Update: Link fixed

Did you know that 50% of second opinions from doctors contradict first opinions? And did you know that 80% of the findings in medical literature are wrong?

I'm fascinated by a new company called Metamed that offers to be your personal medical researcher. For a fee of $200 per researcher per hour, with a $5K minimum, you can make sure the full force of science is on your side. Metamed analyzes the medical literature and tells you which study results about your condition are reliable and which are not. They assess the value of various diagnostic tests, and create a map of all possible medical correlations. It's the sort of thing your doctor would love to do for you if he had the resources.

Metamed's service is pricey, but the cost will probably come down as the process gets more automated. And objectively speaking, the service is already a bargain if your alternative is death by ignorance.

I saw in the news recently that the rate of growth for healthcare costs in the United States was slowing and no one is entirely sure why. I assume there are a number of reasons for the unexpected change, but my hypothesis is that the Internet is already unlocking the power of healthcare information for consumers. Personally, my healthcare process looks like this now:
  1. Observe symptoms
  2. Search Internet for diagnosis and treatment.
  3. If I'm not confident in what I find on the Internet, I email my doctor in the Kaiser Permanente system to describe my symptoms. Kaiser encourages email.
  4. My doctor often replies in an hour with a prescription that has already been sent to my nearest pharmacy, some self-care instructions, or a request to come in for tests.
  5. If I need to book an appointment, Kaiser's website does an automated interview to advise me whether I should treat the problem myself or schedule a doctor.
For the bigger problems, you want as much expert brainpower on your side as you can get. That's what Metamed provides. It makes me wonder how much healthcare costs can drop if we get better at picking the right treatment the first time. My gut feel is that 20% of healthcare costs are directly attributable to ignorance.

My healthcare provider, Kaiser Permanente, operates for the benefit of the members, so they are super-aggressive about preventative healthcare. I would think preventative medicine can take another 20% off of healthcare costs in the long run. And preventative medicine is mostly about getting the right information to the right people.

The Adams Law of Slow-Moving Disasters observes that whenever a massive threat to humanity can be identified far in advance, we always find a way to sidestep it. At the moment it seems that healthcare costs will grow to the sky and bankrupt us, especially as the population of oldsters increases. But I think better information might someday cut healthcare costs by as much as 50%. That better information will come from a variety of sources. Metamed is part of that solution, as is Google, as is Kaiser's extraordinarily effective use of the Internet. And we're nearing a point at which your smartphone will test you for all sorts of problems.

I can also imagine a time in which Google Glasses TM will observe all of your food choices during the day and keep a running record of your nutrition. When you stray from a healthy diet, your glasses might start suggesting a salad. When you don't exercise all day, the glasses might suggest using the stairs instead of the elevator. For all practical purposes, a human with Google Glasses and a smartphone is already a cyborg. And your future cyborg half will do a better job of keeping your organic parts functioning than you are doing on your own.

In the long, long run your healthcare provider will fix both your organic parts and your cyborg parts because it will all be part of the same system. You'll go to the doctor complaining of a headache and he'll update your smartphone software to track your daily habits and look for what triggers the headaches.

Anyway, my point is that better information will solve the problem of increasing medical costs. It's already happening.

Disclosure: I don't have a financial interest in Metamed, nor do I have any firsthand knowledge of their service. The Chairmam of Metamed is Jaan Tallin, one of the founding engineers of Skype, and one of the more important futurists of our time. I know Jaan because of our mutual interest in the so-called singularity.

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Apr 11, 2013
Brilliant, so for $5k they're going to sell you a report detailing exactly how you can fleece your doctor for all his net worth and that of his insurance company.
Because that's the main thing such a service is going to be used for, finding loopholes and things that a doctor "might have done different" in order to file tort suits.

Result: medical costs will rise even further, there will be even more mistrust between doctors and patients, more and more doctors are going to demand patients sign wavers stating they won't use second opinions, etc. etc.
Apr 10, 2013
The devices of the future will be part of our clothing, of which Google Glass is just a primitive sample of what is coming, but ultimately I expect that digital screens will be built into contact lenses, and we will all be wearing powerful computers which are always connected to the cloud and have the potential to communicate with nearby devices.

So, in the future when you go to your doctor, the ability to interface with these devices will be much higher, and your doctor will be able to show you studies and references and upload those directly to you - even to the extent of showing you exactly what they are seeing or viewing. For instance while he or she is looking at the mole on your back and assessing it for its potential as a melanoma, he will be able to show you the mole in high-rez and describe its worrisome features to you.

This will be very good for a fraction of individuals: namely, those who by training or inclination are capable of making valid comparisons of objective data who can wade through the wealth of information that will be available and draw the most logical conclusion from it. Kaiser's email program is an example of that. And future medicine will be enormously different because the doctor-patient relationship will not be merely an interaction of personalities but will also include a high fraction of technology. The problem is for many people this won't change much for them and they are not interested in exploring the medicine and trying to understand it so much as they want to be told what to do. Medical decisions are frequently very complicated and there are generally options and approaches with associated benefits, risks, and costs for every option. But having these choices is stressful to many people. They want things to be simple even if they are not.

And, just as it is so today, this group will continue to suffer. Surgeons are in the business of selling surgery and generally promote it is as the only logical course when often it isn't. A good doctor is careful about referring a patient to a surgeon for that reason.

It is quite easy to confuse most people with complexity and many people get the wrong treatment for this reason.

So - I agree that the trend of technology in medicine is a good thing. But it won't benefit the majority; technology will make decision-making even more complicated and in many ways that is not a good thing. Many people will simply be confused by the options - and oppressed by the volume of data.

Scott's blog about his experience in the supermarket and all the decisions that were prompted by that comes to mind. Imagine the same kind of complexity of decision making thrown into a medical environment. I do in fact think that technology is good in medicine - but it won't be all good.

As for medical costs: this could be solved by politicians but it won't. Politicians make decisions based on whether it is likely to get them reelected next year, not whether it solves a looming crisis ten years from now. It is most of the reason politics in the U.S. is failing the people it "serves". Our leaders have almost no incentive to think about problems from a long term perspective and for the most part American politics coddles the prejudices and fears of various groups rather than approaching problems on a rational basis.
Apr 9, 2013
Preventive care is fabulously important, imo.

My wife's grandfather died a few weeks ago, at 78. He had a brain tumor that affected his memory, clouded his decision making, and made him both irritable and unpleasant. He had other medical problems, too. He frequently (nearly every month) got badly dehydrated, and ended up delirious. Often, he'd wander around outside, faint or fall, and breaking bones, tearing up skin, and bleeding. Assistance was sometimes slow to come, and he ended up in hospitals about six times a year for a week or more.

In spite of the repeated problems, he and his wife refused to go into a retirement home. And there is the crux of our issue... His quality of life was horrible, and his medical expenses were ridiculous because he insisted on "staying" independent. A farce, since he was unable to look after himself, and his wife sleeps 16 hours a day. Since medicare paid his bills, the government got stuck with terrible and unnecessary costs.

In my opinion, people who accept social security and medicare belong in retirement homes. You saved up for retirement or have family willing to foot your bills? Well, live as you please. You didn't, and you're living off the government? Here's your room in a communal facility where you can receive food, shelter, and supervision in a cost-effective manner. If you're not independent, let's not play games and pretend that you are.
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Apr 8, 2013
Reflections of a Medical Ex-Practitioner
The glow of the personal relationship with patients is being extinguished.
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Apr 5, 2013
Anyone or anything that tells you something is so is lying. If you decide to believe it then you are lying to yourself.

( Yes I noted the paradox)
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Apr 5, 2013
My BS-filter tripped at your first statement and all alarms went off:

[Did you know that 50% of second opinions from doctors CONTRADICT first opinions?]

So I started looking for the original statement and found it on the Metamed website:

[Did you know that almost half of second opinions DIFFER from the original diagnosis? ]

There's a big difference between contradict and differ. A contradiction is when A says you have cancer and B says you're allright. They only differ when, well, e.g. A and B find that your cancer is in a different stage.

Any doctor I know will strongly discourage self-diagnosis through the internet. I can only acknowledge this, as the results are very contradictory, misleading and often simply wrong.
Apr 4, 2013
We have over diagnosed ourselves into a state of permanent medical need ... the winners? The medical community, hospitals, doctors, clinics, DRUG COMPANIES, etc. The solution? Get over your fear of death ... IT IS GOING TO HAPPEN ... no one gets out of here alive. I have seen lots of people desperately trying to extend their lives by getting the best medical care they can and by eating right, and exercising and so on ... and they still get old and develop problems. Genetic makeup is the single most important thing in who lives a long time and who doesn't ... MetaMed can't give you any help with that
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Apr 3, 2013
Do you want to spend money on a good purchase?
Look around, find some report based on data, and choose one of the items with the top figures.

Do you want to spend money on a good service?
Look around, find some report based on data, and choose one of the providers with the top figures.

Do you want to spend money on a good healthcare system?
Look around, find some report based on data, and choose one of the systems with the top figures.

Apr 3, 2013
I reviewed several different health and nutritional issues for MetaMed, JCVI, and my own purposes. The 80% figure is incorrect (which we should expect it to be--if it were correct, it would probably be incorrect), but I've found that if you have good critical abilities and an understanding of statistics, and spend one week researching any topic in medicine or nutrition, you will usually find at least one important finding that is accepted but false, or that has high probability but is unknown to practitioners.

For example:

Breast cancer: The conclusions of the Gail model sometimes have no support in groups with slightly-different genetic backgrounds, e.g., Eastern Europeans, and are in doubt. Three studies found that one of the lifestyle factors most-correlated with developing breast cancer is sleeping with a bra on.

Aspartame: Its initial approval in the US was political. The reviews that the FDA and their European counterpart relied on to re-evaluate it last decade were written by scientists employed by companies selling aspartame (though this was not disclosed in the articles, e.g., Magnusson et al. 2007), and were highly partisan. Most studies not paid for by companies producing Aspartame concluded it was toxic, but the effects they found were not consistent. Review articles dismissing them contained biologically-implausible assumptions, such as that any dose/response relationship that was not linear could be dismissed as experimental error.

Food dye and hyperactivity: It appears that some artificial food dye does exacerbate ADHD, but this could not be detected in previous studies because they all assumed that all subjects were genetically identical (a near-universal error; see below).

Vitamin supplements: The studies by Bjelakovic et al. cited to prove that vitamin supplements increase mortality rate used absurd statistical tests, which assumed that "if a little is good for you then a whole lot must be really good for you", and are hence meaningless. It is also never pointed out that their interpretation indicated toxicity only for fat-soluble vitamins.

Lyme disease: The papers claiming that there is no such thing as chronic Lyme disease are all produced by a small number of doctors who cite each others' papers and ignore almost all other evidence. Every line of independent inquiry leads to the conclusion that chronic Lyme exists. The focal point of the argument is the comparative reliability of ELISA and Western blot tests, vs. patient symptoms, history, PCR, and histology. The papers claiming to disprove the existence of chronic Lyme begin by assuming that ELISA and Western blot of blood serum are the only accurate methods for its diagnosis, when experience outside the context of Lyme suggests they are the worst by far. One of the lynchpin papers claims to have proved that ELISA tests are 100% sensitive by showing that ELISA tests were positive on all their test subjects--but the tests subjects were SELECTED for having positive ELISA tests! I suspect the doctors involved have some financial stake in the existing Lyme test kits.

You need to read a paper carefully and analyze all its assumptions and inferences. Most notably, studies test the hypothesis that a certain intervention has a particular uniform effect on ALL subjects. Failing to prove that hypothesis is then taken as proof that the intervention does not have that effect on ANY subjects. Any study attempting to prove that X is harmless to everyone because a T-test did not prove the hypothesis that X is harmful to everyone--and this includes every toxicity study done more than 10 years ago--is worthless.
Apr 3, 2013
Here's something that might be behind the growth slowdown: companies are getting smarter about how they provide healthcare to their employees.

My company, for example, had a premium plan for a long time that boiled down to "Everything short of cosmetic surgery is free". You paid more for it, but if you had just a couple of kids or any sort of recurring medical costs, it was totally worth it. That plan is now gone, though, replaced by a pay-as-you-go system where they give us X dollars a year and we choose how to spend it (on healthcare). The idea was that if an individual has to manage a budget, he is going to be more money-conscious than if everything seems free. And I'll tell you what, it works.

One of my prescriptions is a perfect example. Previously, as prescribed by my doctor, I was on an "extended release" version of the drug, where I only had to take one pill in the morning and it lasted the entire day. I've been doing that for several years. Now, though, because I see the cost of prescriptions directly, I'm on the normal version of the drug, which means I take one pill in the morning, one right after lunch. It's a pain because not only do I have to remember to take the second pill, but I have to carry them with me to work in order to do so. So why did I switch? Because the "extended release" version is $210 for 30 pills; the normal version, $30 for 60. By taking two pills a day instead of one, this medication is costing me (and thus my company) ~$2000 less per year. I have no idea why the extended release version is seven times as expensive, but the point is, I never even THOUGHT about it until I was faced with making the money choice myself.

They also eliminated automatic mailing of prescriptions. There used to be a system where we would get our prescriptions mailed to use on some regular interval. If it was an "as needed" drug, though, that often meant that we would receive a refill while the previous bottle was still half-full. For some things, we would have bottles or jars or whatever just piling up on a shelf, because we were getting them much faster than we were using them.

Another thing that the pay-as-you-go system eliminates is the perverse incentive to spend more. Since it was a flat fee, there was never a reasons to NOT get another treatment, another scan, another appointment. After you've paid the fee, everything was free, so unless you're an altruist who hates seeing those poor, starving medical care providers go broke, you'd get every last test you could think of. No more.
Apr 3, 2013
[I'm fascinated by a new company called Metamed that offers to be your personal medical researcher. For a fee of $200 per researcher per hour, with a $5K minimum...objectively speaking, the service is already a bargain if your alternative is death by ignorance]

You really have lost touch with what its like out there for the rest of us havent you? Objectively speaking the alternative isnt death by ignorance but, rather, taking chances with an inferior product that you pay somewhere between $10 and $50 of your own money for. For a lot of folks out there thats a bargain compared to something you have to spend 1-5 months living expenses for.
Apr 2, 2013
[Anyway, my point is that better information will solve the problem of increasing medical costs. It's already happening.]

I dont doubt that better information is having an impact, but lets not get carried away. There are other explanations for why the growth of health care costs has slowed:

1) Sooner or later it had to run out of room to increase didnt it? Maybe its reaching that point.
2) For years the insurance companies have been trying like hell to hold down costs. Maybe they've hit upon some combination of better information, foisting costs onto consumers, keeping doctors reimbursements down, etc. thats succeeded.
3) Some people may be choosing less expensive health care options for reasons that have nothing to do with better information (anyone know if theres a recent craze for homeopathy or something?)
4) Not that I have any reason for beleiving this to be true but...has anyone examined the possibility that Obamacare has something to do with it?

Other possibilities come to mind but they seem even more farfetched than #4.
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Apr 2, 2013
"Anyway, my point is that better information will solve the problem of increasing medical costs. It's already happening."

That has to be true. I'd be interested in knowing how much of healthcare spending goes to "do-overs". I'm guessing its more that half. In the coming age of Big Data, we won't have to guess. We'll know -and be able to fix the problem.

Of course - we will still have the issue of unreliable reporters. I have a couple of lonely, looney relatives who use the health care system as their personal, emotional support network. (I'm not volunteering to fill the gap here. They aren't a lot of fun to spend time with...). I'm sure some of their symptoms are real - but literally tens of thousands of dollars have flowed into unnecessary care because they are very, very good at performance art.
Apr 2, 2013

[I believe a computer is a better diagnostician than any human can be, because computers understand odds and exceptions. ]

All computers operate under the rule 'garbage in garbage out'. Whoever programs your computer diagnostician is going to have to decide which medical information is going into its database and which isn't. Im sure they could eventually get it right, just dont put too much faith in version 1.0; its the programmers understanding you're trusting here not the computers.
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Apr 2, 2013
I believe a computer is a better diagnostician than any human can be, because computers understand odds and exceptions. I think a smart computer system that asks additional questions can probably isolate anything wrong with me.

The problem is how to fix it, because there are a lot of commercial interests involved in getting me to try an expensive drug over say "take a teaspoon of Bicarb with your evening meal", or "stop eating so many tomatoes".

I have had a painful eczema for about 7 years. Several specialists, and many creams and drugs later I have a cure. It was passed on to me by a guy in a forum, who noticed that when he went swimming sometimes he had relief over the next few days. It turns out that a correctly dosed swimming pool with the perfect Ph, the typical range of anti-bacterial and anti-fungal agents and salt chlorinators produces 20 000 litres of liquid that cures [my] eczema. I scooped up a litre, put it in a spray bottle, and I could now sell it for a fortune. I believe that 90% of medical problems can be solved with a free or cheap plant/food/chemical or simple change in behaviour - if you just knew what it was.

A successful medical system will leverage the [hidden] knowledge 7 billion people who get sick and happen upon something that improves the condition [plus some logic on human anatomy and creative thinking].
Apr 2, 2013

Scott's figure about results from the medical literature being wrong isn't a prank. He's referring to the work of John P. A. Ioannidis, whose 2005 paper, Why Most Published Research Findings Are False, is the most-cited paper of PLoS Medicine. The Atlantic has an article about it called Lies, Damned Lies, and Medical Statstics: http://www.theatlantic.com/magazine/print/2010/11/lies-damned-lies-and-medical-science/308269/

But the impact of this is sometimes overstated. Doctors are aware of the problems with individual studies, especially studies that aren't random controlled trials. The media will report on individual studies as if they're breakthroughs that change everything, but scientific knowledge progresses through systematic reviews of multiple studies. Here's a medical student discussing all this (he even mentions MetaMed): http://slatestarcodex.com/2013/02/17/90-of-all-claims-about-the-problems-with-medical-studies-are-wrong/
Apr 2, 2013

[MetaMed isn't a prank. It's run by some friends of mine.]

OK, but what about the part I mentioned? A 50% difference of opinion rate seems high, and as for 80% of the medical literature being wrong....now that I think of it where DID you get that number from, Scott, if it wasnt a joke? What source of medical information is so reliable that you can check the medical literature against it? Or is the term 'medical literature' referring to anything in the book store that promises to improve your health?
Apr 2, 2013
Of course, the problem with "The Adams Law of Slow-Moving Disasters" is that when it doesn't work out we won't be around to notice.
Apr 1, 2013
MetaMed isn't a prank. It's run by some friends of mine. Here's their page at VentureBeat: http://venturebeat.com/company/metamed/
Apr 1, 2013
The link to MetaMed's site is broken; it should be http://www.metamed.com/
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