part of #1). In a simple model, you could
assert:

risk = the power to make decisions

The more each group tries to get rid of its own risk, the more it also loses
the power to make its own decisions. This is a simple model, but it clearly
has some truth.

What we've also seen in the last few decades is that when risk in the system
goes beyond what private sector actors can manage, then the risk, and the
decision making, gets taken over by the government. This was a long term
trend, but the trend was made very explicit and visible during the crisis of
2008/2009, when lots of private sector actors failed (Lehman, General Motors,
etc) and were taken over by the government.

I keep looking for some sign that this trend might abate, but for now, it
seems likely to continue, if in modified form.

Conclusions?

You can become a doctor. You will be respected. You will be well paid. You
will lack the independence that has been traditionally associated with the
role. But despite that, you may enjoy the work.

~~~
_delirium
Evidence-based medicine is another factor pushing in that direction. There's
been a move away from the idea of doctors as professionals exercising case-by-
case judgment, and more towards scientifically validated treatment methods.

I'm not entirely sure what I think about that. On the one hand, it seems bad,
that instead of having the freedom to exercise situation-specific judgment,
doctors are increasingly being pressured to follow predefined flow charts and
rubrics, turning it into a sort of cookie-cutter medicine. On the other hand,
the statistical evidence in some cases is actually pretty good: for at least a
few kinds of things that have been tested, doctors who mindlessly follow a
validated process have, on average, better outcomes than the more traditional
approach. One explanation that's been advanced for that is that humans are not
very good at conditional probabilities, so doctors often make intuitive
decisions that, if you run the numbers, aren't statistically the best choice,
based on available data. If so, they're better off strictly following a data-
derived procedure rather than trying to improvise.

~~~
anthonyb
Checklists
([http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...](http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all))
are another area where control has been taken away from doctors (medical staff
apparently are allowed to physically restrain doctors who don't follow them),
but with drastically improved results.

------
icegreentea
I think you'll be seeing a lot more processes being 'forced' onto the
profession. I know process and system engineers like looking at the medical
field in general and then pull their hair out at just how many places you can
let human error slip in. And I know a lot of people want to go change that.

So that'll mean you'll probably start seeing more checklists, set procedures,
expert systems, etc etc. And it will reduce your independence. But it'll also
(if we do it right) be better for your patients.

If you want an example of stuff engineers get brain boggled at, look at the
labels on drugs used in hospital. The vials are typically sized for one dosage
and so are fairly small, so you have small label to begin with (nothing
-wrong- with that). And then half the label is taken up by a company label (at
best). And then the full drug name is written out in tiny print.

------
RK
_integrative medicine (whole-body treat-the-cause instead of the symptom)_

"Integrative medicine" is just another term invented for "alternative
medicine". A few respectable universities have centers/institutes for this,
but it is almost always the result of a specific effort on the part of big
money donors.

I think, as many others have mentioned, that more data is becoming available,
largely due to the shift to electronic medical records. As a physician,
especially if you're involved in research, being able to make sense of that
data will be very valuable.

I would suggest checking out <http://forums.studentdoctor.net> if you don't
already read that forum.

------
skmurphy
"Never mistake a clear view for a short distance." Paul Saffo

Look back 20 years to see what's changed to get an idea of what may happen in
the next ten. Look for more innovation to take place in cosmetic surgery,
veterinary medicine, and other practices where the patient (broadly defined)
pays.

Insurance, while necessary for catastrophic events, has crept into almost
every transaction. It distorts incentives and is less concerned with improving
outcomes than minimizing and shifting costs. The financial incentives and
economic models for medicine have to change before you will substantially
alter the pace of innovation.

~~~
yoden
There's a very good reason for medical insurance beyond catastrophic events.
Preventative medicine is much, much cheaper. Insurance makes routine checkups
cheap/free, which means they're more likely to be taken advantage of.

Medicare has a much larger say in what sorts of procedures will be used (the
ever widening--yet still not wide enough--umbrella of PET imaging is a great
example).

~~~
glenra
"Preventative medicine is much, much cheaper"

I question that assertion. Source?

Note that it is _not_ sufficient to merely say "if you have condition X, it's
better to have caught it early", because that ignores (a) the cost of testing
all the people who _don't_ have condition X for that condition and (b) the
cost when widespread testing leads to false positives which cause one to
_think_ the patient has condition X leading to treatment which produces
needless expense, disability and/or death.

Every time you take your car in for an inspection the mechanic is likely to
find things that are wrong and need fixing; ditto for taking your body in for
a check-up. But on the margin, medicine is just about as likely to make you
less healthy as more healthy, so being prescribed more of it is not a clear
win. (see the Rand study, MRFIT, and so on)

------
grandalf
Medicine faces a dystopian future.

Doctors are being paid less and less while patients expect more and more (and
they expect it to be free).

B/c of HIPAA, most of the obvious IT innovations will be stymied by
bureaucracy and stagnation. The recent backlash against personalized DNA
testing shows that regulators are looking forward to squashing that as well.

Waits are long now and will be longer in the future. Doctors are harried now
and will be more harried in the future.

Most speciality medical care (other than plastic surgery and other borderline
areas that people willingly pay out of pocket for) is a financial racket akin
to the banking fiasco. The AMA keeps supply of specialists low to keep
salaries high, and battles are fought over regulations that lead to more
billable procedures, gaming of the medicare system, etc.

Many commonly used procedures and drugs have very little effect and drain
money from society. If you think critically and read the studies you will
realize this. Then consider the Billions being paid the respected specialists
who do these mostly useless procedures. Consider the influence they have in
hospital policy and government policy.

Medicine in the US is a phenomenon of the American psyche. We have too much
faith in the latest buzzword or technology to solve our problems, and we want
to cheat death. Meanwhile, medical diagnoses are the only validation provided
to so many desperate souls whose miserable lives are spent in constant
complaint and agony, defined by their illness.

So many doctors traffic in the misery of these people, and the institution of
medicine legitimizes it (for profit).

There are some niche areas where science is actually making amazing progress
(some kinds of cancer research, mostly) but overall the medical class (those
enriched by the status quo) are exploiters of human vulnerability, hope, and
malaise.

Yes there are some amazing doctors and most I've met are incredibly hard
working, caring people. But there are so many lies so deeply ingrained into
our system that it will be hard ever to change it.

If you're a 60 year old man with significant arterial blockage, it's
considered normal. You'll be sent home on an expensive pharmaceutical and told
to switch from steak to chicken. The population of aging adults (55+) are the
human batteries that power the medical matrix.

~~~
jerf
I don't necessarily disagree with your analysis at a surface level, but it's a
first-order analysis. The forces you cite do not exist in a vacuum; people
will be reacting to them. The situation you describe can not go on forever,
and therefore must cease at some point. If nothing else, then if the
government leans on people too heavily a black market will form through sheer,
rather bog-standard economic forces. I am not saying it absolutely will come
to that, I'm simply saying that places a bound on how far the forces you
describe can progress.

I am not sure exactly what will happen in response to the forces you outline,
nor am I sure when it will happen. I can only say with confidence that
something will. It is absolutely impossible that we will in 2050 be in a world
that is simply a straight-line projection from the one we live in today.

~~~
grandalf
Very true... It will be fascinating to see what happens. A few additional
thoughts:

\- Life expectancy is an s-curve, and recently we've seen the middle get
nudged to the right, creating the impression of tremendous progress. The low
hanging fruit have been picked, so the trend will likely not continue.

------
bendmorris
Since you're so interested in technology and science you might consider
earning a PhD in biomedical research/biomedical engineering, genetics,
genomics, or something else that interests you. The amount of actual science
involved in the day to day practice of most doctors is negligible.

With your interests I'd suggest looking into MD/PhD programs - granted, that's
a long time to spend in school (7+ years for both doctorates, then residency
or postdoc or whatever), but if your interest is really in medical science, it
can be a great opportunity. Also, these programs generally pay your tuition
plus a stipend the whole time you're in school, so you can live comfortably
instead of acquiring hundreds of thousands in debt.

Good luck!

~~~
throwaway80919
This is exactly what I am doing. I am getting my undergrad degree in
Molecular/Cellular Biology with a Computer Science minor; and am lining up
going on to a PhD in Biomedical Engineering. After that, I plan on starting my
own bio-tech company just about anywhere but the United States with a focus on
prion and autoimmune diseases.

I would start the company now if not for the issue of funding. As I do not
possess the correct shibboleths (i.e., formal education, published papers,
etc.), the odds of funding are literally zero (you can stow the replies
claiming otherwise, I've checked). And the no funding trend continues despite
being able to show time and again that my ideas are congruent with, and
sometimes predict, the latest medical research in the above specified fields.

Also, if anyone else is wanting to do a similar track, the key to having your
degree be an advantage to getting out of the United States is ensuring your
university (and specifically your degree) is accredited by a signatory to the
Washington Accord.

------
makeramen
<http://www.zocdoc.com/> is doing some disruptive work in the area, but the
high amount of regulation is really a huge limiting factor in the industry.

It's a field where people are inherently afraid of change due to the lives at
stake. I think it really takes some doctors who aren't afraid to step out of
the system and do awesome things. One of the few I've found is Jay Parkinson
(<http://blog.jayparkinsonmd.com/>).

Jay noted that the healthcare system in the US is one of the best at acute
care, but one of the worst at preventative medicine, which is why everyone is
dying of chronic illnesses these days.

As a Biomedical Engineering Major originally going the pre-med route, I got
really discouraged by the amount of work/studying/brainwashing required to
work in such a highly regulated system where saving lives is secondary to your
fear of getting sued.

And then you have the healthcare and pharmaceutical giants pulling many of the
strings in the background amidst all the crazy regulation from the FDA, it's
just sort of depressing at the moment.

But on the bright side, I do think it's all on the brink of some sort of
revolution. I don't see the current model being very sustainable in the long
term. It's quite possible that by the time you're done with your residency
(and subsequent fellowship?) things could look a lot different.

------
csomar
As a Medicine student, Technology can make doctors pointless. What a doctor
do? He inspect the patient and prescribe medicines. That's all and its'
inspection, while depend on his experience, can never be 100% accurate.

That is, if a new technological evolution, can make it possible to diagnose
the human body with a simple and small device, no one will probably need a
doctor and the device can prescribe you the treatment with even more accuracy.

You can also take daily inspection with the device and it'll follow your
health and gives you suggestions based on that.

You may think I'm too optimistic, but who thought that one day we can see the
interior of the human body without surgery?

~~~
aik
Rather than rendering doctors pointless, perhaps the technological advances
are changing the role of doctors. The same thing is happening in the education
field.

Doctors perhaps need to start specializing more in areas where it is harder
for technology to reach. Maybe they need to think more holistically (something
difficult for computers to do). Perhaps they need to actually learn about
people in intricate detail - about their diet, habits, health history, etc.
prior to diagnosing. Perhaps they need to become strictly health advisors, or
partners of health. Maybe they should perform weekly/monthly/yearly meetings
with individuals, learning about them over time through spending time with
them. Decisions would be truly informed and they would develop true care for
the person (and quality as a result).

In addition, it's important that doctors stop being viewed as creatures with
omnipotent and infallible knowledge and decision making powers (I know there
are exceptions to this but I believe it's true for a lot of people).

~~~
csomar
_learn about people in intricate detail - about their diet, habits, health
history, etc. prior to diagnosing_

It takes lot of time, and the patient won't remember anything. However, the
device can know all that and with precision. The patient doesn't need to tell
the device that he smokes, but it'll discover alone and with high accuracy. It
can uses for example, a combination of radiographic images of the lungs, some
proteins concentration in the blood....

------
huntero
Because of the extreme consequences of failure, medicine is slow to innovate.
The medicine we see 10 years from now will appear very similar to today's
medicine, with survival rates from serious illness continuing to creep up.

Hopefully, I'm wrong. The medical research community needs to focus on
analysis of the huge datasets that will be becoming available over the next 10
years. Coaxing trends and patterns out of medical data could result in big
breakthroughs, but it is going to need a radical change in how medical
information is shared.

------
weavejester
I think we'll begin to see an acceleration of drug research. Pharmaceutical
trials typically take over a decade to complete, so the drugs available for
general use now were devised back in the 1990s. Back then, clinical trials
were largely paper-based, and needed to have a relatively large number of
subjects to be proven safe.

Nowadays clinical trials are usually managed by web applications, which give a
real-time view of how the trial is progressing. We're also beginning to see
drug trials targeted at specific generic groups. The idea is that you need a
smaller sample size to prove a drug works for a certain genetic subset of the
population, so less initial investment is required. If the drug is successful,
further trials can expand the number of people that can use it.

------
Estragon
A lot of people in this thread are too naive and optimistic, but not for the
reasons you might think. We are in the twilight of a long era of peace and
prosperity and are moving toward a time of great disorder. The West seems bent
on abdicating its dominance of world politics, and no one knows what is going
to take its place. Against that backdrop, trying to predict tiny details like
the role of insurance in 10 year's time is pretty ridiculous, because there's
a good chance that the changes won't be incremental.

Becoming a doctor sounds like a great idea, though. Good luck!

------
ck2
In 10 years:

There will be cures for a few more things than now, but the average person
won't be able to afford it (if you live in the USA).

A ride in an ambulance will cost $50k instead of $10k today (if you live in
the USA).

An aspirin in a hospital will cost you $500 instead of $100 today (if you live
in the USA).

Somehow the masses will be convinced to still fight against single-payer and
defend massively profitable insurance companies and hospitals (if you live in
the USA).

But if you want to be a doctor to help people and can maintain that attitude
for a decade, then I applaud you, for what it's worth, you are truly a noble
human being.

------
sown
Since I don't have insurance it'll look the same, perhaps worse.

------
vierja
I believe the thing about innovation in the field of medicine is that it has a
lot at stake when trying new things. From theory to wide practice there are a
lot of barriers, impeding the development of the things you mention.

But there is something certain, technology will play a enormous role in
medicine. You shouldn't be worried about whether or not we will see such
things in a 10 year lapse.

------
jasonz
Why do you want to be a doctor?

~~~
adammichaelc
Because (a) I've always been interested in science, (b) I am obsessed with
learning about new developments in medicine, (c) I would love to help a person
feel better who was suffering from a chronic disease, (d) I think I have the
potential to be a very good doctor because of how interested I am in the field
and how much time I'm willing to invest both during and after my formal
education, (e) it's enough money to comfortably raise a family with, and (f)
it provides tremendous opportunity to conduct research on new treatments,
something I would like to be a part of.

~~~
jasonz
Well I wish you good luck. Be sure to weigh the pros/cons of each career path
that can get you to similar goals - MD vs PhD vs NP/PA. Is there a particular
field of medicine that interests you the most?

~~~
adammichaelc
I think chronic disease is really interesting, and I have a particular
interest in using vitamin D as a potential treatment for certain chronic
illnesses. Much of the vitamin D research has been observational research, and
while it shows tremendous promise in preventing heart disease, certain
cancers, and diabetes, more needs to be done to establish whether these
diseases are caused by a deficiency, if so to what extent, and whether
correcting this deficiency has a treatment effect.

------
alphaoverlord
I am a medical student, so inevitably my perspective will be biased. I am a
first year, so perhaps my perspective is naïve, but I want to share my two
cents.

The broad view: First, life is precious. Our time here on earth is extremely
limited, and despite our best efforts, we have only begun to improve and
increase our time here. Every time I hear about stories like Ebenezer Scrooge
or rich philanthropists donating their money for secure a legacy, I am
reminded of our inherent mortality and life is one of the few things that you
cannot buy. Any society where the basic needs of food, shelter, and
entertainment are largely met, an increasing amount of money is spent on
healthcare. I think it is no coincidence that the proportion of GDP spent on
healthcare correlates extremely well with the GDP proper. This is in part due
to extremely poor diminishing returns – hypothetically $10m spent on running
water can increase the life expectancy of 10,000+ people by more than 20
years, but $10m can fund at most 100 open heart surgeries (which here the 5
year mortality benefit is only marginal). But with increases in the standard
of living, expectations of health increase. Barring catastrophic changes, our
emphasis on health will not diminish. _If you want to work in a field of high
importance, where effort will be rewarded, there are many challenges, and
technology is constantly changing and improving, medicine is a good choice._

A ground level perspective: Second, medicine is difficult. Undoubtedly there
are many challenges in the path to become and the practice of a physician.
There are many problems in the structure of healthcare, there is decreasing
independence, and the training path is only lengthening as medicine becomes
more and more specialized, but there are many benefits and joys unique to the
medical profession. You are privy to the breadth of human experience, from
life to death, and are gifted with a perspective unparalleled in beauty and
complexity. When you work with a cadaver for the first time, I hope you are
overwhelmed by how inherently private and precious the gift is before you. I
am convinced that are few experiences more acutely beautiful or overwhelming
than helping someone overcome an illness or witnessing a birth or death.
Biological science is an incredibly diverse, complicated, and fascinating
field - as a physician, you can help facilitate the next big breakthrough or
be part of its implementation. Technology will only facilitate and augment the
physician’s ability to diagnose and treat disease – there will always be need
for someone who understands and appreciates the mechanisms of the human body.

As a physician, you will be respected and will be compensated by your ability
to help others. I am certain that medicine will be vastly different in ten and
twenty years, but I think the things I mentioned above are constant. If you
are passionate about science, appreciate the ability to help others, and
willing to work hard, medicine can be a good choice. You don’t have to worry
about it disappearing.

~~~
abalashov
No offense, but your comment sounds like a glossy press release or a sappy
existential introduction to a documentary. It contains little to no concrete
information or positive claims, of the empirical or speculative variety. It
has a communicative magnitude of nearly zero to someone reading the comments
because they are interested in substantive answers to the OP's question.

For that reason, I downvoted.

~~~
alphaoverlord
The substantive arguments I am trying to make are:

1\. Despite diminishing returns, medicine/health is a social/individual
priority and significant resources are dedicated to this field.

2\. Health is a core necessity similar to food and shelter - I find it
difficult to imagine a future of substantially decreased health resources.

3\. Current aims are to improve efficiency, and slow the growth of healthcare
as a proportion of GDP, but it would be difficult to actually decrease its
proportion of GDP, particularly if expectations for standard of living and
health continue to increase.

4\. Biological science is really interesting and medicine allows you to help
others.

5\. You get to see some really cool things that most people can't see.

6\. The above reasons are things that won't be changing in the foreseeable
future.

For any career, there are intangible and unquantifiable reasons and benefits.
I am not, and not seeking to, make a completely objective, metric based
argument for medicine. To be successful, I think you need to have a passion
for your career, and I am simply trying to identify the aspects of medicine
that one can find passion for. For that matter, if the decision to choose
medicine is purely quantitative and pragmatic, I would advise you against
medicine. We don't need physicians like that.

------
mbm
On one hand, the healthcare law is a source of tremendous uncertainty for
physicians. As so-called 'medico-legal' liability standards continue to become
more stringent, and physicians are increasingly burdened with administrative
costs, the profession is itself in rapid flux.

From my perspective, there are probably three important things occurring at a
fundamental level which may be likely to dramatically change medicine in the
relatively short-term.

1\. Electronic medical records and more accountability in medicine through the
(eventual) re-alignment of incentives for hospitals and physician practices.

EMR makes it fundamentally easier to track where a physician practice's money
is flowing, and to collect data on the effectiveness of treatments for
different classes of patients. Right now, physician practices are not
incentivized to focus on metrics from a business standpoint because its often
not (a) viable from a cost standpoint or (b) able to be easily actionable for
the physicians. As EMR technology continues to improve (see Practice Fusion
for an example of a great technology which is incidentally _free_ ) and as the
policy environment slowly adapts to incentivize doing what's best for the
patient, I think outcomes will improve. This is, IMO, the messiest problem
confronting medicine today.

2\. Genetics and genetics research

I work for a diagnostic genetics startup. DNA sequencing technology is finally
getting to the point where doing business in this field is able to be viable
from a cost standpoint. As sequencing technology becomes 'democratized' to the
extent that individual research labs are able to purchase essentially desktop
sequencers to conduct research, the quality and breadth of genetics research
will probably be significantly greater.

3\. Bio-engineering

MIT recently added a bio-engineering major. Much of the early-stage research
occurring at MIT, Rice, and other colleges with dedicated bio-engineering
departments is extremely interesting. I hope that more colleges and the
government will put money into translational research programs aimed at
bringing discoveries in the lab into the clinic. Though I'm not qualified to
write about this in depth, I considered attending graduate school in bio-
engineering and found much of the research in tissue engineering and the like
to be very, very interesting. It's just so early that it's hard to tell.
However, I've found bioengineering departments to have this sort of inspiring
zeitgeist pervading them that I imagine is similar to how physics felt at the
dawn of the 20th-century. They aren't exactly sure what they're doing, they
simply can't be at this early stage, but they know it has the potential to be
very important.

I think that medicine will remain viable. Things will change, that's for sure,
but I think it can be a net win.

------
curt
I was literally working on the cure for ALL disease, but stopped because I got
frustrated with all the crap regulations and rules the government forces you
to follow. If someones dieing and only has a few months to live they don't
have the right to try an experimental treatment. Due to my area I needed
people, animal substitutes don't work.

So instead I went into creating consumer products and am now moving on to the
internet space because of new government regulations making the other space to
expensive. As you can figure, I hate the government, you have bureaucrats
making rules on subjects in which they have zero understanding. You have the
lobbyists from the large companies using regulations to great huge barriers to
entry to protect their fiefdoms. Unless the ridiculous health care law is
repealed, the advances and success the USA enjoy will disappear. Before people
quote survival stats, make sure you compare apples to apples, for example
infant mortality is calculated completely different around the world (the
definition of live birth).

My hope is that the US embraces a true free market health care system. The
problem is that we have removed the pricing effect that creates efficient
markets from the health care industry. What we should have is true insurance
where it pays 50% over say $2,000/yr, 80% over $5,000, and so on. Your company
places a set amount of say $3k per year on to a credit card (that roles over
yr to yr) and you can use the card to buy any health related service or
product. This eliminates all the paper cost in the system and brings back the
pricing effect since people will now shop for better deals (ie why does a
procedure cost $7k at one place and $2k at another across town?).

~~~
curt
That was a bit of a rant, but the point I was trying to make was that
innovations such as those I was working on will disappear unless the system is
corrected. What doctor wants to be told you can't save a life because there
isn't a code for it or it violates some regulation.

