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‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

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41–50 of 75 posts

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#41

Earlier quoted context omitted.

> Anyone who can build an ML model to catch these clues is going to make billions. You'd be surprised. IBM poured billions into Watson and appears to have been pretty successful in nearly reaching parity with a certified oncologist, but the results were dismissed because it didn't outperform them. > At first, Manipal used Watson to recommend treatment options for all cancer patients, said oncologist S.P. Somashekhar.…

That's not a great definition of parity. We'd want accuracy and specificity numbers linked to outcomes, not concurrence. The times when Watson agrees with doctors is effectively irrelevant - results would be the same whether or not he was added. We need to highlight whether, given a disagreement, Watson was better or worse for outcomes.

The trick is whether the cases of disagreement were themselves predictable!

Given a fixed number of oncologists and deploying Watson only to support those oncologists, yes, you're correct that its only useful if it outperforms them. But I think of it more like Watson is a single hive-mind team of like a thousand med students near the end of residency: they get most things right but there are a few places where more experienced doctors will be better, though the scale with the hive mind is far higher.

You have one of two reactions to that. 1) Hire fewer senior oncologists and have them focus on the more difficult cases and leave the hive-mind to deal with thousands of routine cases, or 2) ignore the hive mind until its literally better than a typical senior oncologist.

The medial profession seems to repeat this cycle of "only full doctors can do anything because even seemingly routine cases might be hiding something more serious" to "maybe some routine things can be done by people with less training and full doctors should focus on the more difficult cases". See nurse practitioners, dental assistants, and, in my mind at least where we are going with things like Watson.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#42
post #9
post #4

As a non medical professional, I can't even imagine the difficulty in trying to diagnose a severely sick child that is too young to speak or articular symptoms/where it hurts... Scary.

One of the things my veterinarian colleagues talk about a lot is how do you make a diagnosis with "My chicken is acting funny" as the only information you have.

Being a vet is a tough job; they need to be able to diagnose problems with patients that can't speak and sometimes have very, very different anatomies. In farming communities in particular they can sometimes be critical to whether a livestock farmer succeeds or fails a season.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#43
post #27
post #8

> Physiological values are complex in paediatrics. They are more than complicated because although there are published ‘normal values’ which will guide the clinician in knowing whether a child is tachycardic or tachypnoeic, these are in fact reference ranges that were initially based on expert opinion. Although meta-analysis shows these reference ranges to be at least somewhat valid, it is probably safest not to thin…

Yes, but I assume that all children who die in e.g. the States will automatically get an autopsy and a cause of death will be determined, no? (Note: haven't read the article, so I'm not sure if I'm contradicting anything here or just agreeing with it!)

No, generally the parents have to request an autopsy. The provider can always recommend getting an autopsy, or requesting one, but ultimately that decision lies with the parents.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#44
post #9
post #4

As a non medical professional, I can't even imagine the difficulty in trying to diagnose a severely sick child that is too young to speak or articular symptoms/where it hurts... Scary.

One of the things my veterinarian colleagues talk about a lot is how do you make a diagnosis with "My chicken is acting funny" as the only information you have.

If I may ask, what exactly is it that you're doing ?

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#45
post #14

I think another solution is forcing doctors to work more off of check lists and less following their gut. When I was a baby I also had some weird symptoms and my mother took to be several pediatricians who couldn't identify the problem. Eventually one evening my mother ended up in the emergency room with me and got to see a really nervous young doctor who, as my mother describes it, it felt like we where the first pa…

Similar situation, our sick child was passed off by initial doctors as having something minor. We were fortunate to try a different ER where a nervous young doc took a more skeptical approach and ran down the checklist fully before correctly diagnosing with bacterial meningitis. The doctor had never even seen a meningitis case before.

Per discussions with the infectious disease specialists this timely diagnosis likely saved our child's life.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#46
post #27
post #8

> Physiological values are complex in paediatrics. They are more than complicated because although there are published ‘normal values’ which will guide the clinician in knowing whether a child is tachycardic or tachypnoeic, these are in fact reference ranges that were initially based on expert opinion. Although meta-analysis shows these reference ranges to be at least somewhat valid, it is probably safest not to thin…

Yes, but I assume that all children who die in e.g. the States will automatically get an autopsy and a cause of death will be determined, no? (Note: haven't read the article, so I'm not sure if I'm contradicting anything here or just agreeing with it!)

As far as I know autopsies are never automatic in the US.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#47
post #17

Earlier quoted context omitted.

If you are focusing on words, you are missing the big picture. 'Guts feelings' are what you get when your brain process a butt load of informations in a fuzzy way. This includes subtle smells, colors, moves, timing, shapes, sounds, chain of events and how they interact with each others. Words can be a tiny part of it, but usually gut feelings are about all those things you can't process as easily with rational thinki…

The gut feelings a health care professional gets will vary based on the language the patient uses. The gut feelings a doctor has to a patient saying "I have crushing chest pain" will be different to the patient saying "I have burning chest pain".

It is interesting to talk with a family member who is a physician mainly for male veterans of the armed forces. He's got roughly the same training as someone who would treat families, but because he's worked with this older/sicker/male/poorer population with particular shared experiences, he's really developed an ear for what these guys are saying and not saying. It's a whole set of para-medical skills that do not transfer to children, women, guys who come from a very different demographic or cultural profile.

So I sort of agree that gut feeling varies based on the language a patient will use, but knowing your patient population well can help you tune in beyond the words.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#48
I thought that probabilistic decision trees had been around for a long time in other parts of medicine

e.g. http://www.seilevel.com/requirements/visual-models-save-live...

So I'm surprised there isn't a general one for paediatrics.

Re: ‘Why didn’t you think this baby was ill?’ Decision-making in acute paediatrics

#50

Emergency doctor here, I have to say that diagnosing a sick child is one of the hardest things you can do in medicine (aside from figuring out why someone is feeling 'dizzy'). The limiting step here is that we can't do blood tests and x-ray/CT on everyone that walks in the door (which itself can lead to harm: https://emergencymedicinecases.com/overinvestigation-emergen... ) I work in one of the busiest ER's in Canada…

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