I like this and feel it is useful, though an important corollary of this heuristic is that you have to know how much time you will need for the task. This year I at one point had to get a serious deadline moved at (or actually, slightly after) the last minute as I was unable to meet it. I have a tendency to work as you propose but since returning to work after my maternity leave, my internal clock for when to start work pre-deadline was way off. My previous ‘last minute’ was based on an expectation that I could use my downtime to meet a deadline, whereas now with a baby my downtime is inflexible. My estimates of how long something will take me are improving (after a brief overcorrection).
adaloveslace
Karma: 10
This is an argument with some merit presented in a slightly antagonistic way. Some specific thoughts.
First, the case for competence. This post argues that they are not competent on the grounds that:
They should be able to reliably diagnose diseases they are trained to diagnose and should be knowledgeable at the standard to qualify as a doctor. If evidence against this were presented here it would be a concern, however the evidence presented mainly demonstrates that:
they are not good at diagnosing rare diseases (this is not a typical use case for primary care in my experience, and the cited study discusses things like genetic counselling which would follow specialist review where I work (non-US))
that physical exams by both primary care physicians and emergency physicians is inferior to ultrasound—this seems likely to be true but is mostly an argument for increasing access to point of care ultrasound/easy point of care tests, not against the existence of physicians per se.
That professional competence deteriorates over time—this was the best claim here in my opinion, and the evidence matches my personal experience. It is of serious concern that continuous professional development is neither maintained well nor adequately assessed by registration authorities. Unfortunately again the evidence here is not specific to primary care, this problem is more widespread. My (unsupported by evidence here) belief is that this represents a default to heuristics and biases over an attempt to genuinely problem solve for presentations in senior clinicians. It is a serious problem.
Next the post argues that primary care doctors should be attentive and empathetic towards patients but are not: the evidence provided for this does partially support this claim. It is however not specific to primary care and highlights this as an issue for medicine at large. One study cited actually appears to states that primary care doctors were actually better at finding out what the patient wanted from the appointment than specialists. A concerning point about medicine at large.
The final point against competence is the claim that visiting them is not superior to not visiting them. The case made here rests primarily on the argument that decision support systems/LLMs giving medical advice are very good and could be easily used well by a layperson. I’m open to this being true but no evidence was cited to support the argument. A quick review of the literature didn’t give me any slam dunks at the level of confidence the author displays. I think this is true for some laypeople and some conditions, but it merits a more thorough exploration (apologies that I have not had time to do this here and I may come back to this, though I believe aspects of this are in previous medical roundups).
Second, the case of empty credentialism:
The claim is made at the top that standardised decision trees are used and could be easily implemented by a web app. I gave the app linked a try, giving it common symptoms of a lower respiratory tract infection (cough, chest pain, low grade fever and general fatigue). It gave me a list of differentials including several kinds of respiratory tract infection, ‘post-myocardial infarction syndrome’, anthrax, lung cancer and a teratoma. When I gave it a timeline (worsening over a few days, present only for a few days) and a severity (impairing activity) consistent with that diagnosis, it suggested I should go directly to the emergency department. This is not what I did last time I had these symptoms (I went to my GP and got antibiotics that worked, and codeine for post-infection cough suppression). Honestly I couldn’t rate this particular app that highly based on this experience, but perhaps this isn’t the intended use case, I’m open to feedback on how others have used it well.
Then the statement is made that doctors don’t use them because they are too time-consuming, or carry liability risks. No evidence is cited Again, this may be due to the environment that I work in, but my experience is not that this is the case. Actually for a more limited case (weird rashes) dermnet that provides a very simple decision-tree is in widespread use by those who don’t have specialist knowledge of dermatology. At an uneducated guess the case against decision support systems has more to do with employer concerns/perceived risk of patient information disclosure than individual clinician choice.
The next set of claims is that the necessity for primary care providers is:
To diagnose rare conditions: I don’t think this is true and am not sure why it is argued repeatedly—my understanding of the purpose of primary care is to diagnose common conditions.
To prescribe, and deny prescriptions to drug seekers: This is made threefold: that primary care doctors should be able to 1) identify patient error about what treatment is needed, 2) prevent seeking of drugs or abuse, and 3) provide the correct treatment.
The argument they make for 1) and 3) relies on their claim that decision support systems are better at this than doctors. As I don’t feel this claim has been supported by the argument so far it’s hard to accept.
The argument for 2) I skipped over above: that primary care doctors are bad at identifying opiate seekers. This seems true, I didn’t bother to check the evidence—but actually the main reason for gatekeeping in prescription is not in my understanding about opiates or benzos, but rather about antibiotics—for which overuse has societal implications as well as individual-level ones. No good argument has been made here that LLM-based drug choice would be superior for this purpose, though again I think that’s a possibility. The main risk is that a patient given the choice will tend to opt in favour of getting the treatment, which would increase inappropriate antibiotic use overall. I would be interested to see solutions to this that don’t involve primary care physicians existing.
To refer on: this post again argues for LLM superiority, if I accept this here then it is fine. As I have said a few times, I don’t think this post has really made this case but it does seem possible. I do think there’s an argument to be made here that it’s tracking multiple referrals and specialist interventions that’s actually the primary care role here—if you’re attending multiple specialists they may not be paying adequate regard to the interactions between medications or difficulties that are cropping up at the intersections of conditions. A very capable patient can manage this themselves, but anecdotally I have seen a lot of patients struggle with this.
To undertake physical exams: this has been addressed a bit above.
Finally the case for less-trained providers:
The claim is made that typical training times for primary care (6-10 years) are not needed. If we take the reasons for primary care doctors existing in this post as valid (I don’t think they entirely have been as stated above), I think this is a reasonable claim.
Then the claim is made that making it easier to be a primary care physician is the solution. Another commenter has pointed out that this has been/is being tried: nurse practitioners and physician assistant/associates have been attempted in a number of places. I don’t really find the evidence from their practice to be great. However it does appear true that very high demand and (in a sense) poor competition have contributed to the 10 minute review which is definitely not optimal for anyone (except perhaps certain NHS managers). Based on this post though, I’m not sure I think the argument has been made for less-trained care providers. Instead I think the argument has been made for self-referral to specialists based on LLM advice. It’s my understanding that different countries have very different procedures about this and I’d be interested to read if anyone has a good understanding of the economic comparison of different models.
Overall I think this post has unfortunately not improved my understanding of this area, though I agree that this is an area ripe for improvement. Another commenter has already directed the poster to the medical roundups. I would also more generally recommend considering looking at different primary care models in different countries, I’d be very interested to read evidence for or against particular models as I’ve done limited reading on this myself.
This explains something that’s been bothering me. I started reading lesswrong very recently, though I would have been aware of some less than generous caricatures of the community for a long time prior. Initially when I started reading the Sequences I was pleasantly shocked, thinking that a community based off these principles would be incredibly useful and productive. I hope I don’t come across too harshly when I say that I don’t know so far that everything I’ve read in the sort of general rationalsphere has reflected the utopian productive discussion I had briefly anticipated. The distinction between the material I have found good and enlightening and that which I have found hard to engage with or unconvincing and sophistic does somewhat correlate with your stick/non-stick division.
Not to say that I’m rejecting rationalist discourse on political or abstract matters out of hand, but this does help me understand why I’ve maybe updated less on much of it than expected.