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The Uselessness of Phenylephrine

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Re: The Uselessness of Phenylephrine

#361

Post by rscho »

asmithmd1 wrote: post #356
rscho wrote: post #300

Earlier quoted context omitted.

> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in…

There are some things that are helpful that they will answer that have steered me away from a surgeon: How many of these surgeries do you do per year? An answer of 50 or above is good. What is YOUR rate of ? Keep pushing until they tell you their rate, not the overall rate.

They almost universally don't know their own rate. I don't know my own rates of complications. But, if I want you to go away because you seem to be the kind of guy that will come back to bite me, I'll gladly tell you I have a huge rate of complication.

Re: The Uselessness of Phenylephrine

#362

Post by cmrdporcupine »

Pseudoephedrine is a stimulant and not a particularly pleasant one at that. Here in Canada there's still cold medicines with it in them, and to be honest, when I see it, I avoid it.

It may not be as good of a decongestant but phenylephrine won't keep me up at night. And when I'm sick with a cold what I really need is a good sleep.

Re: The Uselessness of Phenylephrine

#364

Post by sxg »

grog454 wrote: post #351
sxg wrote: post #345

Earlier quoted context omitted.

I'm guessing you haven't heard of Goodhart's Law? ( https://en.wikipedia.org/wiki/Goodhart%27s_law ) Under your proposal, surgeons will be incentivized to selectively operate on easier patients and minimize their complication rates while not performing surgery on very sick patients who may also need the same surgery. Different surgeons in different areas treat different kinds of patients. It's hard to accurately meas…

Is it really too "hard" to perform rigorous statical analysis? Why can't you factor in patient genetics + background + circumstances to come up with some expected chance of success for each procedure (in fact, isn't that why doctors have such detailed patient histories?). Isn't it the doctor's job to estimate and inform the patient of the expected outcomes? Doctor's historical success rate exceeds expected success ra…

Yes, it's absolutely very difficult to do rigorous statistical analysis.

Genetics is oversimplified to non-physicians. It's cool that we can diagnose and predict the likelihood of getting Huntington's disease using our knowledge of genetics, but extremely few diseases are this simple. There are huge swaths of the human genome that we don't understand but are likely playing some important role in the regulation of other genes and diseases. We are nowhere close to being able to look at a patient's genome to predict anything useful outside of a handful of exceptions.

Patient histories are honestly often garbage—I say that as a physician. I look through dozens of patients' charts every day, and there are constantly errors, incomplete documentation, and fragmented records across multiple institutions. Just last week I read a chart for a patient who had a documented hysterectomy from years ago. The brand new CT scan I saw showed a perfectly normal uterus. Once something goes in a patient's history it's nearly impossible to correct or remove. If some doctor from ages ago said the patient is allergic to medication X, but the patient denies it, what do I do? Usually, we opt to leave the allergy listed out of fear of the consequences if the patient is wrong.

Re: The Uselessness of Phenylephrine

#365

Post by rscho »

grog454 wrote: post #360
rscho wrote: post #358

Earlier quoted context omitted.

The number of factors you'd have to consider to achieve that is huge enough that it makes it completely unrealistic, both practically and financially speaking. In fact, I'm 100% convinced that it's currently impossible to build such a system, given the extent of medical knowledge.

I'm skeptical. I concede it's probably a hard problem but there is an entire field dedicated to hard statistical problems called data science. What is the point of having detailed patient histories and data if it can't be used to inform decisions?

If data science was that efficient on healthcare records, we'd know it by now and everyone would do it. There is no 'big healthcare data'. We gather mostly noise, and records are full of blatant mistakes. Medicine is still more art than science today, and records mostly give you a 'feeling' for the patient's condition in light of your MD education, with a little hard data sprinkled on top.

Re: The Uselessness of Phenylephrine

#366

Post by sterlind »

asmithmd1 wrote: post #356
rscho wrote: post #300

Earlier quoted context omitted.

> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in…

There are some things that are helpful that they will answer that have steered me away from a surgeon: How many of these surgeries do you do per year? An answer of 50 or above is good. What is YOUR rate of ? Keep pushing until they tell you their rate, not the overall rate.

unfortunately if you need a rare surgery (to treat a rare condition), this doesn't work very well. it also isn't enough for surgeries with subjective outcomes (such as vaginoplasty.) with the former you look for a competent surgeon with many good outcomes on related surgeries of similar complexity, and who keeps up with or participates in research. with the latter... image boards? word of mouth? whoever your insurance covers? I get hung up on that kind of choice.

Re: The Uselessness of Phenylephrine

#367

Post by jonhohle »

cmrdporcupine wrote: post #362

Pseudoephedrine is a stimulant and not a particularly pleasant one at that. Here in Canada there's still cold medicines with it in them, and to be honest, when I see it, I avoid it. It may not be as good of a decongestant but phenylephrine won't keep me up at night. And when I'm sick with a cold what I really need is a good sleep.

I have the same feeling. I’m very sensitive to pseudoephedrine jitters and do my best to avoid it. It may be placebo, but phenylephrine “works” for me and can “tell” days that I forget to take one in the morning when I have post nasal drip. Knowing it should have no clinical effect, I’d be interested in blinding myself to a placebo to convince myself it really has no effect.

Re: The Uselessness of Phenylephrine

#368

Post by ac29 »

wombatpm wrote: post #340
rootusrootus wrote: post #307

Earlier quoted context omitted.

> Why can you go to the store and buy rubbing alcohol to drink? It’s primary ingredient is just ethanol. AFAIK most/all rubbing alcohol (at least that which is sold in the US) is isopropanol, not ethanol. You can buy ethanol in not-for-consumption form, as denatured alcohol.

And it’s chemistry that forces the additional benzene in denatured alcohol. Water- ethanol forms an Azeotrope at 95% ethanol. Benzene is added to break the azeotrope and get to 99.99% ethanol. Chemistry not a conspiracy

No one is selling 99.99% grade alcohol as an antiseptic in the US. Its usually 70%.

There are additives in ethanol sold as an antiseptic to discourage drinking (various bitterants, not benzene).

Re: The Uselessness of Phenylephrine

#369

Post by AussieWog93 »

wins32767 wrote: post #327
rscho wrote: post #300

Earlier quoted context omitted.

> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in…

Risk adjusted scoring is entirely viable in this age of data science, there is just no appetite for it. Doctors fight very hard against it because who actually wants to be held accountable for outcomes? Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they ca…

>Risk adjusted scoring is entirely viable in this age of data science

It's just not unviable, I don't think it's even possible. As soon as a metric becomes tracked, people are incentivized to game it.

From my own experience as a very high-volume eBay seller, mandating a certain return rate led us to simply discourage customers from using the (convenient, well-designed) integrated returns systems. Mandating that only a tiny fraction of a percentage of items can be cancelled due to being out of stock leads to sellers sending either the wrong item or a fake tracking number (this gets us all the time on AliExpress).

If data-driven software companies can't handle it for something as simple as eCommerce, I have no idea how the medical industry is supposed to get it right.

Re: The Uselessness of Phenylephrine

#370

Post by melq »

wins32767 wrote: post #327
rscho wrote: post #300

Earlier quoted context omitted.

> When I ask for hard data on the surgeon’s actual success rate for this type of surgery, well, they don’t track that—but look, just trust me, the guy’s realllyyy good. For good reason. Tracking of clinical outcomes is the wet dream of insurance companies. It's very toxic to the healthcare system, because it pushes practitioners to focus on easy cases where a good outcome is expected and causes major inequalities in…

Risk adjusted scoring is entirely viable in this age of data science, there is just no appetite for it. Doctors fight very hard against it because who actually wants to be held accountable for outcomes? Insurance companies really aren't the villains in the US healthcare system, they're going to make money no matter what because they pass cost increases on to their subscribers and are capped in how much profit they ca…

A good portion of the largest insurance companies are non-profits, look at Blue Cross Blue Shield and their affiliated companies. They still make tons of money, keep tons of cash on hand, enjoy the same high salaries as for-profits (not saying they necessarily shouldn't), and get special tax statuses/breaks.

And the for profit ones are making plenty of money whatever regulations theyre subject to:

>During 2010, Health Care Service Corporation, the parent company of BCBS in Texas, Oklahoma, New Mexico, Montana and Illinois, nearly doubled its income to $1.09 billion in 2010, and began four years of billion-dollar profits.

I'm not saying they're villains, but "they're going to make money no matter what" isn't a compelling argument to me, and I have precisely 0 faith in the government to meaningfully regulate them.

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