I'm not a psychologist but some of the author's quoted text came off extremely demeaning in written form. If the author happens to read this, did you really say those things directly to them?
For example, Susan (psychologist) was quoted as saying:
> "Oh sure! I mean, I think in many cases I'll just prescribe what I normally do, since I'm comfortable with it. But you know it's possible that sometimes I'll prescribe something different, based on your metastudies."
To which you replied:
> "And that isn't worth something? Prescribing better treatments?"
Imagine walking into the office of someone who spent the last ~10 years at school and then potentially 20 years practicing their craft as a successful psychologist and then you waltz in and tell them what they prescribe is wrong and your automated treatment plan is better.
Meta-analyses are a good idea, but the mere presence of a meta-analysis does not denote a useful undertaking. The literature is polluted with thousands of meta-analyses. As far as I can see this is mainly because there is software available which lets almost anyone do it, and once someone else has done a meta-analysis it is much easier to do another one because they have already found all the papers for you. The publication rate of meta-analyses far outstrips the publication rate of all papers, and shows some unusual geographic variation (Fig 2) .
I mean, despite all stuff I've heard on HN about how a lot of big VCs passed on AirBnB, when I first heard of it it seemed like a very natural evolution from sites like Couch Surfing and VRBO that had existed for years.
Point is, the effect of the company on the society can’t just be measured by market cap.
Back to the original article, the author was using statistical analysis to provide medical advice. Now, it’s incredibly easy to arrive to false conclusions with statistics. That’s why there’s regulations, peer reviews etc. What if the “Egyptian contractors” screwed the data up. Was the founder qualified to spot an issue?
HN has drifted further and further from reality, which has been very strange to watch. The classic example was someone dismissing Dropbox when they first launched, but now it’s turned into dismissing billion dollar companies after they’ve clearly won.
I also note the "weasel word" idea. This wasn't just an idea, but an implementation.
The same thing might make sense as a value-added feature in a more comprehensive health service (so the "idea" might be good when put in that use).
But as an idea for a service based entirely on it, it failed hard. What exactly twist do you have in mind to save it? Or are you just saying "we'll never be sure" with more words?
I think posting haughty words is a lot easier than trying to make something work.
Also the opposite: dumb ideas are tried again and again to no avail ever.
The meta-analysis idea wasn’t terrible. It’s just that there’re many assumptions in a statistical sense, the founder might not be the right person to implement it and he might have targeted the wrong market. Some people are under the impression that everything can be solved just by build an app. However, some fields are much more complicated than your gig economy food delivery.
We just got an impossible vaccine in under a year, I'm happy for all of medicine to spend a bit of time in a "legal gray zone" to see what might happen.
> Many people all over the world think their lives were made much worse since Airbnb is negatively affecting the long-term rental market.
Absolutely, just like the Luddites (Although they would be well off Luddites) their world is worse. But humanity has been made far better.
In all seriousness, with meta-analyses it's still "garbage in, garbage out". It only takes one or a few egregiously bad studies to throw off your results if that study has a large sample size but something fundamentally wrong with its methodology or implementation.
The only assumption you may reject here is that there's no systematic bias in the papers. Perhaps there is... or perhaps most papers are just very unreliable, in which case there should also be no convergence... but if you find convergence, there's a good chance the result is "real".
For a good read about studies with solid statistics and bogus results, see .
In The Mom Test, he suggests getting right to the core of a customer's pain points. This is just corollary to that.
The fact that they agreed to talk to the OP probably means they aren't going to be immediately dismissive, but I'd hesitate to assign any supranormal human traits to doctors.
The typical doctor has minimal training in evaluating medicines - that is not their job.
They defer to so-called opinion-leaders, who are the experts on particular diseases.
These people are the targets of drug companies' marketing - think scientific conferences in 5 star hotels in exotic locations.
The cost of influencing them would be millions.
So,the author was barking up the wrong tree.
That's not to say that he didn't have something, but had no idea how to market it.
edit: There's a whole industry around providing pharma companies better tools to influence doctors. I believe the industry name for this part of pharma companies is Medical Affairs so feel free to google the tooling being offered.
Psychedelic-Assisted Psychotherapy: A Paradigm Shift in Psychiatric Research and Development: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041963/
Reviewing the Potential of Psychedelics for the Treatment of PTSD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311646/
Maybe they want to convince their friends?
It is still early days. If one can end depression with an oral medication that isn't scheduled one is better off.
Trial and error with prescription drugs without a diagnosis as you suggest is malpractice. Maybe you're specifically referring to psychiatry? That specialty is uniquely difficult since our understanding of psychiatric diseases is still murky. But even within psychiatry there are best practice guidelines on how to manage and treat different diseases.
Having been for 18 months through different types of psychiatrists and clinics, I came out quite surprised in how "trial and error" this whole system is.
I'm writing this from Switzerland, where we have an (arguably) high quality health care system. But the amount of "OK, that didn't work, lets try this other drug". Or, now, 18 months later, "Oh well, we did the list once through. But who tells me that the MD prescribing the first drug did a correct analysis? Lets start the list from top again." Or, for a friend of mine, his girlfriend found a working cure like that: "Oh, this brochure describes your symptoms so clearly, and it's completely different from what you've been treated for these last 20 years. Let's try it!"
Spoiler alert for my case with the list: the top of the list was not better the second time around.
If you think this is cynical, well, I would like at least _one_ of these drugs to work. If you think the MDs are all useless: well, at some times I was glad they were there.
So, well, I think having a little less than random system might be helping. Let the MDs watch if it makes sense, enter the correct diagnosis, and catch the stupid errors data entry people can make. But i'd give it a try...
It's like Googling coding questions and reading a StackOverflow thread. Obviously no programmer is solely relying on StackOverflow to do their job as no physician is solely relying on Google, UpToDate, or any other resource. They're simply quick references.
I've encountered a few people who were doing something very close to this. I really hope that doesn't happen in medicine too.
I think this is especially visible in software "engineering" with people joining the craft after a few weeks of boot camp. (think engineering vs programming)
However, we put doctors through an especially rigorous and long training and certification process to minimize the amount of unqualified practitioners.
The position that doctors should be trying new things to improve their care sounds good but in practice most doctors are strongly biased towards the status quo and usually inaction is preferred to a slightly unknown action, even if that action has better expectancy.
Not everyone, and not all the time. But many people, and often enough that it's a stereotype. So I think it's worth considering, particularly when you're looking at a customer base who (by and large) really aren't used to being condescended to.
Even if you and I personally aren't offended in the slightest by what OP said on sales calls, it's possible a psychologist in the fourth decade of her career might take "Are you sure that's right?" differently than we would.
His approach was never going to work, as doctors do not spend their time evaluating drugs in the way that he imagined.
It may have been a great product like you and others have said, he hasn't the faintest idea what physicians actually do day-to-day. He had apparently spent $40k over nearly a year before he talked to the first physician.
This biz was clearly made for consumers but yea ads are tough - need a lot of eyeballs.
The argument that “patients won’t know the difference so I can just do whatever” must break down at some point (hopefully before malpractice) but I think an argument of “I’ll just keep doing what I did before, it’s worked fine so far” doesn’t encourage worsening treatment or paying for more experimentation.
Edit to add: if you think a practitioner putting their own revenue/profits above providing quality care, then something's wrong with you.
So I'm not sure why you would expect a psychiatrist to do something she's not trained to do to (maybe) increase an already acceptable metric some arbitrarily small amount higher.
This is actually something that drives me absolutely nuts about doctors in the UK (I presume they are the same elsewhere) - inertia.
It's like doctors leave medical school with "best practices" about what they should prescribe - like they are glorified, human decision trees - and then across their 40-year career, they never read a paper, never read any new guidance, and general never change.
Inertia seems to be a particular problem in the NHS, where doctors have a set list they are willing to prescribe. Why? Because it's what they've prescribed previously, so they are "comfortable" with it. You can see there is a bit of a "chicken and egg problem" with other medications.
If you want better options, the only choice in the UK is private healthcare.
But yeah, I do still agree with you - GPs don't seem to even be up-to speed on the latest info with regard to a patients condition - surely their industry requires on-going professional learning like the rest of us ?
There are lists of recommended treatments, and there are many restrictions on prescription of medications, expensive ones in particular.
At a national level, NICE (or SMC in Scotland) decide what medicines the NHS will pay for, and for what conditions. They determine what medications are licensed for different treatments. They also set guidance on what treatments should be used for different conditions, what the 1st line, 2nd line, 3rd line treatments should be, and what treatments they think should not be used.
At a regional level, there are "formulary" groups, which take the national guidance, and make some tweaks - for example, for monetary reasons, they often increase the restrictions on expensive medications, making them harder to obtain. An example of those restrictions might be that the patient has to have been suffering for longer, the impact of the condition has to be more severe, or the patient must have tried several other (cheaper) medications first.
For expensive medications, it's often not as simple as a consultant saying "I want my patient to have this" - at a regional or hospital level, there are quotas/limits on how many patients per year will be treated with sich expensive medications, and there are comittees that meet regularly to decide who is worthy.
Now, if we put aside those expensive medications for moment: yes, technically consultants are free to use their experience, knowledge and judgement, and prescribe what they see fit (even unlicensed drugs) - but in reality, within the NHS it is uncommon to prescribe outwith the regional formulary guidance, or/and outwith licensed medication uses. There are a number of reasons for this:
1. Consultants take on individual liability when they prescribe unlicensed medicines, and individual hospitals fear legal risk too
2. Consultants will have their balls broken by their department head when they prescribe expensive medications - dept heads have budget responsibility, and in turn they will have their balls broken by the board
3. Consultants regularly meet with others from their department to discuss difficult/unusual cases, and have to justify their decisions to the panel
4. Perhaps it's the workload, but (IME) NHS consultants often have outdated knowledge. I swear some have never so much as read a journal article since they left medical school 30 years previous :( Again IME, private consultants seem to be much more confident to think out of the box with treatments; perhaps it's the commercial competition?
* Pharmaceuticals: science, mostly, but beware of "pseucutcals" like supplements and herbal remedies. Also beware of new ideas that cut into profits.
* Cutting-edge surgery: science
* Mental health: art, with a dose of science from big pharma
* General practice: mostly the art of laying on hands, distilled experience, a bit of research with your sales rep and whatever you took with you from medical school.
If this feels harsh, remember that, despite solid scientific evidence, it took over two decades for the conventional medical wisdom to move stomach ulcers from "caused by stress you need to relax" to "caused by helicobacter pylori we can treat it with a convenient antibiotic." Inertia is a helluva drug.
If you're on a sales call selling a product that increases user retention and someone says "no we don't need that", you would often reply with "So you have perfect user retention then?" to probe them and re-open the conversation.
It could come off as standoffish but when used correctly it's very effective because it gets the person on the other end to open up more and you try to get to the bottom of their objections.
But "Are you sure increasing your user retention isn't worth something to you?" or something like that maybe.
"So you have perfect user retention then?" is a better question because you know for a fact that they can't have 100% user retention and they know that as well so it forces further dialogue.
Anecdotally, it feels as though it leans on a lot on the targets level of politeness and decorum to want to continue the conversation. I favour polite but abrupt and seemingly heartless conversation enders for this reason.
"Hello sir, would you like to help a child keep eating for $2 a month?" "No, thank you!"
Back to this specific case, I guess the trick is to deliver your question almost rhetorically with both parties knowing that it leaves an answer that is common knowledge. Kinda like safe small talk about the weather.
Keeps the conversation going buying time for another hook to be deployed.
There are definitely better examples I could come up with, but now I'm stuck with this one because it's what I quickly typed out earlier.
It's not sarcastic, it's serious and that's the point.
Obviously they don't have 100% retention, so this question might open them up to talk about their retention instead of saying "no, it's fine like it is".
It doesn't matter how good your retention currently is, if the product can boost it even by a couple of percent it would probably pay for itself many times over.
I think you could make the argument that saying "no, we don't need it" before even trying to understand the value prop is just as demeaning.
Assuming that I didn't initiate the call, if I tell some sales punk that I don't need their product and they come back at me with "So you have perfect user retention then?" my answer is going to be "fuck you" followed by ending the call.
Arrogance might work in used car sales but it's not a panacea for closing the deal.
I get it, sales people can be annoying but it really only hurts your business (in this hypothetical case) if you have a user retention problems and are actively fighting against people trying to help you solve that problem with a mutually beneficial business agreement.
They will call the next person on their list, I'm sure it won't matter much.
Oh please. Not every product that's applicable to a given business would necessarily be beneficial to that business.
I get it, sales people have to drink the kool aid, but some humility is needed. Your product isn't right for everyone, and the sooner you understand that the sooner you can improve the quality of your lead generation.
I know you know this, if you're in sales, but I, like many other engineers who read this forum was overly cautious when I first started speaking to people because I anticipated that 99/100 would be upset at having to talk to me.
The truth was that 99/100 were willing to speak to me and listening to HN and Reddit set me back farther than I expected until I unlearned that lesson.
So I'm saying this for the benefit of all those other engineers like me.
People hating spam will complain about it, people not hating it will not bother with commenting.
And HN may have higher share of people more affected by spam (surveys send to emails scrapped from github and so on) and more likely to be able to find needed services - what makes beneficial cold calling even more rare.
And I guess that my reaction is unusual. I moved to another phone service after previous one cold called me offering a loan on bank service operating under their brand - and that was a sole reason.
I quit that job as soon as I could because I was sick of manipulating people or pressuring them into buying something they didn't want. At the end of the day that's all sales is. If your customer wants your product then by definition you don't have to sell them.
>If your customer wants your product then by definition you don't have to sell them.
That's a misnomer, what if they don't know you exist? That's what sales and marketing are for, to inform people that could benefit from your product that it exists, essentially. Will their business implode if they don't buy your product? No, almost certainly not. But, they might derive a massive cost savings, time savings, increased employee satisfaction, or other efficiencies by using whatever you're selling and your job in sales is to get them to listen which is the hard part.
This is a fiction that salespeople tell themselves to help them sleep at night. I use twitter not because someone from Twitter Sales sold it to me but because I sought it out of my own volition.
Only bad products need sales. Good products can thrive on marketing alone because people want good products.
I would presume that sentence is a quickly typed paraphrase. If you presume they are a competent salesperson, you can also presume that they say it less antagonistically in real life. Edit: Or perhaps they have found that antagonism is the most profitable solution for the business to turn around a “no” answer.
The comment to which I'm responding explicitly argues that the phrase, verbatim, is a good sales tactic.
i.e. when I read your comment it struck me as much more revealing about you than about the salesman, his technique, or his product.
That doesn't really capture the conversation though. Susan specifically said (as you quoted) that it was possible she would use the recommendations of the app. If she took a recommendation that means she agreed it was a better treatment. His question was not whether his algorithm was better than her default prescriptions - because they both agreed that was the case at least some of the time - it was whether it was better enough to be financially worthwhile.
This tech could be used to replace the function of this doctor making them less useful.
> I started babbling about network meta-analyses, statistical power, and p-values, but he cut me off.
> "Yeah okay that's great but nobody cares about this math crap. You need doctors."
So true. As an insider in healthcare I would probably have disregarded this for idealism.
Though back in the day, I did support for a CD-ROM based CME product... It was simple software so most of the people who called were in their 70s and 80s and not very comfortable with technology. They all seemed pretty concerned with learning the new stuff.
When it comes to the business of healthcare, doctors are generally open to things that will make their jobs easier (they are money motivated creatures too). But, they don't necessarily like learning new things themselves. As a whole, they are rather resistant to change. It took a long time to incorporate any technology bedside (e-charts, etc).
As a patient, I/family has been referred to other doctors specifically because they were younger or knew their education differed in a meaningful way. The old guy knew his ways were outdated and we would benefit from the new ways. So he was aware of the new way, but wasn't practicing it.
As for the actual content, there’s a massive difference between customers dying to use your product and them telling you it’d be “neat”. People don’t buy “neat” products. This is why you talk money to them as soon as possible. No real surprise it didn’t work out for him, the incentives just aren’t there.
He could have prevented all this by reading the Mom Test - oh well, experience is the best teacher anyways.
There in a nutshell is the problem with healthcare. Doctors care about different outcomes. Doctors have this image that they care about your best health outcome but they would always trade an extra dollar over any patient outcome as long as they are legally within guidelines.
As a developer. I went to school for a period of time. I have had a 20 year career of sucessful development jobs/projects.
If someone walked in without any experience but showed me a better way to develop a project through understandable datapoints I would listen and not ignore them because I was somehow all knowing. I may even buy. Why are Doctors different?
I do not see any issues telling doctors that they are prescribing the wrong medication because you may know it better than them. I personally learnt a lot about pharmacology due to my illness, and I know what kind of medications are should not be supposed to be prescribed which the doctor working at the ER at that moment may not. In any case, you could just point out the reasons, I believe.
For example: highly lipophilic beta-blockers are an issue in my case as I get anxious over its CNS side-effects that others may take it for performance anxiety, see: propranolol. The doctor prescribing me propranolol would be in the wrong. My own psychiatrist had no clue that lipophilic beta-blockers can cause all sorts of issues (CNS side-effects, such as brain fog) that lead to anxiety and even panic attacks for me. In my case, something like atenolol or even nebivolol would have worked better. Some doctors know this, some do not. I do not reasonably expect them to know everything though. It is sort of a detail that is not known because it is commonly prescribed to the elderly who do not report those CNS side-effects because they attribute them to their old age.
There were cases of metoprolol causing hallucinations. The old person attributed it to having some kind of a super power of seeing the dead because their heart stopped for a few seconds and they were "dead". I am not sure if this is the article I posted, but there was such a case.
People who research their own specific illness may know better than some doctors, really.
Sorry if I was a tad off-topic.
If you're not comfortable with a medication's potential side effects I do think it's worth bringing it up (I'm not a doctor, just an occasional patient) but it really comes down to how it's phrased.
There's a very big difference between:
"Actually propranolol won't work for me because after Googling around I discovered one of the side effects makes me feel anxious, can we try atenolol or nebivolol based on what I read online?"
"I know Googling for medical advice is sketchy but I read one of the side effects of propranolol is brain fog and this really concerns me because my job remains that I stay sharp. I trust your diagnosis and I know just because a side effect is listed I'm not guaranteed to have it, but are there any other beta blockers that we can start with that don't have this side effect and will still work?
There's a lot of very carefully selected phrases in the 2nd way of saying the same statement.
- Admission that Googling for medical issues isn't usually a good idea on its own to take actionable advice on
- You bring up a valid concern about one of the side effects
- Saying "diagnosis" vs "advice" is respectful of their decision ("advice" and "opinion" are a bit demeaning because it discredits their decision)
- You call out that you know not all side effects will come true (you come off as someone who isn't just blindly Googling stuff, this raises your credibility)
- You name drop "beta blockers" which shows you've done a decent amount of research
- You let them take the reigns and offer alternative medication, giving them a chance to maybe pick the ones you've researched
- You close things out as being optimistic by saying "and will still work" rather than questioning their decision before they give it by saying "think it will work"
If I said the 2nd wording to a doctor and they denied my request without even discussing it then I'd leave and look for a 2nd opinion. Asking people questions without demeaning them is a great way to get an honest look at how someone operates.
The difference in both cases is the gatekeeping.
As I understand it, this is exactly what new pharmaceutical sales reps are asked to do?
In the same way the author was selling the outcome of the knowledge of their algorithm.
Do they have such fragile egos that they can't have someone showing them the "new Google for doctors" without feeling offended?
(Sorry if that came out a bit edgy. But this hole story irks me. It's frustrating when value can't be delivered because of cash flow issues.)
It's very hard to understand their thinking without being yourself a patient or doctor.
TLDR: You need to spend 1K hours as a doctor, or shadowing, or something similar.
When you are responsible for people with psychosis your perspective changes. Can't play nosql games with people's lives.
Reading this story and talking about his marketing and product development process feels like watching Lovecraft Country and then then only talking about the time travel physics of it. There's something real and awful here, hopefully presented in a fictionalized or highly exaggerated form. The people in my social circles who mistrust tech and despise startup culture -- this is exactly how they see us.
Even though for headache this is the recommended first line medication:
Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500–550 mg, acetaminophen 1000 mg
 Given the reproducibility crisis, I'm not sure we should trust these much either, but that's a discussion for another time.
He even called what his software did a meta-analysis. My understanding is limited, but a meta-analysis is difficult and laborious to do correctly. You have to design the standards you use to include and exclude studies and examine each study to decide whether including it will improve or harm the quality of your results. For example, maybe a method to evaluate outcomes that used to be common has been discredited. Maybe a study was done under a principal researcher who has been caught fabricating results in other studies. Maybe a study claims to be double-blind, but when you read it carefully, it turns out that it isn't. Maybe a study is well-designed in every way, but it was designed for a slightly different purpose, so the data can't be used the way you want to.
Factors like these result in the exclusion of a lot of studies from a meta-analysis, after painstaking examination by researchers who have the expertise to design and run the studies they're reading. It's scientifically difficult and important work. The author is bragging about not doing this work:
> On July 2, 2018, GlacierMD powered the world's largest depression meta-analysis, using data from 846 trials, beating Cipriani's previous record of 522.
Rather than building a product that informs medical professionals about effective interventions, I wonder if the creator would have had more success if he deeply explored what sources of information these medical professionals pay for now - do they pay for anything at all, such as UpToDate, and don't want to pay this because it's an additional expense? If the creator found which sources people are using, the creator could sell this database as a feature for these partners and widely disseminate this data through partner channels rather than creating a competing source of information. It seems to be a case of this being a good instance of a B2B2C model, where selling this service to other businesses that sell directly to medical professionals could be more viable than trying to sell directly to them.
Alternatively, if the creator wanted to sell to patients, rather than medical professionals, the blueprint here is all of the consumer reports companies, such as Wirecutter, which is one of the New York Times's most popular services. Here, again, a "Wirecutter for medical interventions" could be quite successful, and you could sell this service to media companies that provide consumer reports as a service that would bolster these companies.
It's bad the creator wasn't able to find traction, as getting more medical data into the hands of consumers could have a huge postive impact over time.
I doubt UpToDate makes their bones off individual subscriptions. The real money to keep a company afloat is from b2b enterprise contracts.
It's a crudely built version of UpToDate from 2018 as it was on April 2018. Useful for 98% of the population still.
Edit: definitely works better on mobile, and the search needs to be fixed.. this isn't my website but a resource that I've been passed down/told about by medical students.
There seems to be a ton of good data here that you could use to build some type of WebMD competitor.
When you run a service that provides information you either make money through ads or direct subscriptions. And if it's B, you better have an airtight value proposition and an intimate understanding of your competition.
The tool should have been designed (IMO) as a consumer tool, either a kiosk at CVS/Walgreens/pharmacies to assist with OTC med selection or possibly as a website with ads/referrals. I would absolutely choose a pharmacy over another as a result of them having something to help through that process, especially when I have a headache.
I'm reading the epiphany part of this post, to quote:
You have a mind-shattering headache. You're standing in the aisle of your local CVS, massaging your temples while scanning the shelves for something—anything—to make make the pain stop.
What do you reach for? Tylenol? Advil? Aleve?
Most people, I imagine, grab whatever's cheapest, or closest, or whatever they always use. But if you're scrupulous enough to ask Google for the best painkiller, here's how your friendly neighborhood tech behemoth would answer:
[Screenshot of Google Search Results]
Oh thanks Google that's just all of them.
The author immediately identifies that this isn't a real problem, by their own admissions that "Most people, I imagine, grab whatever's cheapest, or closest, or whatever they always use." Yea, most people when they have a headache and know that most painkillers on the market will result in about the same degree of relief, don't bother to cross reference a medical meta-analysis, because they have a headache and if the $0.01 worth of aspirin doesn't make it feel better they will just take a second pill and eat the penny.
I like the author's conclusion about how to quickly validate business ideas, but even in the title the author still holds firm to the belief that this was a "fantastic startup idea" even though reality seems to think otherwise. Was this such a great idea, do most consumers actually want to review a meta-analysis when picking their OTC medicine, or do most people just try a few things, get influenced by advertising, and purchase the most reasonably priced medicine they think will help. I am just a single data point, but I don't normally feel naked and unscrupulous when I just read the symptoms that a medicine treats and pick one, and that strategy generally works just fine.
Solution in search of a problem and also in search of humans that act in this weird atypical fashion.
I used to live in the US and I'm certainly not used to that either. I wish that kind of great pharmacist care were more widespread as a norm.
I have never smoked or vaped or anything, but it's the homeopathic OTC meds that viscerally upset me, that they should be allowed on the shelves.
I get tired trying to explain, and if I'm not convincing anyone, maybe it's me who doesn't understand...but, I feel like the key is to ask yourself, if the placebo effect is something that you can scientifically demonstrate, how would you arrange a control group?
Failure to identify a reason for an apparent effect cannot be turned into proof that "nothing" has an effect. It's just a mental short circuit that people get trapped in.
Easy, just don't give the control group any medicine. Give the other group a placebo. If outcomes are better for the second group, it's evidence that placebos work, just as clearly as the usual trial provides evidence that medicines work.
In many countries the pharmacist is a doctor and they are there to handle simple cases. Thailand, Singapore, Malaysia all seem this way. VS the USA (and Japan?) where all the pharmacist does is handout the medicine some other doctor prescribed.
It's basically akin to looking at Google Analytics and trying to predict what your next website visitor will do. You'll have an idea of what someone's going to do, but you can't perfectly predict it.
If you think about it, the author's desire to choose 'the scientifically proven to be the most effective' is just another example of such a superstition. If you could convince him that a particular medication was the winner in the meta-analysis, he would probably objectively feel better, even if it wasn't actually true.
On the other hand, for depression medication, they don't want their doctor to look at an online tool and choose the most effective antidepressant. They want their doctor to look at THEM and say "hmm, we'll try you on X but if it doesn't help with the intrusive thoughts we'll maybe switch it out to Y and up the dosage of Z". Or they want to tell the doctor what they think they want to be prescribed. They are paying big bucks to see a psychiatrist. Most of them are not on a self-optimization trip, they just want to feel better, and also feel like someone takes an interest in how they are getting on. Using a snazzy tool would probably lead to the patient being less satisfied with the doctor's service, even if they have slightly better outcomes by whatever questionable metric is in the study.
I've not had this experience. For me, Ibuprofen works, aspirin and acetaminophen have zero noticeable affect. It's been that way my entire life. The other two might have some affect on fever? (no idea) but none on pain, at least for me.
A friend did a ton of user testing of improvements to a price-comparison site back when those were the rage. With some frequency the engineers would come up with a way to help people make a better buying decision. E.g., picking a TV is a problem, so they'd make a wizard that would ask you questions and then give you a recommendation. Problem solved, right?
Alas, no. Turns out most of these user guidance things wouldn't help, because people had no reason to trust the thing. They might go through the process, but their behavior didn't change. I'd expect to see the same effect with a kiosk. Most wouldn't engage, and those who did wouldn't weight the recommendation very highly.
A website would have an even deeper trust problem, and would add an SEO problem on top. Imagine a referral is worth $1 on average and you spend $0.50 on coming up with good answers, $0.49 on making sure you're on the first page of Google results, and take $0.01 in profit. You'll very quickly have a competitor with that spends $0 on research and $0.99 on being ahead of you on Google. Sure, their data will be garbage, but the page will be just as convincing to somebody who doesn't know anything, which is your target market.
I suspect the real outcome, as with many would-be startups, is that this is a feature, not a business. Somebody like Wirecutter or Consumer Reports could turn this into solid content that would be a nice addition to what they have already. They've already built a trust relationship with their users, and they don't have to specifically find people in the (very rare) moment of choosing a new medication.
The only time I use headache medicine is when I have a headache and that is the exact time I don't want to be trying to read a huge block of 6 point type to see how many I should take. (A couple of times in the past I've written the dosage in Sharpie on the piece of masking tape that I wrap around the bottle but I'd rather it was done for me as I'm lazy)
Sure but... would you really need any clinical data to make this valuable? A pharmacy could just make a decision tree with some common symptoms and do the same thing based on their own recommendations. Including data from studies is a neat enhancement but not necessary IMO.
I think perhaps there's greater value in the platform or methodology the author built for doing this type of meta analysis for medication. Could it be applied to other research fields I wonder. Could the software be licensed?
Sure, and I’d go to a pharmacy who did this based off of science instead of whoever paid for an end cap advertisement that month.
You're making a similar mistake to OP. You're considering the end user, the pharmacy, but are now ignoring manufacturers, suppliers and wholesalers. Why would a major supplier provide their goods to a pharmacy who ranks them last in their kiosks? Why wouldn't they give preferential pricing to pharmacists that give better rankings?
Perhaps large chain pharmacists have buying power here, but they don't need help attracting customers. Perhaps small pharmacists could benefit from this system to attract customers, but if the system ranks Pfizer products last they wont be in business for long.
Point is, perhaps you want it, and perhaps you think pharmacists should want it for you, but the entire supply chain does not want it.
I've made this very mistake myself but I was lucky enough to have enough runway to start over and talk to customers first then pivot the product to something that they actually need.
I call this the "I have an idea for a startup!" issue. You hear it all the time from family/friends. Where they tell you this great idea for a product they had. This is the wrong approach. What you want to say is something like "There is this really interesting problem that everyone in ecommerce is facing right now"
Did he though? He even mentions that customers generally pick whatever (because they don't really care what's the perfectly optimized headache pill they should take) and doctors thought it was neat, but no one really wanted to pay for it. Their solution (e.g. prescribing what they would typically prescribe) was good enough.
It doesn't really sound like there's a problem there.
Tom Blomfield worte about how during YC S11 they had trouble growing at all. He chanced upon a customer who fit their product's user persona to a tee but at the end of a 20m conversation Tom realised the it wasn't really a burning problem for them at all.
And so they pivoted...to GoCardless.
I don't care if the medicine is perfectly optimal in terms of standard deviations above placebo (which I don't trust, since the data is not likely to be reliably comparable); I care if it sufficiently solves my issue with least hassle (side effects/access/cost/works for me personally). Placebo might just be fine, in some cases.
If I am not able to identify what medicine to take, I ask my doctor, who has years of training for that, already knows what Google sources are good, and can look it up in a reference manual.
No, he didn't have a problem.
He proposes that OTC is the target. The reality is, the problem is not very deep here. Without access to prescription medications, you basically have a handful of options that are more of less the same. It's like walking onto a rental car lot. You need to know what category you need, but everything in that category is pretty much the same.
He isn't solving anything for the physician market. His recommendations are very naive and lack the clinical backing to support actual usage. A physician isn't going to buck their go-to's because a random tool suggests something else. This tool needs to provide scientific backing for it's recommendations and why that recommendation is better.
I go to my local grocery store and look at the painkillers they have. There are generic aspirin and Tylenol available for a price almost anyone can afford. There are branded versions which are still reasonably priced. There are reasonable variations such as with caffeine or with decongestant, again priced perfectly fairly. If you want to pay $2 extra for awesome marketing you can.
In some stores you might find a 'natural' remedy - essentially a placebo, again priced ok.
Everything on sale is basically safe. Nothing has a business model that relies on addiction. Nothing costs hundreds of dollars. Nothing is adulterated or counterfeit. It's easy to get information about everything available.
The vast majority people would be able to choose something to match their own needs (for example, they might be allergic to aspirin, or need to avoid Tylenol because of a kidney condition).
If you bought the worst painkiller on sale in the store, it would be fairly effective and not too expensive. The experience in most stores in large parts of the world would be very similar.
Also, $40k is downright cheap compared to most failed projects to improve medicine. If it were someone else's money, that is.
Also I don't think $40K is cheap for an MVP. He could have used static HTML mock-ups, or even a few Power Point slides to see if his potential customers would have paid for that service.
His work is interesting as a free product, maybe as a side project could of grown over time into a potential acquisition. Slapping a paint of React (or Svelte) on top of his Excel-driven POC and a "show Hacker News" post might of been a better way to go.
However kudos to him for not only trying to pursue the idea but also for the write up. It's easy for me to armchair quarterback this one, especially since my father was a doctor who got hammered weekly by drug companies, but I'm sure his blood/sweat/tears will pay off in other ways.
Everyone thinks there are two modes for a service: dead or worth $1B+.
Not to like bash you while you are down but you may have been able to do this while working and not spending $40k on contractors.
Not everyone needs to raise $10M, get a flashy office, employ 200 people and have all of the trappings of a "successful" startup founder; if anything, that's antithetical to what you should be doing.
No MVP, no testing their model, just straight to "Next Best Thing". It definitely hurts, I've been there too for my first "next big thing" and I doubt you'll be the last to get burnt by the image VC firms sell.
Sure you need to spend a lot of money to grow a $1B+ business, but the same is true for a $100M business or a $10M business and even most $1M businesses.
It's a definite that people have to eat. I would assume most failures in restaurants and convenience stores are operations, not a critically flawed business model.
But yes, I guess $40k is less than $2M, but it also takes $40k away from another venture and possibly having to go back to a day job to take another run at something.
All because you didn't validate the problem before cutting off your income source.
I still feel the same about it:
> Don't shut down the website. Keep it running and make the data available in read only mode and add a donation button (alternative to ads). It should cost $5 a month to host on linode or digitalocean. Don't let the money you spent go down the drain.
I'm not sure he still gets it. He didn't built something people want (even less so want enough to pay for).
He built something he merely thought people should want. In the end, people didn't really want it.
That's not the right question (as based on the well-known quote).
The right question is: if I showed people a car on actual paved roads, with its load capacity and speed benefits over horses, would they jump for it?
And they did.
But for this thing, they didn't.
This person didn't merely talk about his yet un-made app to some people who couldn't even imagine what could be.
He showcased it, working in full form, and different target audiences could not care less.
There is no single formula for success. Sometimes you are too early and you fail. Snake oil startups are getting billion dollar valuations while a legitimate idea may be rotting in another corner of the world. It's a combination of lot of things. Sometimes I feel many of the yc companies are successful not because people are jumping to buy the license, but because they have a network effect and are vetted by a community and perceive it as the better option while it may not be such. Connections, Money, Advices, Talent, Idea, Marketing, Sales, Management - every single thing is part of the puzzle.
Somtimes you are lucky to get the market fit right of the bat, but many times you have to try hard and struggle a lot before you even have a chance to have a glimpse of market fit. In the case of the author of the blog, if he had build a hype around his product like this is the next biggest thing and got a network effect going (your peer doctors are using it) it may have turned out way different. He wouldn't need to charge it initially or have a free plan that is good enough to get them hooked etc. Don't know there are thousands of variations possible. He simply stopped too early IMO.
Think about the problem horses/cars were solving. It's clear people 'wanted' that problem being solved just by how prevalent horse-as-utility were.
> Turns out the world's biggest health website makes about $0.50/year per user. That is...not enough money to bootstrap GlacierMD.
Doctors definitely don't need your product, as they pointed out.
But consumers do!
I think you should have sold to consumers.
Having three doctors in my close family, I often found that whatever the tired doctor at the hospital is recommending is in contrast with what a doctor who care about my health (and is willing to look on their proprietary platforms) is recommending.
That's why you ask different private doctors' opinions when things matter.
I found myself googling studies on what's the better treatment for $x
and I would pay for better-than-a-doctor-advice backed by actual studies.
I think the problem, in your situation, is the scale of the operation.
If you want to do B2C, you often need investments and you can expect to become profitable in a few years.
Either find some funding or fix your cashflow.
So, in essence, before spending any money, I would go out and interview doctors to see if they're willing to pay for a channel of new customers. I would also try to gauge how many customers would be willing to sign up and enter their info so local doctors could advertise to them. And, of course, I would check with a lawyer to ensure I'm not bumping into HIPAA.
I am sure he could self-host it or rent a cheap server somewhere. AWS is crazy expensive so it seems kind of unnecessary to host it there if you are low on cash. I host a site with 40 TB worth of images and my bill is probably way less than his was.
Then doctors get the product without having to sell to doctors. they are less tech savvy than a software vendor, and they also don't want more tools to have to use technology wise.
A lot of people in this thread are talking about the woes of ethical doctoring, the problems of healthcare, and so on. The reality here is that no one wanted it -- at least no one that he was selling to. I can relate. I've been there -- building something for months and then hearing crickets. The Y Combinator motto -- "Make something people want" -- is actually pretty tough to get right. In fact, it's the crux of any viable business. The reason why 9/10 businesses fail is largely in part due to the fact that they aren't making something people want.
Prospective customer interviews suck (especially for technical folks), but they are integral to building a product people want. Doing them before an MVP is crucial.
I think the author makes the wrong assumption that his product does improve health and that the current practices of GPs or other health professionals don't (as much as they could). He misses the most important thing of any professional and successful health care worker: experience.
If a doctor has a high success rate with drug A on their patients then even if some website tells them that drug B _could_ be slightly better why would they try it? There has to be more of an incentive than _just a website saying so_. The doctor has a high success rate with drug A, has seen it working many times and knows everything about side effects or maybe the lack of those. If nobody has complained and it works miracles then it would be foolish for the doctor to start prescribing a new drug simply based on a random website's recommendation. Also doctors do have to stay current and they get medical journals sent home, attend training courses and conferences and learn about new stuff when it's actually relevant and needed.
$40k and 9 months is not that much. Either you gave up just before you figure out how to make the business work or maybe GlacierMD wasn't that revolutionary.
Why not open sourcing and publishing all that work? You can still recoup some money via ad money even if it's not the millions you were expecting and at least you have something to show off.
this is the problem. the incentives in healthcare are messed up. doctors are paid for their time, not for their outcomes. if a patient comes in and is prescribed a therapy, and they don't have to come back, the doctor should receive more than if the patient returns because the therapy had an issue.
This is opposite of the desired outcome, which is that the best doctors see the hardest cases.
Always pay professionals for their time. Patients are not widgets.
I do, however, think it makes much more sense as a consumer tool rather than a doctor tool: if I've already gone through the trouble of making an appointment at a doctor, who I trust, I've either given up on trying to resolve the issue myself and will trust their prescription, or I have no idea how to approach the issue or symptoms I'm feeling as communicated by WebMD. Your value proposition is saving the consumer time and effort of booking an appointment to find out how to best fix a minor-medical issue they (or, say, their child) may have. Is that a sustainable proposition? I don't know, but it makes much more sense to me than as a tool to tell doctors how to do their job "better".
I'd imagine if you went the WebMD consumer route, too, once you reach a certain user-size, you'd have no problem partnering with pharmacies (or even pharmaceutical companies) to offer coupons for some OTC medicines in exchange for a referral fee, as is standard in the industry (a. la. GoodRx). Then you're providing value to the consumer in the form of recommending useful medicines, providing the consumer a way to get that medicine for a lower cost, saving them time and money spent at the doctor's office, and providing the pharmacy/pharmaceutical company a new customer.
Not only that, he would have a highly targeted group of users that he could tailor all kinds of products and services to.
The 20% margin is risible and those who live by SEO die by SEO: https://cdixon.org/2011/03/05/seo-is-no-longer-a-viable-mark...
Presenting medical trials and statistics to an uninitiated reader will probably also cause more harm than benefit, so it's good he canned this idea.
About 8 years ago, we've built a SAAS for purchasing material for companies using auctions. The idea was that if it will be super easy for companies to do reverse auctions and use them to buy material they will save a lot of money (proven concept in those who actually used it).
But what we learned after some time was it didn't matter. Because people in the companies responsible for buying material didn't really care for how much they buy it. They care that they call their favourite supplier have a nice chat and then order whatever they need. And those suppliers throw some "gifts/rewards" to the package here and there. And without appraisal of those people the business owner never said yes.
The thing was that those people who effectively decided if they will use it or not didn't benefited from it at all.
We haven't lost so much money on that, but the lesson learned was huge.
Moral of this story is if you got a good product don’t quit just because America can’t see the value lol. The irony that the American healthcare system didn't value this overwhelming.
The fact that the people giving you the money I.e doctors / hospitals didn’t want to pay for your product proves you built something no one wanted. Wanted enough that they were willing to pay you money for it. Or go out of the way to find the budget for it.
I think the only thing that went wrong is the budgeting, OP might have made it had he dumbed it down a little and made it 100x more simple (on the backend).
Additionally, I'm sure they audit Dr prescriptions, if you get the insurance companies to use your service in the audits the hospitals will also purchase it to pre-audit themselves. Perhaps the drug companies can mandate its use. If you can't get a business to want your product, make them need it :)
My top recommendation would've been to find someone in medicine as a co-founder. This could've helped him find flaws in the economic model faster. I still think his project has amazing potential, except that it's going to have to go through a couple of iterations. For example - what if he somehow integrated this information to make it so that it's easier to connect customers to future doctors and take a affiliate fee?
Also imagine if we had a better medical search engine. There's so much information in medicine that is still blocked off to consumers. The author mentions that consumers do not want to go through the details - maybe we can make something that can dumb it down for people and put a directory of doctors who can help explain further?
Consumers don't see the value at all.
Doctors see the value, but won't pay for it, because it doesn't change their bottom line.
Whose bottom line does this change then?
HMOs, insurance companies, organizations that want to improve the health of a population in aggregate. They'd pay money to have healthier people (on average) to provide the service to their docs (who see the value) to use for free.
Well, maybe; but I was hoping to see that theory validated in the last turn of the wheel.
If you convince say, NHS, that this service would make their medical practice more efficient they would totally buy it! For this you'd need to hire MDs and play lots of regulatory tricks. Plus, after that, probably private medical offices would follow the lead.
Companies doing genetics-based prediction are trying to fight the same uphill battle, and I think it's one worth fighting. So don't give up!