Not sure what you mean by "unfolding". But, unlike Watson, Google Health seems to be building tools that may be useful for healthcare providers rather than just marketing hype.
It was just IBM throwing stuff at the wall to try and keep up with big tech companies. They have been in decline for a long time, and I assume this marketing stunt did not fool anyone actually involved in the businesses of healthcare or tech.
It wasn't a product. It was a business unit created by the acquisition of (at least) 4 separate companies that had wildly disparate products, data sets, and consulting teams. The only thing they had in common was the focus on healthcare (and even that could mean anything vaguely related to providers, payers, or life sciences). "Watson" in general evolved into little more than a branding that was applied to anything remotely related to AI, analytics, or data management.
"billed as a revolution in medicine" by whom? IBM's marketing department?
Anything "Watson" (together with 95% of that company - optimistically) is marred too deep in bureaucracy and yes men to do anything productive and innovative.
There should be a way to bet (short) against “projects” or products, not the whole company. When they hyped about Watson Health, I “knew” it will fail.
Yes, I think youtube is making billions of dollars a year. Youtube's revenue was $25 billion last year. It's a mature product. You don't think it's making money?
Google still doesn't release the profit figures for youtube, only revenue. Even the revenue figure was a secret until 2--3 years ago, so it was probably not that high. If youtube was very profitable, I'm not sure why Google would hide it in its earnings since they almost always try to show how they aren't exclusively dependent on their search ad business. I'm not saying youtube does not make any profit at this point, but if it wasn't tiny there's no reason for them not to talk about it.
I mean, the opposite is also true, isn't it? If Google's search ad revenue was going down while YouTube ad revenue was going up, I feel like Google would want to keep that a secret so that people don't realize that search ads are shrinking in relevance.
Basically, I don't see that Google has any incentive to break out its profits by line of business unless someone forces them to. They're better off if you just look at a black box of ad revenue and say "yeah it's all profitable, so ads are as strong as ever."
Being profitable is only one angle though. Youtube is the biggest media network right now. I wouldn't be surprised if it beats Spotify as a music streaming service and a host of other unrelated sectors as well.
Good question. Prediction markets [1] allow people to bet on outcomes and benefit financially if they are correct.
However, many jurisdictions ban them outright claiming that they a form of gambling and challenging the unregulated nature of questions leading to misaligned incentives (“When will that building burn down?”).
Yet despite these issues, the scheme can offer a neutral ground for betting against overhyped technologies or registering dissent against the policies of authoritarian regimes.
Cryptocurrency based prediction markets further protect the participants by masking or hiding their identities.
The combination of these features makes prediction markets an effective way to deliver global-scale censorship-resistant voting to the masses.
I never said that prediction markets should be illegal -- I'm just acknowledging what you stated, that in some jurisdictions, they are. That's a fact. Running a cryptocurrency-based prediction market doesn't make it less illegal.
Your argument isn't with me, it's with whoever decided a prediction market should be illegal. Go change that person's mind.
Neutral ground is useless if the blockchain doesn't have an oracle to know what happens in the real world.
The blockchain only knows about things on the blockchain itself. So someone has to do the actual data entry into the blockchain, and that person is the weakest link in any 'prediction' scheme.
I'll give a different answer, which is that a blockchain-based prediction market can be used as an oracle for other blockchain-based contracts. So there can be both a final answer and a mark to market for the contract which should approximate reality in some way. However, being unregulated, there's always the possibility of cornering the prediction market and causing the derivative contracts to end with unreality. So you may need another kind of oracle to finalize the market price of the prediction market.
Probably could be accomplished without crypto, but it can also be accomplished on some blockchains with minimal additional investment.
being cynical is easy because most things fail, the challenge is in identifying winners early or identifying losers after they’ve had some measure of success.
I could be mistaken because it’s been a while, but I read that Watson’s diagnostic capabilities turned out to be mostly marketing and that eventually IBM ended up hiring teams of doctors to process the diagnosis requests that were coming into Watson.
Sounds like what happened at Theranos! I read the analysis Watson was generating was ultimately just ignored by doctors because it came to inaccurate conclusions, so that makes sense.
Watson became a marketing term after the company spent hundreds of millions to brand Watson to be synonymous with AI. The term Watson then got appended to existing businesses as it allowed them all to benefit from the brand equity and Watson ads. This unfortunately happened even if there wasn’t any AI capabilities, so it eventually backfired.
Watson Health seems to have been focused on selling the narrative of AI in healthcare, even though the technology wasn’t there.
The divestiture is only for IP also, and it seems most people in the group will be laid off.
As someone with no inside knowledge, it seemed to me that watson started as a technology (or maybe solution/set of solutions) and as time went on, it was pivoted to be a brand? Hard to tell for sure with how difficult it is to get IBM to answer questions about what they actually do...
Worked for IBM for three years, this is accurate. To solve some clients problem we would build an ML solution from scratch just like everyone else, and then try to shoehorn some Watson service into it so we could use the Watson Brand to distinguish our product.
The solutions we built were generally pretty good and our clients were happy, but the Watson part was never anything more than marketing,
I personally feel Watson was an extremely clever marketing boondoggle. If you think of it, machine learning, neural networks and AI were just making a return into the public mind around the time they announced Watson.
I think somebody thought if they "humanized" AI by making it seem like it was a character, it would make AI seem all that much more closer to the dream.
On the face of it, not a horrible idea, but applied to what was essentially a bunch of separate algorithms.. pretty misleading, but that's just an opinion.
Worth noting that Jeopardy Watson had very little ML and absolutely no deep learning (it was a few years pre-AlexNet). I don’t even think it used any neural networks; certainly not in any major way because they’re not a major topic anywhere in the press releases, working group notes, or the papers published by the Watson research group. Watson was an incredibly complex mixture of bespoke implementations of “classical” AI and NLP techniques to handle questions of different classes by transforming them into search & information retrieval problems. They were able to make it work pretty well for the very limited domain of questions that arise in Jeopardy, but it was also obviously a Herculean task to generalize that approach. I can totally believe that as executives started to grok what Watson really was they realized that it had more value as a brand than as a technology.
Like in Neal Stephenson's Diamond Age with the on-demand voice actors.
I wonder if that was a lack of imagination about what AI will become, or if it was prescience that AI will turn out to be cost ineffective or not capable for most uses.
A friend of mine wanted to show off his Tesla by making it come to the front of the restaurant from where he parked it. Like he hit a button and it was to drive up. It got stuck somehow and was diagonal in the row. He was like “ehh sometimes it doesn’t work.”
AI in general is very over stated. When it works it’s great, when it doesn’t (which is often) then you lose all trust in it.
I think that's the wrong conclusion from this story. The conclusion I draw is that some companies (and Tesla in particular) don't appreciate the "last mile" when trying to apply AI breakthroughs to consumer products.
"The plane lands safely 99% of the time" is an impressive demonstration and a completely worthless product, but if that's all you have then what can you do other than launch it?
It says that (driving) AI is a rapidly changing technology, pushed along by these companies.
The definition of "reliable" here is also important. Usually this devolves into a series of moving goal posts ending with "if it can't do everything perfectly all the time then it's not real!"
It's a fuzzy thing yes. But it is still clearly not safe to drive everywhere with AI. A claim was made by experts and leaders about AI how by now self driving cars would be ubiquitous. That claim was wrong. That does say something about AI. It is a counter claim against the initial claim.
The technology they sent on Jeopard answered a question, I think, that was looking for the name of a specific king of Egypt with "What are trousers?".
Seems pretty obvious that anything that would do that is not human-like intelligence, and probably the search results should be taken with a handful of salt even if they stuck some impressive natural language generation after it.
I'm okay with this: humans likely make hilariously bad guesses about things that are obvious and easily accessible to machines, and therefore the reverse is also true.
Guessing "what are trousers" for king of Egypt isn't in itself an indicator the whole Watson system is flawed. Although you're right: it's an indicator the intelligence is non human-like.
Just like, from Watson's perspective, a human named John making hilariously bad guesses related to coin flips isn't in itself an indicator that John isn't intelligent either.
Just that there are some categories of knowledge or application of that knowledge that some systems are bad at handling.
> I'm okay with this: humans likely make hilariously bad guesses about things that are obvious and easily accessible to machines, and therefore the reverse is also true.
Yes, it's almost perfectly dual: the things we do easily, without thinking, are hard for machines. Many things that we can only do with years of training, machines do effortlessly.
I think technology like Watson has a bright future when applied in the right way, but I think it's counter-productive to wrap it in anthropomorphic marketing, and especially to give it these direct natural language interfaces. Because that makes people misunderstand what it is.
That's really a choice. I mean most machine learning models wind up outputting a confidence distribution over possible outputs, so it's up to the user to decide how to extract an answer from that. They can and do have low confidence when they aren't sure.
This is kind of funny to see after reading the Tech Review's piece on Watson Health from 4 years ago (https://www.technologyreview.com/2017/06/27/4462/a-reality-c...). They were wrong on the outcome but right on the diagnosis - that the marketing got way ahead of the engineering.
I really expected that we'd see a change in my lifetime, that GPs in particular would be replaced by a lower-cost Watson descendant, with there being some other role for patient interaction, wet work, and data entry (perhaps just nurses).
My mom worked for a GP for about 20 years, and it seemed to me that most of what made that guy a doctor was bedside manner + being able to remember a lot of things. But GPs often make astounding amounts of money while leaning heavily on their staff to actually handle patients and keep the business running. I thought it could help drugs get a little cheaper too, because there wouldn't be any point in the pharma companies sending out salespeople to do lunch seminars to convince the GPs to prescribe this or that drug (this still happens).
Maybe this will still happen, but it doesn't seem imminent anymore.
> bedside manner + being able to remember a lot of things
My impression is that accompanying a patient is super important, it helps to understand illness, to have a plan in case of more complex treatments, etc.
Then my doctor has the ability to know me and gauge my health. She's also very good at probabilities and detecting when something really goes wrong.
I'm sure that being able to do that require a lot more than numbers.
(I'm studying data sciences, I trust them, but my guts tell me that diagnosis is in a whole different ballpark)
It also helps to have a relationship with a patient (or person).
There are some people who will never, ever complain about anything. When they complain of severe abdominal pain, for example, you pull out all the stops immediately to figure out what's wrong, because it's probably really bad.
On the other hand, there are hypochondriacs and people will low pain tolerance. While they can certainly also become seriously ill -- and one must never forget this -- the tempo and pace of workup and order of intervention is markedly different, absent other information that shifts the pretest probabilities.
That’s me. I really, really appreciate a GP that both understands that I’m not doing it on purpose, and can reassure me that nothing is wrong, or figure out that we actually do need more testing this time.
Unfortunately it’s been years since I had one like that :/
Sometimes a relationship is bad. If you think someone’s a hypochondriac, but in fact they’re unusually sensitive, you’ll dismiss a lot of what they say and that can be quite damaging over time. (Especially if they’re female https://www.health.harvard.edu/blog/women-and-pain-dispariti...).
I wouldn’t eliminate GPs from the process, but many people actually would like to hear what the robots have to say about their medical conditions. Having second opinions of this sort available might lead to better patient outcomes.
Lol. Maybe people who don’t have any medical problems.
There isn’t enough humanity in healthcare to begin with. Replacement of doctors with AI sounds pretty horrific. General practice isn’t where healthcare costs are going bonkers, and it seems weird to want to cost-cut something that actually kind of works in favor of bullshit.
Know what would be a great use of AI? Something real like analyzing all of the telemetry in EMRs to provide better guidance to doctors to proactively guide people. Some CVSHealth chatbot telling me whatever is a waste of time.
Automated diagnosis applications have existed for decades. They have proven useful in limited circumstances for certain specialties and rare conditions but for routine medical care they're more hassle than they're worth.
There is no evidence that diagnostic robots would actually produce better outcomes. The hypochondriacs are already able to Google their symptoms and make themselves sick with anxiety.
Knowing the ontology of your patients and their risk is also a tenet of a doctor's job, but we can do it with AI too. Hell, ontological engineering had a revamp specifically so that we could have a standardized model to describe any and all "parts" of a "whole" in a way that machines could understand.
What data is being collected on you? Once a year blood test if that even?
I actually suspect it would be trivial to beat my doctor after 5 years of higher frequency full blood panel data collection.
10 full blood panel samples a year, have 20 million people do that for a data set we can do classification on. I think my doctor is kind of out of business then.
Will never happen in my life though with health insurance and health bureaucracy.
Beat your doctor on what? You can already get 10 full blood panel tests per year if you want. You can just pay for it and don't need insurance. But what will you do with the data? For most people the results won't tell you anything useful.
It won't happen primarily due to government regulation. Medical information has "dangerous, don't touch this" written all over it, and everyone is scared to try.
“Super important” — more like “super nice-to-have.” Hospitals don’t have any single person on staff who stays attached to particular in-patients. Who knows you? Your chart.
Yes, of course, hospital care would be better in many ways if we did have somebody who statefully understood particular patients’ needs.
But what I’m saying is, the GPs in hospitals could be replaced with stateless diagnostic AI without making hospital care any worse than it is now. And hospital care is a large part of the medical system, so only replacing diagnostics there (while leaving primary-care GPs alone) would still be a major optimization, freeing many doctors to provide better care, go into specialties, etc.
That's simply false. You obviously have no idea how hospital care is actually delivered. To start with, every admitted patient has an assigned attending physician who is responsible for coordinating the care team. Some things can be documented in the patient chart but there are always gaps. Clinical decision support systems for partially automating diagnosis could potentially be helpful in some limited circumstances but the ones built so far mostly don't work very well.
Then where exactly does the oft-cited kafkaesque nightmare of being "lost in the US hospital system" come from (with patients put in the wrong wards and forgotten for sometimes months; given inappropriate medications that doesn't end up recorded; tested repeatedly for the same problems because the test results were "lost"; etc.)?
Just because someone is responsible for you doesn’t mean the system works competently enough to make sure you receive only what you need in a timely manner
> To start with, every admitted patient has an assigned attending physician who is responsible for coordinating the care team.
That's rarely (if ever) a 1:1 ratio. That attending physician is almost certainly juggling multiple patients. Same with the rest of the care team. There's a reason why the first thing one does when approaching a patient bed is to look at the chart.
> Some things can be documented in the patient chart but there are always gaps.
Then those gaps need closed, stat. Once those gaps are closed...
> Clinical decision support systems for partially automating diagnosis could potentially be helpful in some limited circumstances but the ones built so far mostly don't work very well.
...then this will improve considerably. Garbage in, garbage out.
That's largely pointless. The critical data elements do get charted. But time spent closing data entry gaps on patient charts is time not spent actually caring for patients. There are simply not enough clinicians to do all that, or funding to pay them. Furthermore there are many aspects of patient conditions that can't really be coded in a useful way. A skilled, experienced clinician can intuit a great deal from subtle signs like skin color, breathe sounds, tone of voice, small movements, etc. Healthcare relies on tacit knowledge far more than arrogant, ignorant software developers understand.
And in most routine cases the diagnosis is the easy part. The hard stuff is actually working with patients and doing the hands-on procedures, which won't be significantly automated in our lifetimes.
Pattern recognition algorithms do have some promise for computer assisted interpretation of things like medical images and ECG waveforms where the input data is already in digital form. We can't rely exclusively on algorithms for patient care, but if the physician reaches a conclusion different from the human physician, then it's probably worth taking a deeper look and getting a second opinion.
> And in most routine cases the diagnosis is the easy part.
...which is why we shouldn't be wasting such valuable resources (people with an aptitude for medicine) on doing such an easy, routine task all day long, no? It'd be like if chefs spent most of their time hand-grinding spices rather than cooking.
> A skilled, experienced clinician can intuit a great deal from subtle signs like skin color, breathe sounds, tone of voice, small movements, etc. / Pattern recognition algorithms do have some promise for computer assisted interpretation of things like medical images and ECG waveforms where the input data is already in digital form.
You're seemingly contradicting yourself here: you're saying that the places where ML shows the most promise, are exactly with the tasks that would best replace the things doctors are doing. The only reason that ML can't do those things, is that people aren't putting data like "a video exam of the patient by a nurse" into the chart where the diagnostic algorithm can see it / be trained on it.
>Hospitals don’t have any single person on staff who stays attached to particular in-patients.
This is incorrect. Doctors are assigned to patients, and if there is a complication any time or day or night the doctor is contacted to decide what to do. The entire point is so that there is one person who is familiar with the patient, who is also responsible if anything goes wrong. I don't know how malpractice would work with an AI, but given the number of malpractice cases yearly in the US it'd either be sued out of viability or have to be provided with legal immunity(possibly the worst scenario IMO)
What many people don't realize is that medicine as a whole is already some sort of expert system (i.e.: a flavor of AI).
There are researchers that conduct experiments to produce meaningful data and extract conclusions from that data. Then there are expert panels that produce guidelines from the results of that research. Most diagnostics and treatments are prescribed following decision diagrams that doctors themselves call... algorithms!
There are several limitations that prevent us from applying other AI techniques to the problem. Off the top of my head:
- We do not have the technology for machines to capture the contextual and communication nuances that doctors pick up on. There can be a world of difference between the exact same statement given by two different patients or even the same patient in two different situations. Likewise, the effect of a doctors' statement can be quite literally the opposite depending on who the patient is and their state of mind. One of the most important aspects of the GP's job is to handle these differences to achieve the best possible outcomes for their patients.
- Society at large is not ready to trust machines to make such intimately relevant decisions. It is not uncommon for patients to hide relevant information from their doctors, and to blatantly ignore the recommendations from them. This would be many times worse if the doctor part wasn't human.
- We cannot apply modern inference techniques (e.g.: deep learning) to the global problem because we have strict rules that prevent medical data collection and analysis without a clear purpose. Furthermore, these techniques tend to produce unexplainable results -which is unacceptable in this field-. As a result, there's not enough political capital to relax those rules.
> We cannot apply modern inference techniques (e.g.: deep learning) to the global problem because we have strict rules that prevent medical data collection and analysis without a clear purpose.
I mean, China will likely do it, as long as they can capture high quality data, so there's that.
The attending physician in a modern hospital system is primarily a manager. Their main concern is treatment of the patient's medical issue, but their role isn't limited to that. This patient is refusing care but also refuses to leave, what do we do? How should we schedule care around a patient who requires the entire floor to assist in daily activities of living? They may not get the last word on matters outside of their responsibilities, but being the physician their words carry weight. This role has remained pretty much constant through the modern medical system, even as medicines change and nurses and technicians gain more responsibilities.
A computer cannot perform that role with the current paradigm of AI, even the worst and most arrogant doctor is more qualified leader than any computer.
Those are both people problems. Tech can't solve many people problems, especially something as entrenched as healthcare. Isn't it huge, something like 10% of the US economy?
To put it even further into perspective, that's 2x as much as comparable western nations with single-payer, who have similar or better outcomes in most cases.
Why do you think nobody important (politicians, primarily) is really trying to solve those major healthcare problems?
If politicians are willing to pork and barrel over a random soy farm employing 2000 people, for sure they're not going to throw away, say, 5% of the US GDP and possibly 5% of all employment in the US.
I don't know how you're going to get out of it...
[1] "There were 22 million workers in the health care industry, one of the largest and fastest-growing sectors in the United States that accounts for 14% of all U.S. workers, according to the Census Bureau’s 2019 American Community Survey (ACS)."
We have this health system to avoid taxes, but this crazy US system probably costs 97-98% of Americans pay more for health stuff than all of their actual taxes combined.
It's funny how on these forums people who actually do something good and useful like GPs are considered overpriced, but at the same time many here work for FANGs or other webad businesses often making more than GPs. I know that if it comes to decide between the health industry and Facebook, Google, Apple or MS I sure know which I'd rather keep.
Interestingly, I assumed they were outside the US. Primary care docs (especially independent primary care docs) are one of the lowest paid medical doctors. Most specialists make significantly more money (and have a significantly better workload/schedule).
>that GPs in particular would be replaced by a lower-cost Watson descendant
It is happening. They are called physician assistants and nurse practitioners, "supervised" by a doctor. I assume going forward, they will take more and more of the usual pink eye/ear infection/flu and other common work that does not require 6 to 8 years of post bachelor education.
It's happening because hospital corporations love them.
Corps can pay less, and since they have a tenth of the education, they order tons of profitable tests, consults, and scans because they don't know otherwise.
It's a mischaracterization for PAs because doctors only have ~7.5x minimum more clinical training and not 10x, 15000 clinical hours (for med school + family medicine, the shortest residency program) vs 2000hrs. Ask any radiologist you know what they think about the imaging orders from NPs and PAs and that will give you your answer.
It's worth noting that the higher tiers of nurses have at least a masters degree, and like more time working than a doctor spends in residency. They are highly trained/skilled professionals.
I would guess that most people entering NP programs at this point have less than 3 years of work experience as a nurse, a job where you are not diagnosing, coming up with treatment plans, performing procedures or doing any other physician tasks.
I don't know if 500hrs of shadowing after a 2yr part-time online only program that you don't need any nursing degree or experience to enter would count as highly trained or skilled. Here's a list of direct entry nursing masters programs - https://nursinglicensemap.com/nursing-degrees/masters-in-nur...
Here's Johns Hopkins doctor of nursing practice program's curriculum - https://nursing.jhu.edu/academics/programs/doctoral/msn-dnp/... - where more than half of your classes are not medicine related and which requires an astounding 1000 clinical hours and less than 10 credits a semester before you can call yourself "doctor". Most medical students will have 1000hrs after 3 months in 3rd year, where they will be expected to diagnose and come up with treatment plans vs just shadowing, and they still have 9 more months of 3rd year, 4th year, and a minimum of 3 more years in residency. Doctors will likely end up with a minimum of 15000 hours of training. The difference really is that large, and I feel bad for the patients and for the NPs who have no idea how deficient their education is. PAs have 2000hrs of clinical experience. Here's a chart - https://i.imgur.com/Cj5z4f8.jpg
Is there any evidence that patients of NPs actually have worse outcomes? Given the current physician shortage would it be better to wait to see one, or get an appointment with a NP right away?
My expectation is that the outcomes would be similar for the common issues, and would start to deviate as you got into more uncommon problems. A doctor will have a lot more "background knowledge" to be able to consider things that are outside the every day. At least in my mind, it's not unlike someone in software development with a degree in it vs not. For most things, the person without a degree will do a fine job; but for some things, they won't be able to consider many of the possible options/tools, because they just haven't been exposed to them.
correct. except the person doesn't even know when they don't know. and that's the most dangerous part. If you at least know what you don't know, you can re-direct to the right resources.
Many studies comparing NP and physician outcomes will have the NPs under supervision by physicians, which is ideally how they would be used, but in practice the true supervision level varies widely. I wouldn't see an NP for my care personally, and I doubt there are many physicians who would. The wait time to see primary care physicians is typically less than a week in most places and would be worth it. If you're experiencing something you feel is too serious to wait a week I would visit the ER (and make sure to ask to be seen by the physician also). It's your health. Personally I would only trust mine to the people who are the experts in their subjects, and not those who have less training and can switch between specialties without any additional training.
I don't have anything against NPs when the supervision is close, but more and more doctors are put into positions where they are acting as liability sponges for de-facto independent NPs/PAs.
Here are a few studies -
(CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625
NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696
The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)...
Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m...
I will add my anecdotal perspective as a rheumatologist at a tertiary care centre to your second last reference. I have a lot of respect for the work my NP/PA colleagues do, particularly on the ward. Yet I see a notable difference in the quality of referrals from MDs vs. most NPs/PAs whether it be from clinic, ER, or ward. With some exception it's often please see for [subjective complaint], a + random test that was checked, and query [disease that goes with that antibody] or a misunderstanding of what I see in my discipline. Not to say that MDs have it perfect but I'm not sure if it's the shorter training, more algorithmic focus, less confidence in their physical exam that drives this. As a healthy 20 year old I'd have said an NP/PA is great for primary care but I just don't see it as a solution as people age and get more medically complicated.
I didn't say that nurses have the same medical training as a doctor of medicine; just that they are highly trained professionals with a fair amount of experience. If you match the 3 years of residency with 3 years of working as a nurse (they're clearly not the same thing, but both are "experience" for the purposes of this discussion), a starting medical doctor has 2.5-3 more years of training/school/experience than a nurse practitioner. That's a lot; but it doesn't reduce the fact that the NP has a lot of training. The post I was replying too sounded like it was dismissing the amount of training/experience being a NP takes, and it bothered me.
the real problem with NP/PA is now what they know. It is that they don't even know what they don't know. There's a large body of basic science, biology, that a doctor has to acquire that helps underpins a lot of the clinical medicine they practise. It's not just following guidelines and algorithms. It is understanding why the guidelines are, it is understanding why what looks like a typical case isn't, but is that one rare thing you absolutely can't miss.
Honestly, if not for the weirdness of the US system, mid-level providers shouldn't exist. But we are where we are. There absolutely is no room for independent practise for mid-level providers.
>Corps can pay less, and since they have a tenth of the education, they order tons of profitable tests, consults, and scans because they don't know otherwise.
Hence the purpose of managed care organizations (MCOs, health insurance companies) employing people to approve and deny (or design systems that approve or deny) payment for unnecessary tests, consults, and scans. And in a taxpayer funded system, the government employs people to performs the same roles.
This is why insurances are moving toward capitated plans. Instead of paying for services provided health care providers get paid per patient they care for. That way the perverse incentive created by asymmetric information is removed.
Well implemented capitated plans are value based. Value based just means there are incentives for better than expected health outcomes and disincentives for bad outcomes. If you have a non-value based capitated plan health care providers would reduce the quality of care, so value based strategies were implemented to ensure patients receive good care even though providing it costs money.
Yep. The midlevels are supported by automatic protocols in Epic (e.g. sepsis, DKA -> put these dozens of orders in with 5 clicks) that physicians decide on and approve. They also rely more heavily on imaging instead of a physical exam and history. When unsure, they can consult a physician, even a specialist.
It’s a very polarizing topic in medicine that patients generally aren’t privy to. Especially for resident physicians who often make half as much as these midlevels yet have more education, there’s a lot of bitterness. The federal government is ultimately to blame… having a fixed number of residency spots to artificially limit the supply of new physicians is terrible, and this is the predictable result.
I think hospitals support inefficient midlevels because they can bill patients for the increased resource usage, but it’s not good for the system overall when unnecessary scans and consults are done, and more complex patients don’t get comprehensive care. Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.
>Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.
There already was a tiered system, with rich people being able to buy concierge medicine and getting preferred treatment based on who knows who on the hospital's board or if their name is on a wing of the hospital.
The change now is a more visible and more granular price segmentation.
There’s no price segmentation. You pay the same for a visit with a PA or NP as for one with a physician, so why see someone with less than a tenth the experience who may have gone to an online only school with 100% acceptance rate and shadowed for 500hrs of “clinical experience“ right out of nursing school?
It will happen via in network and out of network agreements.
Healthcare providers with greater proportion of NP/PA will be selling for cheaper, so MCO will sell access to only them in their lower price plans, and healthcare providers where you get to see doctors will be in higher price plans.
This already happens, especially with many healthcare providers not accepting lower reimbursed Medicaid patients.
I'm having a hard time understanding why they would be bitter. Residency is temporary and a part of the training process. Once completed, doctors will make 2x-3x+ compared to midlevels for the rest of their careers.
Because the future is for doctors to not make 3x compared to them. The mid levels are being used to increase supply of healthcare, using the doctor’s license for liability, in order to reduce the price doctors collect (per unit of time and effort).
Basically, they are watching their expected wealth / purchasing power be reduced.
Residency has a lot of problems. The match is stressful enough. Medical school graduates carry a huge amount of debt, but must complete residency before earning enough to meaningfully pay it off. Residencies pay 40-85k and most resident physicians are expected to work 80+ hours per week. 80 is the theoretical maximum, but that doesn’t count time arranging work, studying, taking board exams, etc.
All this, and if you don’t complete your residency, you have no prosperous future as a doctor. You might re-match to another residency if you’re very lucky. The hospitals know this and act accordingly. Residents and even medical students paying tuition (!) were assigned to treat COVID patients and couldn’t really decline without risking the future they’re heavily invested in.
Keep in mind, the federal government pays ~150k per year to the hospital for having the resident. Yet the residents are often more indentured workhorses than trainees. It’s not uncommon for entire departments to run overnight with only residents, but no attending physicians.
Now imagine being in this situation, and not being allowed into the “providers lounge” because you’re a resident. Or using a broad-spectrum antibiotic instead of something more specific and being scolded for poor antibiotic stewardship, while the NP who has “completed their training” can’t even properly decide antibiotics are indicated some of the time. And if that NP were ever treated the way a resident is, they could go get a job at the hospital on the other side of town and start in a week.
If someone was making more than twice as much as you, working half as many hours as you, seeing half as many patients as you, and were less qualified for their similar role, you would be upset too.
A two tiered system might actually be better for improving access to affordable health. Mid-level providers seem to achieve equivalent outcomes for routine cases at lower cost.
I agree that Congress should increase funding for residency programs.
I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.
There’s definitely a trade off between resources devoted to education vs. acceptable risks from failed procedures, missed/delayed diagnoses, and increased utilization of imaging and referrals (and the physician radiologists and others who participate in that - it goes full circle). Physicians now are probably on one extreme end of that, and midlevels on the other.
On the topic of servicing rural areas… the problem is that nobody with better options (which includes midlevels) wants to live in these places. These educated, high-earning people want to live in urban areas, and they can. CMS has tried to incentivize this with billing by offering higher reimbursement rates to rural places that have a midlevel on staff. That’s about it, though.
> I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.
If midlevels can successfully detect complicated cases to a supervising physician, and handle a whole lot of other care independently... and the net result is equivalent outcomes... this isn't a massive win? You've conserved the really expensive and contended resource for where it's needed and not made anything worse...
#1 - Funky/misleading statistics - Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients. It's not claiming that of any randomly selected patient, regardless of who they see, the outcome is the same. Therefore, if uncomplicated patients saw physicians, outcomes for the physicians could improve. In primary care managing hypertension or diabetes, this isn't as pertinent. For something like anesthesiology, it's more so counting how many times shit hits the fan, and brain cells die when the anesthesiologist takes time to be summoned.
#2 - They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here! The patient no longer has use of their interphalangeal joints. The physician would probably try to shine a light through it, note the patient's Scandinavian ancestry and family history of plantar fasciitis, and tell them to live with it and come back if it changes.
No resources were saved here, but the patient's DASH score (disability of the arm, shoulder, and hand) is still 0 so the outcomes are the same.
This happens all the time.
#3 - Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.
#4 - It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor... in many places, that doesn't necessarily need to be an anesthesiologist, and the surgeon performing the procedure can suffice. The AANA recently changed its name to the "American Association of Nurse Anesthesiology"... It used to be "Anesthetists". The CEO and president (two different people) of the American Nurses Association both refer to themselves as "Doctor" in a healthcare setting even though one holds a DNP and the other a PhD. It's pervasive.
> Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients.
The studies I've seen have compared practices where NPs are seen first vs. physicians are seen first.
> They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here!
Your claim is this kind of excessive testing and referral doesn't happen with physicians? Do you have some kind of evidence this is more common with NPs?
This kind of overtesting leading to unnecessary procedures and bad outcomes has been pervasive through care in the US. Don't blame it on NPs.
> Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.
Ditto
> It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor...
Welp, we're not creating anywhere near enough residencies to create enough physicians to do the work, so I'd suggest we'd figure out ways to either do that or use people with lower levels of training well (preferably both!).
I've heard Canada is like that. I've had similar experience in South Africa, even in private health care, but I definitely had the impression that my doctor somewhat cared about me, especially after going to them for a few years
It is so in China and it is every 5 minutes in most cases.
Precisely because of this, I chose doctors from good public hospitals because of their super rich experiences instead of fancy private hospitals.
This is more or less the case in many European countries. Less so here in the UK, but approaching there rather quickly due to astoundingly poor management by various successive governments. It’s tough back in South Africa as well, and they pay their doctors extraordinarily well.
This is true in the US, too. GPs have become "procedure mills". It's almost as if management figured out they just have to put the right code on the bill enough times a day. Since no one is accountable for outcomes, money happens.
In my country, patients will go to the public healthcare unit at 4 AM in the morning in order to try and get an appointment. It opens at 8 AM and by that time there'll be a queue of about 30 people. Doctors are expected to see them all before 11 AM. Such is life in "family medicine", theoretically a medical specialty but mostly filled with doctors who just graduated medical school and who are looking to make some money before they start residency which pays a pitiful "scholarship" and is essentially indentured servitude anyway. There's barely any time to do anything more complex than chief complaint or chronic disease management.
It's funny because it's the complete opposite of what family medicine was supposed to be. The doctors were supposed to live and work in those towns so they could get to know the population and form stronger bonds with the community. Instead, they either burn out quickly or move on to far better working environments, specialization or not. Some of these public healthcare units don't even have sinks you can use to wash your hands.
Everyone talks about the relationship between drug reps and doctors like it's the most incestuous, evil, corrupt thing. How else are doctors, especially those who are 10, 20 years removed from their residency, supposed to learn about new treatments and medicines? Alexa, what is best current treatment for a duodenal ulcer? You think a doctor is going to spend his limited downtime perusing the PDR (which no longer exists, and was always heavily influenced by the drug manufacturers anyway)?
Sure, there may be some excesses (although the truly major perks like entire vacations dressed up as a "conference" no longer exist), but I would much rather have doctors be aware of new drugs and yes, subject to marketing pitches, than have these drugs languish (eventually leading to drugs not being created) because nobody knows about them.
In Illinois Doctors have to go to a one week conference every year that is supposed to talk about this stuff. They also have to take board exams every few years that make sure they're staying caught up on new advances.
It's 60 hours every 3 years, of which webinars are acceptable, and no records need to be submitted with the renewal application. There are no tests or exams. The "new advances" they must keep up on include Sexual Harassment Prevention and Implicit Bias.
It's their responsibility to stay up-to-date. If a dev can keep up with front end tech stacks, doctors, who are much more elite in their education, should keep track of latest treatment breakthroughs in their domain of expertise.
First of all, the vast majority of devs do NOT stay "up to date." Most know one language or even just one platform... i.e. "WordPress developer" or "Oracle admin". Secondly, how do you think YOU hear about new technologies... usually due to marketing. Did React just come out of nowhere? No, Facebook marketed it relentlessly. Did people discover Kotlin on their own? No, JetBrains and Google hit people over the head with it. Etc, etc
Is it really the case that Facebook marketed heavily React? Why? What do they gain from it? Real question, or not like react was an entry point to their API?
It was fairly obvious when it was an up and coming thing. They sent out engineers to talk about it, you had these articles popping up about it more or less out of nowhere, etc. If you weren't there (which I'm guessing you're not, otherwise why would you ask), it is hard to imagine. Perhaps it makes more sense when you consider how normal "advertorials" are now.
Take a look at what that actually entails. Inexpensive online courses with guaranteed passing exams, many of which have zero to do with actually treating sick people -- Secondhand Smoke. Medical Ethics. Herbal Medicine Review.
Even if a practitioner took it seriously and wanted to get a real education about actual medical issues, they aren't going to find coverage of brand new drugs in an educational setting unless it was arranged by the drug companies themselves.
Part of the job, as stipulated by medical regulators around the world, is keeping up-to-date with evidence. This can be achieved by reading journals and attending conferences, in theory.
But.... journal publishers exploit their monopolies, and conferences are funded by corporate sponsors. So perhaps they're not so different.
Medical conferences basically would not exist if it wasn't for suppliers and drug companies paying for sponsorships, trade show booths, opportunities to speak, etc. Not really any different than any industry's trade conferences.
Sounds just like every technology conference I've ever been to. A bunch of software and hardware vendor booths, and most of the speakers being authors hawking their latest books.
> How else are doctors, especially those who are 10, 20 years removed from their residency, supposed to learn about new treatments and medicines?
With some other mechanism that doesn't have major conflicts of interest? Like, I don't know, attending to actual courses, like any other profession that requires continuing training.
Who is teaching the courses? Where do they get their info? Given the very limited oversight of "continuing education", it's trivial for Merck or Pfizer to ensure their advocate teaches the class or records the online seminar -- with zero requirement that they disclose that fact. At least when a drug rep visits the office and buys lunch, you know the source.
Study what? Even the New England Journal of Medicine is full of articles funded by drug companies. And for good reason -- the results of drug trials should be communicated to physicians. Buying them lunch may be less prestigious, but it's essentially the same thing.
There's more material available, not just scientific journal articles. The medical specialty associations periodically release detailed guidelines covering new criteria, methods, treatments. For example:
There are courses available if you wish to be taught. There are events where people present new developments. There are paid sites like UpToDate. Even textbooks eventually get new editions and there's always plenty of fundamental science in them that doesn't change
Did you check the Disclosures section of your article? Are there any drug companies NOT included there? Like it or not, private companies fund the vast majority of medical research in the U.S., and any doctor who wants to stay up to date cannot (and should not) ignore it all.
The authors have no conflict of interest to declare, but declare lecture honoraria or consulting fees as follows: T.U., Bayer, Boehringer Ingelheim, Hexal, Vifor Pharma; C.B., Servier, Menarini, Merck Pharma, Novartis, Egis, Daichy Sankyo, Gilead; N.R.P., Servier, Pfizer, Sanofi, Eva Pharma; D.P., Torrent Pharmaceuticals; M.S., Medtronic, Abbott, Novartis, Servier, Pfizer, Boehringer-Ingelheim; G.S.S., AstraZeneca, Menarini, Pfizer, Servier; B.W., Vascular Dynamics USA, Inc, Relypsa, Inc, USA; Daiichi Sankyo, Pfizer, Servier, Novartis, Menarini, Omron; A.E.S., Omron, Novartis, Takeda, Servier, Abbott.
I did see that. I don't see that as a reason to doubt the recommendations of this particular article.
I thought we were talking about direct marketing by pharmaceutical company representatives by the way. It is of course impossible to separate modern medicine from the pharmaceutical industry since many therapies depend directly on them. It's still the doctor's job to figure out which medicines are actually good and what's merely some salesman's product.
Why is "direct marketing" (drug reps) verboten but an article paid for by the same company is legitimate? What if the reason for the drug rep's visit is to bring a copy of the article to the doctor?
> Why is "direct marketing" (drug reps) verboten but an article paid for by the same company is legitimate?
Scientific articles are published and read by the community. There are, for example, social media and messaging groups where doctors will post and discuss articles, including their methododology and limitations. There's always the possibility that the study could actually be relevant.
Drug company representatitives talk to doctors in private in order to try and convince them to prescribe drugs. Like all marketing, there's an inherent dishonesty to it. You always assume they're overstating the positives, downplaying the negatives and ignoring alternatives. Doing this is actually the doctor's job. It's our job to pick these claims apart and figure out what's true and what isn't so that patients don't have to do it.
Doctor-drug industry relationship is at its healthiest when they're just giving doctors free samples of the drugs they were already going to prescribe anyway. Doesn't change the doctor's conduct and helps patients with free medicine. Doctors are already going to prescribe angiotensin receptor blockers for hypertension, drug company representatives won't change that. They can and should provide free samples though, free medication helps everyone.
> Drug company representatitives talk to doctors in private in order to try and convince them to prescribe drugs.
Everything a drug company does is ultimately about selling more drugs. It's not limited to the drug reps.
> they're overstating the positives, downplaying the negatives and ignoring alternatives
Again, not at all exclusive to drug reps. This behavior can be traced all the way back to Phase I of the clinical trial.
Your position in this thread makes no sense. I stated the drug reps help doctors stay up to date on the latest drugs and treatments, you disagreed and said doctors should "study. continuously." What should they study? Articles sponsored by the drug companies. How can you square that? Further, I'm sure you're aware that only a tiny percentage of doctors actually read the fancy journals and fewer understand the statistics and the details (perhaps those are the docs who sit around on the message boards you mention). For the other 90+%, the drug reps are the conduit who deliver relevant info to doctors. Ate they aggressive? Yes. Sneaky? Sometimes. Ultimately, do they help doctors discover drugs that help their patients? Unless you believe the drugs being approved by the FDA are ineffective, the answer is yes.
> I don't see that as a reason to doubt the recommendations of this particular article.
No conflict of interest, except they're directly paid by drug companies. That's the sort of thing you'd expect to see in a banana republic, not established medicine. It should call the integrity of the entire system into question, frankly.
The NIH funds a huge fraction vast of biomedical research in the US. Pharma does important work too, but it’s largely concentrated in the very last stages of getting a product to market.
These COI disclosures also strike me as hard to interpret. It’s certainly possible that some of these people are deeply invested in a company and are pushing its particular therapy hard to buy a new boat or something. However, I’d bet many of them are $250 to participate in a focus group, or free conference registration to be in a panel. It’s important to know who’s buttering the authors’ bread, but it’d be helpful to know how much it’s being buttered too.
> The NIH funds a huge fraction vast of biomedical research in the US.
This document https://www.researchamerica.org/sites/default/files/Policy_A... states that in 2017 private industry spent $121 billion on Medical & Health R&D Expenditures in 2017 compared to $39 for the federal govt ($32 of which is NIH). $121 billion in a single year -- I honestly assumed the number was in millions till I re-read it.
You are probably right that the drug companies are (not surprisingly) focused specifically on drugs while NIH research is more general and widespread. But that is still a very large difference.
I used to see this in our country, where 10 people are queueing outside doc's office ( this is public health system) when some well dressed man goes straight into the office not even bothering to ask if there's anyone in there and fast forward a few min and the doctor is 'on break', whilst drinking coffee with the sales rep, while all those people sit and wait. Eventually it got outlawed.
That's extremely rude. How could he just barge into the doctor's office? A physical examination could be taking place.
In my experience at a specialized neurology practice: they wait outside until the doctor is free, then knock on the door and ask if they have a moment. They would almost always get straight to business, never wasted more than half a minute of people's time socializing.
Drug companies offer a lot of free samples. It's the same drugs the psychiatrists were going to prescribe anyway, they're just trying to get them to prefer one brand over the other. Sertraline, for example, is first line treatment for depression, anxiety. Getting free sertraline samples reduces costs for patients and really helps them out. Especially in my country where generic medication is often found to not be of the same quality as those manufactured by big pharmaceutical companies.
> there wouldn't be any point in the pharma companies sending out salespeople to do lunch seminars to convince the GPs to prescribe this or that drug
Right, but there would be a lot of point in making deals with whoever builds Watson-like devices, to turn them ever-so-slightly more likely to prescribe one drug over another or make one diagnosis over another. It might even be cheaper than hiring and sending out a bunch of salespeople.
There is no need to market to Doctors now when they market directly to consumers who go demand they get the new medicine.
If we want to reduce costs, we need to move to lower level providers like a LPN or CRNP. Most people coming into a GP have the flu or an ear infection or .... and that can be handled by them. There will be one MD and to handle complicated cases and to supervise. We've already switched so that intake is done by CNA making $15/hour. In the US at least working at FAANG pays far more than being a GP.
According to the Bureau of Labor Statistics, the mean salary of "family and general practitioners" in May 2020 was $214,370 [1]. This figure includes salaries from GPs throughout the country (i.e., not just in the Bay Area).
You can also look at median salaries. According to the BLS, all ten of the occupations with the highest median incomes in the U.S. are medical occupations [2]. "Family medicine physicians" are 10th on this list.
Mediocre GP makes 200k cash in Omaha or any average city and has choice among many employers and systems. Stanford CS represents top talent and moreover does not make 200k cash in Omaha, and can only make the big bucks at a fixed number of entities in fixed locations with fixed hierarchies and systems.
A freelance GP (waarnemend huisarts) in the Netherlands makes on average 65 euros per hour... It pays better to be a freelance software engineer. Less education required, less responsibilities, impact of mistakes is also usually less.
USA has an extremely inefficient system of training for doctors which wastes literally years of human potential. First you go to university from 18-22 but not even 2/3rds of the year. The rest of the year is some level of waste for most students. You often purposefully dumb down and study less rigorous subjects than an engineer because you need all top grades to be get into medical school and can't risk it. Then medical school is an excessively long four years which has further periods of time waste and a lack of integral training until late in the process. Then there is a highly unfocused three year residency with what are widely understood as illegal discriminatory labor requirements holding on to their anachronistic 1910 white-male origins by a proverbial thread. So at age 29 you can finally be a GP after many unnecessary years of wasteful, repetitive, unfocused study, vacations and debt. This exclusivity and opportunity hoarding results in a reasonably high skill at a very very unnecessary level of cost and personnel shortages.
Dutch system is quite similar: 3 years bachelor, 3 years masters, including 18 months coschappen (residency), and then 3 years of specialization to GP (other specializations take longer). (https://universitaire.bachelors.nl/faq/ik-wil-dokter-worden/)
Many specializations come with very low job opportunities, being a GP is very stressfull: low paid assembly line type of work, a GP is expected to see 6 patient per hour, do home visits, follow up with patients and hospitals, and run a practice, manage employees, follow lots of trainings, etc. Having your own practice as a GP is not very popular any more, a lot of GP just want to freelance part time, not having the additional stress of running a practice.
Reimbursement for GP services in the USA runs $150-$300/hour depending on whether you are seeing elderly patients or people on employment plans, and a doctor will see about half that, plus or minus depending on the setup. Hence $200k per year if a doctor sees about 6 or 7 hours of patients plus a few hours of paperwork, calls, and emails 5 days a week.
I thought the same, but as I grow older, I believe people would reject this. Even a subpar human GP would be much more accepted than a computer. That's not necessarily true in some societies though, e.g. Japan probably would accept it.
That said, I would probably focus on fixing the system first in a way that a significant percent of population doesn't need to order fish medicine off amazon to get treatment.
I wouldn't mind seeing a computer first before a GP. A lot of the time a GP will say something like "here try these tablets and come back in a week". The true worth of a GP is the follow-up appointments and understanding conditions over time.
> I really expected that we'd see a change in my lifetime, that GPs in particular would be replaced by a lower-cost Watson descendant, with there being some other role for patient interaction, wet work, and data entry (perhaps just nurses).
Perhaps this indicates a major gap in your visibility into and understanding of modern medical practice?
> My mom worked for a GP for about 20 years, and it seemed to me that most of what made that guy a doctor was bedside manner + being able to remember a lot of things.
"being able to remember a lot of things" -- Yes, absolutely. This is an area where AI-assisted decision support (like Watson) could be, and I hope will be, extremely valuable.
OTOH, you also rightly recognize bedside manner -- as anyone who has been a patient or a patient's family caregiver will attest, this is an essential component of core, and I think likely also the healing process. We won't get this from a machine until there is a true general purpose AI, at which point I expect an AI singularity anyway.
But consider that there are other factors of the practice of general medicine that you haven't even touched upon. For example, liability: In the office you envision, where Watson/AI makes medical decisions and these are executed by other roles like nursing, where does ultimate responsibility (and legal liability) lie? Remember that Watson outputs probabilities -- suppose the following:
Chance of disease X: 89%
Chance of disease Y: 10%
Chance of disease Z: 1%
If disease X, intervention A has an 80% probability of success.
However, if disease Y, intervention A has an 80% probability of harm.
(before you object that this is contrived, this represents a realistic situation I encountered recently, where intervention A is high dose steroids)
Now, will we put the onus on the patient to select an intervention? I don't think that would be very popular. While I certainly do not advocate paternalism, when faced with difficult decisions quite many people openly defer to their physician.
> But GPs often make astounding amounts of money
I suppose this could be true for some definitions of "astounding," but it's generally accepted that GP/"primary care physician" pay is essentially the lowest of all specialties , which is a major contributor to lack of access to primary care in industrialized countries (while you'll not have a hard time finding a private pay dermatologist, for instance)
ANd on top of this, we are posting on HN where a mid level software engineer total comp can EASILY outpace the average US primary care physician salary.
> while leaning heavily on their staff to actually handle patients and keep the business running.
Do not all professionals and business executives rely on highly trained staff as force multipliers? This is a fundamental principle of the advancement of human economies. It is grossly inefficient to operate with individuals as "jack of all trades" when they can instead each become specialized to support a bigger or broader goal.
By "leaning heavily on their staff to actually handle patients and keep the business running" are you suggesting that the primary care physician should be performing check-in, insurance verification, rooming, vitals measurement, blood draw, medication administration etc? That is a certain recipe for massively decreased throughput and shortages/decreased access to primary care.
> I thought it could help drugs get a little cheaper too, because there wouldn't be any point in the pharma companies sending out salespeople to do lunch seminars to convince the GPs to prescribe this or that drug (this still happens).
This has been massively curtailed for 20+ years, at least in the US. I am not sure about other countries. But overall I think this is a seriously minor portion of the (exorbitant) price of medications in industrialized countries.
In any case, I doubt it would make much of an imp...
Of course AI could replace doctors. Some people will always prefer the bedside manner a person provides, but many others won't care, and AI will eventually do a good job at imitating a good doctor's bedside manner.
Most of what the doctor is doing is a type of modern shamanism though. Person doesn't feel good, so the doctor orders a useless test, test comes back negative so the person feels better. Then we complain health care cost too much.
10 full blood panel samples a year with other bio-metric data and a data set of 20 million people to do classification on would crush the doctor over time.
This bullshit health system though makes it impossible to have any real innovation at a mass scale. We will never have personal higher frequency medical data in my lifetime that would actually hugely improve the system and cut most of the cost out.
The hard part in medicine isn't diagnosis and it's not performing the surgeries, it's disease prevention, it's working with patients to find treatment plans they can tolerate, and it's coordinating all of the moving parts (skilled nursing facilities, pharmacies, inpatient rehab facilities, outpatient rehab facilities, durable medical equipment, home health care, insurance companies) to deliver care that results in a good outcome. Where hospital care falls apart is when labs/tests don't get performed in a timely manner and when protocols/standardized treatments aren't followed. You don't need AI to make that work, you need wider adoption of checklists with workflows that are efficient enough to continue to deliver care to the same amount of people while they're being implemented so that hospitals are willing to adopt them. The diseases that can be effectively caught with screening tests - colon cancer, cervical cancer, breast cancer, lung cancer in high risk patients, abdominal aortic aneurysms, hyperlipidemia, hypertension, depression, etc. - already have screening programs in place.
Every dollar spent coming up with the next automated imaging diagnosis model would be better spent on a model that encourages people to get up and exercise 5x/week, quit smoking (or never start), and get their colonoscopy. Once the patient is presenting to the doctor with heart failure, coronary artery disease, carotid stenosis, COPD, colon cancer, etc. the battle is already lost.
Complain all you want about the healthcare system holding data back. You don't need the healthcare system to make the biggest impact on people's health.
—- I’ll add that your shamanism comment sounds like the typical bs that the 20-something software engineer, who thinks they know everything because they make more than 100k a year and have never had to go to a doctor for anything other than strep throat or generalized anxiety disorder let alone spent anytime in a hospital other than to visit family members, that are everywhere on this site loves to say about physicians or other healthcare workers to shit on them.
> Person doesn't feel good, so the doctor orders a useless test, test comes back negative so the person feels better.
Person doesn't feel good. Mild flu-like symptoms. There's a good chance that the patient will get better if I do literally nothing. However, I also know that it could be X, Y, Z... So I order a test to prove that it's not those diseases because if it turns out to be them it would make me guilty of gross negligence.
Concrete example: symptoms of hypothyroidism are similar to depression, therefore you must rule out hypothyroidism in order to diagnose depression.
> 10 full blood panel samples a year
Why? Where's your evidence that this waste of money will benefit anyone? Even yearly screenings are sometimes questioned in medicine and they do have evidence backing them up showing reductions in mortality. What are you even trying to find?
Also, because we haven’t done this at scale, we don’t know the true baseline for most people who may have something on the blood panel samples but never get tested because they are asymptomatic. So then we have this whole group of people with recommended treatment because of the results, even though they are asymptomatic. And they are treated, which then leads to increased costs and side effects…
And now we’ve effectively increased medical costs and decreased quality of life for asymptomatic patients. BUT - if we do it with just a drop of blood, we might be able to start a startup and raise some funding… We could call it Thermos or something…
The only way AI is going to replace doctors is if medical technology advances to the point where you can repair a human as well as you can repair a machine (or someone invents AGI, I guess)
There are just too many unknowns and fiddly things going on with human bodies
edit: Haha, I guess Tex's sibling comment makes a good point though..
Yeah like most businesses the owner his staff to help out. I’m curious what you think GPs actually make, because in the US it’s not astronomical. Watson went after the wrong problem— doctors don’t comprise huge amounts of healthcare spending. It’s a recurring issue, tech thinks they have a solution and in reality the devs don’t have a good grasp on the actual landscape they’re playing in.
> GPs often make astounding amounts of money while leaning heavily on their staff to actually handle patients and keep the business running
I’ve seen this in Japan (ish), but in the Netherlands it’s definitely the GP’s doing most of the job. The assistant just does bookings and waves me in when it’s my turn.
Medicine is a business. Its incentive is profit, not patient outcome. Everybody knows the problems with medicine and the solutions are straightforward. But they don't result in more profits, only better patient outcomes. So you only get advances when it increases profit.
Come up with a way for better patient outcomes to result in higher profits and you'll see advances in patient care real damn fast.
1. Stop charging so much. People aren't seeking treatment because they're afraid of the bills.
I have other solutions, but there's no point in listing them because nobody will implement them (for the same reason that one won't be: profits over patients)
> most of what made that guy a doctor was bedside manner + being able to remember a lot of things.
Sure, that, and recognizing patterns and adjusting medication and being able to use good judgement for when to escalate to a referral for a specialist. But that's a lot!
I actually go to a teaching hospital for my primary care. It means I get seen by residents, and almost always also by very experienced teaching doctors. It ends up meaning that I get more time and attention by people who are actively learning and trying hard to do the right thing. The trade-off is there's no long-term trust relationship, but I am OK with that. I've also experienced care from elderly family doctors who run a "one-man-band" with a nurse and a receptionist, they're nice but I think I get better care at a teaching hospital.
> My mom worked for a GP for about 20 years, and it seemed to me that most of what made that guy a doctor was bedside manner + being able to remember a lot of things.
That’s exactly right, but there’s nothing wrong with that.
A good doctor’s memory of patients spanning decades of a career and all of the various treatments that they did or did not respond to is very valuable. It’s a good thing that they offload as much as possible to other people so they can focus on doing what they do best.
I think the comment above, most charitably read, is that a lot more people would have access to high-quality healthcare if you could put this work on robots instead of people, because computers excel at storing data and looking it up accurately and following predetermined rules. There would be fewer cases of people going to their doctor and being told "oh, it's nothing" when it actually is a specific, rare, and urgent problem. And then they would end up going to a human specialist to figure out how to fix that problem.
> ...I won't even use the self-service kiosk at McDonald's
As lame as it may be, but I just used the McDo kiosk for the first time.
Why? I'm a very infrequent customer at McDo and have 0 knowledge of options and combos, but also remember the mutual annoyance when previously asking for menu details from a min-wage clerk.
In a perverse way, the kiosk gives that power to choose back to me, the customer. At the same time relegating the supposedly more able humans to even less meaningful role.
This worked quite right in this case. I can see this approach applicable as well for some medical need that could be mapped onto a sequence of a "few" choices.
This could be resulting in some assistive pre-screening report.
Well, that's the stuff the assistants do at the beginning of a doctor visit. Not that different from a slot-operated scales of ancient times.
But in the end, I still want to see an immediate human responsibility in such transaction. By the same token, a GP won't be leaning heavily on such "assistive report" and would still go on and ask all of the questions again, as trained, as allotted, as billed.
Each doctor visit begins as a custom solution, no matter how cookie-cutter it turns out to be at the end. That's what we expect and that's what it ends up being billed to us.
IBM is such a shadow of what it used to be. Hopefully newer health+genomic+ai startups or initiatives at less dinosauresques companies will make the next leap happen in our lifetime.
I attended a talk a few years ago given by one of the blockchain VPs at IBM.
It turned out that under the hood they were just using conventional distributed database technology. All marketing in order to get multiple companies to work together on shared systems.
I agree when thinking about building software in one org where there is coordination. When expanding to multi org and international, the problems to solve become much clearer imo.
Federated, hashed data stores in zero-trust environments is one (though this isn't the best or only way to approach it, and blockchain is almost always unneeded), where you don't want to share the underlying data but want to provide enough information to support reporting requirements. Public health, taxation, etc. come to mind.
HyperLedger Fabric docs have an example of a manufacturer, vendor and short term finance provider all on the same network with transactions happening instantaneously. Then when you look into case studies, Honeywell has an airplane parts marketplace that’s apparently streamlined their sales process. I’ve seen some Upwork contractors demoing medical data platforms. I didn’t understand that one as much.
What data was it using again? The blood panel your doctor orders every one to two years?
Medical diagnosis is a trivial problem for machine learning to beat humans. Humans are terrible at this.
The problem is there is not even the concept of high frequency medical data. Imagine machine learning in quant stock trading with samples once a year. Of course it isn't going to work.
The problem is all in the externalities. Doctors don't want AI. They can see the automation path and their bank account change down the line quite clearly. Not to mention most doctors don't know anything about data science so how can you have any faith in the algorithm prediction? No one wants to be the test case and then get a law suit. "I was just following what the computer said was correct".
Wrong answer, pay up.
The real irony to me is in a 100 years people look at the current medical system as complete quakery. Literally have everything right now to build medical super intelligence but stuck with the human doctors doing the exact same things from 50 years ago.
I agree with this so strongly. The medical gatekeeping is absolutely absurd. I can't remember the last time I learned something from a doctor that I hadn't already learned myself with a quick online search. For every visit in the past decade or longer they either told me what I already knew or we were both stumped.
If drives me crazy that I can't make my own decisions about my own health, even for trivial cases. I've spent countless hours and dollars going to pointless doctor visits just to get a routine refill. Literally the conversation at most of these visits is as simple as me telling the doc that everything is fine with $medA, lets just keep it the same; followed by the doctor saying sure and writing me a new script. Such a massive inefficient waste of time.
Yep. Rank and file MDs don’t provide a whole lot of value except to people who are totally ignorant of common illnesses, health issues, or injuries.
If I had the ability to order my own tests, blood work, and adjust the dosages of my meds I could do it a hell of a lot better than the doctor I see every 6-12 months. Antibiotics are the some of the worst with this. The doc literally doesn’t even look at me, I just describe my symptoms and they go “yep sounds like an infection” — like Gods almighty you could be a web form. And it would would actually cost my insurance less which is even more infuriating.
Specialists I have found are actually useful and so I can’t really bring myself to hate that Tier 1 MDs act as a screen for people whose time is valuable.
> to people who are totally ignorant of common illnesses, health issues, or injuries.
Hundreds of thousands, no, potentially millions of people have decided to take hydrochloroquine and ivermectin as a treatment for Covid. The people who believe that they're in a position to dictate their own medical treatment are the ones who most often are "totally ignorant".
Yes, it's more expensive in isolation - in the best case scenario - to have someone competent see a doctor for a refill. But it's a hell of a lot cheaper than the rare case of someone saying "I have self-diagnosed as needing hydrochloroquine for my Covid" and then dying from an overdose after they passed out and their family took them to an expensive emergency room. Your experience is not universal.
I'm not sure that it would be necessarily the doctor that would actually gets condemned in this case. Could as well / instead be the programmer(s) that made the AI.
But this is why the current crop of AIs (which Watson itself might NOT be part of) is problematic : they're too much black boxes.
So they directly clash with the laws that assume on one hand perfect transparency of the tools used, and on the other perfect responsibility of the people using them.
How long before the use itself of a neural network is deemed to have been illegal because it broke one of the laws mandating the explanation of the algorithm that has been used to make a decision to the person that this decision targeted ?
Eventually, way down the line, this might involve giving some kind of civil status to computer programs so they can actually be made responsible.
A lot of the hope seemed to be in document summarization from the latest medical literature, plus integrating patient data from electronic medical records.
The autopsy of this could be interesting. Some of the critiques against using electronic health records previously was that many of them were designed for medical billing (I don't have a good link, but Eric Topol's "Deep Medicine" has some notes on this problem https://www.basicbooks.com/titles/eric-topol-md/deep-medicin...).
It will be interesting to see if self driving cars and the way they've been rushed to market with the same brute force marketing will meet a similar fate.
Agreed, AI is just like any software. There are good, bad, scammy and brilliant examples of it. With AI somehow though people like to use one bad example as a referendum on everything.
I think I understand why (because AI as a term is overloaded by marketing teams), but the inclination is to paint with a broad brush is still inaccurate here.
Yes. The IBM Rationale suite failed even though it wasn’t AI. It’s the IBM way they commercialize things by going to golf with execs which is the problem.
Self driving cars are just that, marketing. Tesla for all their hype have limited driver assist only and even Google who seem to have the most advanced offering only works in limited areas in good conditions and the dataset that drives it requires lots of maintenance.
The general problem is too hard, and general practice has some of the same problems. Probably less adversarial data, but there’s still litigation to be had from confusing an AI GP. Or narcotics.
In aggregate, Tesla’s FSD is demonstrably not up to the task. “Limited driver assist” is a much more fair assessment of what their software is actually capable of than the “full self driving” branding.
It's unpredictable enough that it should be considered just "limited driver assist". Only a fool would look at https://www.youtube.com/watch?v=2ub2F-UnXIU and go "yeah, that's full self-driving, all right." Slapping a "beta" label on it means nothing - you could be talking about how Gmail was in beta, or you could be talking about Fallout 76.
Tesla's marketing is extremely disingenuous, IMO. The name of your product creates expectations in peoples' minds, and sure, you can absolve yourself of liability by putting in the fine print "this isn't anywhere close to true FSD and your car might not be powerful enough to support it by the time we get there, so you gotta keep your hands on the wheel," but that doesn't make it right.
If they called it "advanced driver assist" or something similar, I'd be fine with it (it is more advanced than traditional driver assistance tools like cruise control and lane departure warnings, after all). But I doubt they could get people to pay $10k or whatever the current price is if they were more honest. Instead, they would prefer to earn more money by slapping that FSD label on it and letting people immediately turn their brains off.
Tesla advertises their technology as being on the cusp of Level 4/5 applications but legally (when defending its actions to the California DMV) argue that it is and will continue to be a Level 2 (i.e. limited driver assist) into the future and that FSD beta should not fall under regulations concerning testing of L4/L5 autonomous vehicles.
Perhaps most importantly, all legal responsibility falls on the driver, regardless of the fact that the car can cause accidents faster than a human can realistically react even if paying perfect attention.
History will see our current decade of AI and only see over promises and under deliveries.
I have decent amount of hope for AI, but corporate greed, hype by practitioners, a general explosion of various edTech companies hyping up the hype to drive online course sales and general excess of VC money is driving an embarrassing amount of AI failures.
I am sure that any fad now and in the future, will have a similar cycle.
As far as I’m concerned the only cool engineering thing IBM does anymore is POWER, which has a sort of unique memory architecture but otherwise is well behind everyone else.
What else did they do in my lifetime? They took a profitable RedHat and gutted it, they took the best Laptop line and sold it to Lenovo and almost ruined it, they tried to be a front runner in ML but blew their budget on marketing (remember Watson on Jeopardy?)
The final straw for me was watching football with a techhy friend and a commercial for IBMs “hybrid cloud” came on. There’s some executive mulling over whether to “go to the cloud” or whether to go with on premises, and they have a eureka moment where they learn about IBM hybrid cloud and they go into a board meeting and save the day. We both just burst out laughing.
IBM doesn’t make stuff anymore. That’s the core problem.
I was part of that acquisition. To be fair, Weather Channel was already running Weather Underground into the ground when they acquired it first. IBM just came in and helped them finished the job.
A huge part of it was the incompetence with which IBM pushed us to use Watson modules in our products, which I could see 6 years ago were worse than open source AI options and had no application to Weather Underground's services. They were basically toy projects being advertised as ground-breaking AI. I'm not surprised at all to see Watson finally collapsing under the weight of its vacuous claims.
>> They were basically toy projects being advertised as ground-breaking AI.
They were media events that lead to powerful media events, which in turn lead to investors pumping money into the stock price. Shareholder value is the only real profit. Watson being on Jeopardy no doubt garnered investment dollars from thousands of wealthy retirees. Those toy projects earned their keep many times over.
This is a great insight. Even if execs know $x billions will be wasted on such trendy projects (toy projects to those who know what’s going on), they will still go and spend $x billions. Why? Since it keeps the market cap going up. This positive delta in the market cap is almost 10 times more than $x billions.
It is even worse than it looks considering the opportunity cost of not sticking the money in basically risk free and cost free SP500 ETFs. Even Warren Buffett took a huge bath on IBM.
I don't mean to inject cryptocurrency cynicism & NFT skepticism into this discussion about IBM Watson...
But as someone who doesn't know the tech, but worked in the media side as a vendor at the tail end making marketing materials for IBM during their "Internet of Things" craze, I couldn't help but feel, as a laymen, so excited at what IoT (and other crazy developments like Watson) could be, because apparently IBM at the time was hitting up a buncha different vendors and just blanketing a certain sector of the marketing industry with jobs. Any colleagues I talked to were on some IBM marketing job or another.
Fast forward to about 7 years later, and I still have no clue what IoT is or does, but I sure saw a buncha marketing material flood mainstream media for a minute, with IBM saying it'd be revolutionary!
Just makes me think about web3/ crypto/ NFT's, how it's coming down hard with media campaigns, claims, yada yada. Definitely seems about hype & optics, just like IBM in their IoT media carpet bombing era.
They completely destroyed the iPhone app. It’s been, what, more than a year at least and the new version’s hourly forecast still shows the beginning of the day (1am) even if you look at it at 7pm. So many things about that app that made it great got ripped out.
I think they still make a lot of money from their legacy business, z/OS & mainframes, DB/2 etc still run basically all large banks, insurance companies and many other types of businesses. IBM can charge whatever they want for the hardware and services to support these things because their customers have no alternative. So they have just been farming this for decades, and can afford not to succeed at anything else (so they don't).
I’m not sure about the architecture, but airline booking is very complex. You basically need to support a traveling salesman algorithm. It’s also one of the original use cases for large scale computers. The Sabre airline booking program dates back to the 60’s so it’s also very legacy. The Arstechnica article (below) has a good history of the original military program and how it helped to spin out airline booking.
Modernization for these systems was probably long overdue.
I recall talking to people who worked at a company that competed w/ Sabere/IBM
There was a project they did not want to do. To avoid saying "no" and risking the relationship they quoted what they thought was an outrageous price, expecting to loose. The customer said yes. They had underestimated how much IBM had been gouging them for so long.
It's kind of similar in some ways to the traveling salesman problem. Which is not considered np-hard.
"How do you get to tokyo from paris", the cheapest, the shortest time, the least layovers, add a stop in X, etc. Not that easy.
Then you have to remember all the stuff under the hood like how are you caching all that information, how do you actually register the sales of all those tickets. Are they in your flight alliance? Are they goign through your regional airline systems too?
I would never want to touch that stuff. Way too hard. Way too many legacy systems powering it too, probably.
Every single airline they ingest probably has a phone book sized list of special cases and edge conditions that are distinct and unique. Multiply that by every airline on the platform and every consumer of the dataset and yeah… it’s incredibly complex.
Not to mention the uptime requirements and other SLAs in place (which probably are all different for each contract they sign)… yup. It’s probably a monster.
No one talks about Oracle. But they're still around. We did a major tech project to migrate off of Oracle after an acquisition of a large org that was running it.
It was a year-long effort to migrate. But it was worth it since Oracle renewal costs were going to be nearly 50% of our IT budget.
Oracle is also arcane, buggy and poorly documented (the buggy really surprised me when I first started using it). And there are much less resources online compared to the other big databases.
I did a similar year long migration off Oracle. What helped were all the automated integration tests that had been built previously. It made it so much easier to verify that everything would work after the migration.
They also do a lot of reselling. They will pitch some sort of cyber security upgrade to their client and after the client signs they will ask Akamai to onboard that client
There's still a phenomenon in advertising where it increases your awareness of a category, but you don't correctly ascribe it to the correct advertiser in that category. So funnily enough, I could still see someone going to IBM based on this ad.
HPE is kind of even more baffling. They make generic servers while, at least, IBM can sell you a brand new POWER 10 (running AIX, Linux or IBM i) or a mainframe. A new generation of mainframes is due this year and the crazy cache architectures they have shown last year is quite unique.
Thanks! I think the commercial is ok, at least it makes an attempt to explain what the product is. The IBM "hybrid cloud" commercials I found on youtube were just awful.
They have a product called Hyperledger Fabric that is marketed as an enterprise-scale permissioned-blockchain. I’ve tried to get it working before with some free credits and couldn’t figure it out.
Most big tech companies got out of or significantly scaled back their blockchain business, it is solution chasing a problem. The web3 people apparently haven’t caught on yet
I think secretly they are aiming for the digital currency aspect of blockchain, e.g. Bitcoin but couldn't understand how it works as MBA schools havn't mint out bitcoin graduates yet. Maybe in abother 10 years.
The problem is infinitely printable FIAT, controlled by corrupt and incompetent politicians that is very slow and very expensive to to transact overseas and mutable.
The solution is 100x faster, cheaper, more secure, immutable, less prone to fraud and limited in supply.
Those are problems in theory, but I don’t think most people are concerned or affected by them. I’m certainly not.
I never need to transfer money quickly between accounts — it’s never once been a problem to wait a couple days. And sure there are real economic problems with printing money, but again, the government does a decent enough job at keeping the dollar stable that it doesn’t affect me.
And there’s the fact that the US gov has tons of power to maintain the validity of the fiat dollar through legislation, and as a backup they have the use of force through police and jail (in the case of tax evasion, or avoiding the laws). Then there are international alliances, and there’s the largest military in the world also with a strong interest in maintaining the dollar’s value.
So I’m not worried about the value of the US dollar in the long term — at least I certainly trust it more than a purely technical solution with none of the US Gov benefits.
Faster: I don’t have any problem with speed of USD transactions. In fact, most transactions are faster than crypto via credit cards or cash.
Cheaper: there are $0 transaction fees for cash, and low fees for credit.
Secure: US laws do a decent enough job
Fraud: crypto exchanges get hacked and there is often no recourse — if my credit card is stolen, there are laws that protect me
Limited supply: by definition, that makes the currency deflationary, which is horrible for a growing economy. And it’s obvious in bitcoin. Nobody spends money today if it’ll be worth more tomorrow — that’s why everyone just buys and holds bitcoin as an investment, not uses it as a currency
You’re saying that you trust the government a lot in making sure the dollar value stays stale, however, it has lost 30% or more since the start of the pandemic if you look at price increases of commodities, so you are already very wrong.
It might not matter to you that sending cross border transactions have very high fees, because you live in a first world country and are rich, but 99% of the world aren’t as rich as you.
I was surprised by some companies too, until I worked outside of tech.
The whole rest of the universe needs software too. Most companies are grossly incompetent to develop it themselves. Most are things that SWEs of the type which visit HN would never, ever want to work on. IBM does that adequately well. That's "services."
If I need a tool built which will manage workflow at a management consulting firm, a custom tool for managing cases at a law firm, or some custom supply chain kludge -- the 99% of other "boring" software -- and I happen to know nothing about technology, who do I turn to?
IBM isn't a bad choice. It's a major step up from Indian firms in terms of both price and quality. It has significant in-house technology to leverage. It's a safe choice. It will usually do better than in-house IT.
I recently evaluated the business of a company which builds ships. They developed software in-house with an IT staff who weren't qualified to tie their own shoelaces. They had huge military contracts. They didn't subcontract to IBM, but it wouldn't have been a bad choice.
Honestly, I’m not sure IBM is a step up from the Indian firms. It’s certainly more expensive (like, ridiculously so) for not much more quality, if any.
Is it? Really? No. In fact it's not. Name one Indian company that ever reached 1/10th of what ibm had so that it's a candidate for seeing it on the way down.
A serious insult because it'd be much more true would be to look at it's OD, culture and demise since Gerstner. Gerstner wasn't happy with a lot of IBM slop, paper pushers, and corporate BS either. That'd keep it on track rather than spurious comparisons.
Gerstner layed of somewhere around 20% of work force, sold off tons of ibm art, real estate etc because IBM was lost ... And losing money. That says something. Spurious comparisons don't.
Labeling IBM bad because it out sources to India is a vieled insult to indians and it's culture I guess. If that's the position -- not mine --- have the galiteantry and courage to just say so.
I'm reminded of the Futurama line: do you idiots where you're from? Nobody nowhere can say no to that. American culture, OD, and common sense when it's not losing money, playing golf, splashing around shareholder cash on art or tieing up innovation in BS (all of which IBM did pre Gerstner and was called out for) expects problems fixed, brings out the best in all comers, and expects comers to be value add. Thosr that cant play that game are out.
Regrettably this has one dark corner. Management isnt so good at overseeing itself. So in really bad situations they are good at shifting blame. Well nobody said it'd be easy. Let's start by not gossiping however.
This assumes that IBM's core business is the same as their Services business. I doubt they have any overlap. They got onto the bandwagon after seeing how successful some of the early Indian services companies were (in terms of revenue) such as Infosys, Wipro, and TCS.
I would put the IT services business of Accenture, Cap Gemini, and IBM in the same bucket as the rest of the Indian firms.
> Name one Indian company that ever reached 1/10th of what ibm had so that it's a candidate for seeing it on the way down.
I'm not sure what your point is here, but based on Forbes 2000 for 2020 via Wikipedia [1], by market cap Tata Consultancy Services and Reliance are both larger than IBM. Both have grown faster than IBM since 2020. In terms of companies overall a number of other Indian companies are larger than IBM.
If you look at infotech alone, Tata Consultancy Services is the one bigger than IBM, and Infosys (>50% of IBM market cap), HCL Technologies and Wipro are all larger than 1/10th of IBM.
2020? Big deal. IBM has been around for serious time. Like I said show me an Indian company that was a tech giant for analysis on the way down. No doubt IBM has got work to do. But tata ain't no ibm. Furthermore my take stands up for Indian know how not crapping on it as others have done here. It's just that indian companies nowhere near have ibm corporate legacy. As for ibm: it wouldn't kill you to try to innovate again not react and buy innovation even if Watson was a bust
Tata is nearly half a century older than IBM. IBM is older than the TCS subsidiary, sure - TCS is "only" 54 years old. But I have no idea why that matters to your argument as it's still not clear to me why you were making the comparison.
That said, IBM does today have more employees in India than in the US, and IBMs current CEO is Indian-American, born in India and educated in part at an IIT so I can see why some would describe it that way. To me at least there's no value judgement - positive or negative - attached to that. It seems like you took offence at the comparison of IBM to an Indian company, and I can see why you'd think so in context, but I don't see why that justifies downplaying the success of companies like TCS.
> Like I said show me an Indian company that was a tech giant for analysis on the way down.
I still have no idea what you intend this to mean. TCS is a tech giant. It's the largest IT service company in the world.
As for Tata being no IBM, you're right, Tata Group is older and several times the size of IBM. The Tata Consultancy Services subsidiary alone is larger than IBM, and Tata as a whole employs about twice as many people as IBM, most in TCS. IBMs original business was thematically closer to what they still do today, I guess, but only marginally.
>> Like I said show me an Indian company that was a tech giant for analysis on the way down.
>I still have no idea what you intend this to mean. TCS is a tech giant. It's the largest IT service company in the world.
What is so tough here understand here? I've done IT for 30 years. I don't think I've used a gadget, O/S, compiler, cloud resource, dev-ops, or distributed algo from Tata once. IBM? All day long. I consulted at AT&T ... man the number of things they made I used was insane.
Moreover, given time all large companies cycle between running on all 8 cylinders to periods where marketing, paper pushers, corporate culture BS, losing contact with customers and customer satisfaction, poor quality erode the top/bottom line, lead to a loss of market power, pricing power, and so on.
Tata, assuming it ever had the towering heights IBM hit on all fronts, may be big now. But wait around long enough and Tata like most large human organizations will fall from grace too. And I bet, at it's core, outsourcing will not be found to be root-cause; related perhaps but certainly blaming the outsiders isn't wisdom. So as I said, then re-said, and say again show me one of those Indian companies *who are on a down cycle now*. The way I have contextualized it here makes for a relevant comparison.
While I'm at it: I'll say again unlike posters earlier up, I refuse to crap on IBM because it out-sources to Indian companies. Like anywhere some Indian companies suck. Some don't. Some may be on a high cycle like Tata. Those in the US doing the outsourcing maybe already sucked before outsourcing began. It's those kinds of spurious insults which are not appropriate and not my position.
There is a world of difference between a US ship building company outsourcing to India and a US tech firm intermediating that transaction:
- A US intermediator can know the climate in India and navigate the cultural differences because they do this day in day out.
- A US tech company can properly vet whom they're subcontracting to because they have engineers in-house
- A US tech company will have a contract in US jurisdiction. If there is e.g. a data leak, there is liability through US courts. A step down from that, a US company can have US-based oversight and escalation mechanisms
- Social networks and relationships matter too. If you're working with Bob from the golf course, and his company messes up, you'll see Bob again next month at the golf course and chew him out.
... and so on.
I'm not suggesting you or I (personally) should subcontract through IBM, but for a US-based non-tech firm, it can make a lot of sense.
To flip this around, whom would you rather hire to do your accounting (presuming you're not an accountant and know nothing about accounting):
- A US company which outsources to India
- A random company in India
I would go for the former, since I know there would be liability if they messed up, and they'd make sure the US tax code was properly complied with. There's nothing wrong with the latter, but I'd have no way to vet them, and if they messed up, no recourse.
> IBM isn't a bad choice. It's a major step up from Indian firms in terms of both price and quality. It has significant in-house technology to leverage. It's a safe choice. It will usually do better than in-house IT.
Having been there, I can say that IBM is no different than the other Indian tech firms like Infosys, Wipro, HCL and other. Infact, there is a rotating door of employees among IBM and other Indian firms.
1. Since the last 5 years, IBM has more employees in India than in the US or any other country [1]
2. Secondly IBM pays more that the Indian companies in India to poach employees but shortchange their US counterparts. [2]
Infact, the only difference between IBM and other firms is that the initial sales procoess is handled by American counterparts. Once the sales piece is done and the actual project starts, it is replaced by the offshore team.
I work in a role where half of our stuff is in IBM's cloud (for decisions made before my tenure). On a day in Mid-November, we started receiving alerts from our UAT and PROD environments. Logged in, all our stuff was gone. Opened a ticket and did some digging and found in our audit logs an IBM SRE had deleted all our stuff. They then told us there was no way to recover and we'd have to rebuild from scratch.
They had apparently been doing some "cleanup" and somehow our site number got on to a list. All our servers, attached volumes, subnets, load-balancers were deleted.
My boss and I spent the next 30 hours applying terraform and rebuilding anything not automated.
Would not recommend IBM Cloud. We are moving off in next 6 months.
In civilised lands the loser has to reimburse the winner's legal costs, so at no cost. If you don't live in civilised lands, well you have other problems.
I'm not sure that is as civilized as you think it is. Loser pays discourages any small company or individual from suing because the cost is too great if they lose.
Even AWS contracts are vague enough to not make this a slam dunk. They pretty much explicitly say if you don’t store stuff in multiple regions you are going to take outages/data loss.
Does your civilized legal system also force the inevitable loser to front your legal fees while the case is ongoing? Or is it possible the plaintiff with deeper pockets can just stretch things out until the legal system has bled you dry and you must withdraw?
For breach of contract and negligence, IBM were successfully sued, and then banned from all future projects, by the Queensland government in 2013. [0] Which sets you up with a nice precedent and set of documents to see their angle of attack.
> IBM will not be allowed to enter any new contracts with the State Government until it improves its governance and contracting practices.
With that ban _still live today_, it astonishes me that any corporation would trust the organisation to actually carry through with their obligations. You have to really, really, royally screw up for a government body to consider you anathema.
The old adage of "No one was ever fired for hiring IBM" is no longer true or reasonable.
> For breach of contract and negligence, IBM were successfully sued, and then banned from all future projects, by the Queensland government in 2013. [0] Which sets you up with a nice precedent and set of documents to see their angle of attack.
I mean, yes, but also think about how long a government can afford to have their lawyers pursue a case like that. If you don't have those kind of resources, it's a lot riskier.
They also have a very significant interest in pursuing it, in that they often have to follow procurement rules that prevent them from excluding vendors without good reason. If you think a vendor will be a problem in the future, getting a legal judgement in place may sometimes be necessary to save a lot of grief that a private company can avoid by just privately and quietly blacklisting the vendor in question.
We're a pretty small org, and not sure we have the organizational heft or resources to do so. That being said, the $1k discount they gave us for Nov based on the broken SLA (resources down) was kind of a slap in the face. We had our minimal core services up in 16hrs, but recorded about 100-120 internal engineering hours for config, testing, and other fallout +1 month.
When we opened the initial ticket, the IBM engineer kept saying "you should ask X why they deleted your stuff". Eventually after attaching the LinkedIn page for the IBM SRE in the audit logs, they realized something was screwed up on their side.
so I worked at IBM cloud, and can confirm this. They bought a cloud service, that by itself, and if left alone would been great. Soft(....something...) was the company... then IBM came and changed everything. I remember the SVP / President of ibm cloud showing up... talking 3 hours about how her son is so great and that we should 'follow' his example... after hour 3, man goes and interrupts and asks a question that was "please get to the point of talking about your son".
Few weeks later, massive layoffs, that triggered the warn act. So now I know how IBM works, see first hand meeting, after meeting being totally worthless. I would say stay far away from anything the touch. Just be glad you could move off their platform and not stuck using their platform with their CICD ... else you would be in living hell.
I’ve sat in an all hands like that before. Literally 50k$ an hour being wasted listening to some guy we’ll only ever see once talk about his sons 18th birthday.
I think it's a power move. Nobody got up and said, "Fuck you, I have better places to be." So they win. You probably thought it was about the business or something.
Mandating it is a power move. You can give folks the option to come back to the office if they so chose, and let others work from home if they want to.
This implies the company has set itself up to do remote work well. Not every company has, not even through the pandemic. Many are still struggling to get back to the performance they were once at.
It isn’t always a power move, even if HN wants it to be; and yes, I realize that’s an unpopular opinion here.
To be fair, it was the general manager’s bosses boss. No body was surrounded by him and by the time we were due another visit by this position, he had been promoted on.
Owner of the company spent half the meeting talking about how they take their grandkids anywhere in the world they want to go when they turn 16...I look at the audience paying rapt attention and I'm thinking 'this is a little odd'
Then he mentioned the 'merger of equals' and I thought 'this isn't good news'
Also been on one of those. One of the employees raised the fact salaries had been on a freeze for the last two years. Answer from VP doing the all-hands meeting: "My wife also wanted me to buy a new boat this year but I could not"
Everyone wanted to be on Softlayer for a time. It was THE hosting provider. I don’t know if they where any good, but the got great press coverage.
Two years ago I had to help a customer debug some weird nginx behaviour, resulting in their traffic spiking at ten times the expected rate. The IBM/Softlayer VPN required that I used Internet Explorer, but it still failed to work. We spend three month with IBM and IBM Cloud consultants to make it NOT work.
IBM destroy everything it buys. They have POWER, their mainframes and associated software left. How that keeps them afloat is a mystery.
Softlayer was solid at providing colo and dedicated servers. But they were never really architected with the cloud in mind. The pivot to cloud came later on. I always wonder why IBM didn't buy a provider like Linode.
Softlayer had the idea of API-driven bare-metal server hosting (as opposed to ticket-driven or phone-call-driven) early on, which was a big differentiator for a while. But AWS came along with an even more extreme version of API-driven hosting and they never caught up.
As an example, most network or server changes you made through the API resulted in an automated email saying your sales representative would be in touch about your order, followed a minute later by an automated email saying the change was done at $0 charge.
Gives me the unpleasant thought of how much value is destroyed and lost in these mindless corporate acquisitions. Incentives are broadly misaligned with what we should want as a society, instead investors want a payday as well as founders, and the acquiring corporation wants a fresh coat of paint and has access to the finance that can make it happen and only hurts 10 years later. In the end promising human efforts are destroyed because the rewards for doing so are too great.
OTOH the average startup is garbage held together with duct tape that naturally falls apart without the founding team who created it. By the time of acquisition it’s usually reached a point of technical debt bankruptcy. This goes hand-in-hand with an over-heated sales team pushing hockey-stick growth that will crash back down when those brand-new customers churn at the next renewal - because the product, while nice-looking, is unmaintainable garbage.
Nice payday for the founding team and the ticking time bomb is paid for out of bigcorp’s wallet. They go on to great new things and the eventual demise of their garbage pile will be blamed on bigcorp.
Not to say that large companies don’t destroy value - they absolutely do, frequently - but that the main error they make is not being able to appraise which startups are smoke and mirrors and which are legit. The rest of us are not so great at it either.
> This goes hand-in-hand with an over-heated sales team pushing hockey-stick growth
This seems like just another argument for limiting startup acquires. Perhaps if a big exit wasn't the goal, the company would focus on more long term viability.
Anyway, I don't think they big companies care as much about whether they destroy value, as long as they destroy a potential competitor.
I see competition often being less about the startup and more about which other competing big tech company could buy the startup to consolidate an existing market strategy. I’d more charitably call it “revenue protection” to preemptively acquire them.
Startup acquisitions, in the absence of astoundingly deep due-diligence should probably be placed in portfolios where a 5:1 failure rate can be tolerated. I’m not sure how such an acquisition would be compensated.
It's not just the company internally that want (needs?) those big exits, the whole VC architecture is built around shot gunning out money for the occasional huge pay off.
It's not easy to know when is the right time to jump your old trusted provider. At the beginning of the acquisition not much happens. Things degrade slowly because employees take the burden of doing the job for two people. But nobody can be subjected to the stress for too many years.
Big corporations create nothing, only abuse the good faith of employees and the cost of moving providers of small companies. I have seen that happening in tech. When small innovative companies grew they got enough economic power to not have to innovate anymore. Purchase small good companies and drain them is the new business model.
And it's a shame, there was a time that liked IBM, and others.
I stopped using Softlayer after IBM took over. I still get emails about the daily "incidents" in "IBM Cloud", as well as monthly billing notices for my $0 bill. I don't know my "IBM Id" or "Softlayer Id" to log in any more as it's been almost a decade, so I can't unsubscribe from any of it.
Relationship messages (like incident reports and bills) aren't typically covered by the CAN SPAM Act, but that law's never stopped anyone anyway. I don't have enough fingers to count the number of daily commercial emails from otherwise respectable US businesses that don't include a mailing address or don't honor opt-out requests. Cold sales mails from tech startups are a big offender...
That was the biggest problem. It wasn’t quite possible yet, at least with how IBM wanted to use it. Rometty and her executives believed their own marketing hype. It’s why, billions of dollars later, Watson Health failed because it couldn’t make better cancer treatment decisions. Watson Talent Management failed because it couldn’t make better hiring decisions. The tech was misused.
Hmm... maybe the magic in magic quadrants is in how they attract the sorts of people that will act on the information conveyed by the grid. Way better than an Ouija board for IT recommendations. Ouija is very hit and miss, really depends on what spirit you get connected with. Magic quadrants just work.
As a worker drone who has spent my career in Sector 7G, I'm continually amazed at how many business decisions seem to be based on these "magic" quadrants. We spend 12 months building a capable and flexible infrastructure on Product A, only to have our management ask us why we haven't moved everything on to Product B, which is slightly closer to the top-right corner in the magic quadrant.
I always answer, "Sure, we could, if you're fine with not other progress getting made towards your business objectives for 6 months."
I set up briefings to Gartner Analysts seeking to get our consultancy on a quad early in the mobile era.
One of them was on the earliest examples of hybrid HTML / native views in iOS. One of our engineers was implementing them in the Apple Store app.
IIRC, Gartner was not ready to split out boutique mobile dev but getting an earworm into an analyst with influence over a quad is still valuable.
I presume there is chatter on potential forming of quads before they make print.
Working these executive-influential information sources, and our firm continuing to land major app dev contracts led to an acquisition by Deloitte Digital.
A former employer tried for years to get onto the magic quadrant, and never succeeded. Until they started paying gartner for access to their “specialist knowledge”, and suddenly they were on the magic quadrant … in the lower left, with gartner pushing them to pay more to get better access.
That's a joke. If you read that drivel prepared for the stock market, you would come away thinking IBM is the biggest Cloud operator in the world. In reality of course they have just rebranded all kind of cash flow streams as "cloud" - because they know "cloud" will make the stock go up whereas "mainframe" makes it go down.
They also provide mainframe-based Linux VMs for clients that require the encryption technology built into those machines. If you need to give certain assurances by law or contract, they may be a good option. Apart from that, if you need on-demand VMs for IBM i or AIX, they are one of your only options.
I worked breifly at IBM research last century. The spent a lot of money on research (6 Billion). software, chip design and algorithms and a lot of just basic research.
But when I left to go back to school "global services" a business to business consulting division was the big up and coming division. It seems that division is where IBM decided to go. Honestly they'll just sell to some big businesses so likely you'll never hear about what they're doing.
I'll agree they seem to have lost their way. Its a shame really. They did some good things: I remember a lot of the engineers there would travel to schools and promote engineering careers.
They are in the audit business. Large companies have pockets where outsourced engineering teams have installed or forgotten to delete their outmoded software. They send in an audit team, and come up with a massive payment due. Then they negotiate with their “customers” to have them buy new software for approximately half the cost of audit payment. IBM gets new revenue (and new products to audit) and companies pat themselves on the back for averting disaster. And the new software never gets used.
My stepdad manages a team in IT for a very large, very slow company in the banking/financial sector. The decisions about what software and hosting solutions they'll use are made by execs at the upper echelons, probably over games of golf by people who don't know that much. They just know, "I really like Jim over at IBM, he's got a real swagger to his step" and "other big companies are using them" and "hell they just bought a Super Bowl commercial." So a $2M deal gets done, and IBM stays in business.
I spent 10 years at a small (<80 people) CX company that was full of intelligent, motivated employees. We were smart and quick and lean and did very good work. But we never dragged in big deals because no one at the company had that swagger/access to high-levels. The scenario you describe is dumb and ruinous and, unfortunately, true.
Big deals can really put a company in danger. If the company you work with closes or cuts the deal or whatever you could loose half your revenue. On top of that big clients can be really needy especially dinosaurs companies that aren’t nimble. They take forever to pay, have lots of meetings and unreasonable expectations and expect lots of free stuff and service because they are incapable of processing Non standard invoices due to internal politics. It’s a mixed bag to deal with the big guys
While that's true, the execs who make these decisions usually don't care about the actual implementation. Once the deal is done, it falls on their "IT division". And two things happen: Jim over at IBM still pampers the exec with a dinner or two. And the exec also suspects that some, if not most, of the problems are with his IT team.
Big companies have very strong anti kickback rules. You can get around them through board level connections but not much sort of That. Nobody Is risking 500k a year compensation over a dinner or 2.
I saw this play out first hand: a local digital agency run by a friend essentially ended up "captured" by a major player in the aerospace industry, to the point that 65-75% of their business came from $BIGCO. They grew by 100%+, had employees flying all over the world to set up for trade shows, and were making money by the truckload.
Then Covid hit, nobody wanted to fly, and $BIGCO took an earnings haircut and decided to cut back. My friend had to let dozens of people go. It ended up costing him his company because he'd neglected bringing other work into the pipeline.
Yep that’s super dangerous especially cyclical industry like aerospace. Plus aerospace companies are notorious for paying late are having unreasonable demands.
Coworker dad went from being a millionaire to living in a truck this way too.
100% agree. I know many capable developers who will never do anything other than close tickets because they cannot build relationships. Some of them do not even understand why building a relationship might be fruitful.
Big corps tend not to do deals with small corps. They don't want the small corp to become dependent on them. Simple contract termination becomes costly and litigious otherwise.
I've worked as a sales engineer/architect in teams selling to people like your stepdad's execs for almost a decade. I can 100% guarantee the sales reps and their leadership constantly practice "swagger" and remind each other of its importance. It's hilarious.
IBM is old, it's good and bad (probably not the first time they made bad decisions). Let's see if they can wash off the last decade or two that were full of mistakes.
They still do stuff but it's hard research and niche so business wise it won't make them short term success. You mention power but they also have a good hand in Quantum Computing.
They make money on those who have more than they know what to do with.
Case in point: I spent six months in a project, which at its peak had about forty people working on it. Eventually it was scrapped and replaced with a solution from IBM, which in turn ended up... not being used at all.
Overall it was a hilarious waste of everyone's time, but somehow that was okay.
Similar. Worked on a project where there were 50+ contractors to automate simple biz workflows. Run that for a few years @ their rates and you'll see how much enterprises spend on relatively simple software projects.
I understand why you're saying this. I have no idea either. However, open their 10-K and you'll find out how they make money. In fact, while their revenue and profits are declining, they still make more than $70B in revenue a year with a profit of about $4-5B, so their ability to stay in business is higher than many tech companies that are not profitable.
Extremely reliable, and extremely good at what they do.
They sure are expensive.
A lot more companies should adopt them.
Yet its going the way.
They run at scale at a lot of companies.
AS/400 / iSeries was awesome at least in the beginning.
I think it may be discontinued now.
Those machines were extremely reliable and well made.
Often companies who had bought one had no idea where it was.
Someone had set it up for them 7 years ago and after that nobody
paid attention.
Some places were better and did proper backups.
Which means stuff the right tape of a rotation into the slot.
They would also call home to tell IBM of a proper that is developing
and they would send a tech out to switch the parts prior to anyone
using it had any problem.
(and that is when the machines were sometimes hard to find.
One was buried in a closet, with tons of paper cases, paper archives.
stack buttom up to the floor.
I wish there was a way to learn mainframes that were accessible to mere mortals. Some toying around with a (almost certainly illicit) emulated copy of z/OS revealed an extremely complex, no doubt powerful, but entirely alien system that I'd have loved to get my head around, but alas, I could find no good resources.
I'm a Red Hatter, and I'm not sure what they mean either. I obviously only know my own little corner of engineering, but I've seen no signs whatsoever of being gutted. From where I stand, it's just a change of ownership that, at least for now, is completely transparent on the ground. I expect the situation to continue for as long as Red Hat keeps making money.
They haven't. I have no doubt that IBM has historically mishandled a great many acquisitions but thus far I haven't seen any changes that feel pushed by IBM.
Source: I work at Red Hat.
It's a bit of a strange comment considering it blames IBM for Lenovo's management of the Thinkpad line and a commercial that they later realized (but still haven't corrected themselves) was actually an HPE commercial [0].
Before IBM purchase: Travel to clients, build and/or fix their things, suggest improvements.
After IBM purchase: Travel to clients, build and/or fix their things, suggest improvements.
At least from my side of Red Hat I've experienced zero changes in how I go about my work. In fact, my schedule is even more packed now, we can barely keep up with the demand. As far as I can tell IBM has left us alone to do our thing. Maybe it's different for other departments.
Longtime Red Hatter here (in a non-engineering role). No "gutting" has taken place whatsoever. Thus far IBM has had an almost entirely hands-off, do-things-your-way, noninterference-in-internal-affairs sort of approach to Red Hat. That's not to say Red Hat hasn't had challenges but those likely would have developed even if it had remained independent.
I think what many people don't realise is the insane amount of research that is being done at IBM. In lots of areas, I know of quantum computing, silicon photonics, process development for integrated circuits, processors... They still file the most patents per year in the world by quite a margin (9000, the only one being remotely close is Samsung at 6000, for comparison apple and MS have 3000) and while I am not a big fan of patents, I do realise that one has to do significant research for getting this amount.
They probably could just run much of the business just on the licencing fees they get. If you think they are not doing anything you're likely not their target customer.
I don't think they do either, judging by my experience working there as an upper-level-support technician 15 years ago.
It seemed like the organization was book-ended with decent brains: engineers and front-line managers were decent to fantastic, and the upper-management seemed to be decent at the time. However, both ends seemed to be choking to death on a hundred layers of middle management. 7 years after Office Space was released and I actually had three(3) managers. Three! I had a technical manager with whom I had bi-weekly meetings where we talked about nothing, a non-technical manager with whom I had monthly meetings where we talked about nothing, and the head of my department who was the only one who meaningfully managed me in any way. (And he was absolutely fantastic.)
For example— they made some big announcements about their impending migration from windows to linux for everybody from admin assistants to sales to developers. Exciting! I loved that linux was getting more professional credibility, and my product ran on Solaris, so having a local UNIX environment would reduce some of the cognitive load for networking, scripting, etc. etc. There was no internal mandate to start the migration yet, but I was too eager to wait. I found the official image on the intranet and started writing documentation for my coworkers. It was pretty smooth! The complex GUI apps like the Lotus suite worked great! Well, as great as they did on windows, anyway. The installer was quite polished! I was excited!
I had one more thing to install— the ancient, internal defect and ticket tracking clients used by every technical worker, product designer, all of their managers, etc. Neither the intranet page for the clients nor the Linux image docs had any info. Hours later, I found a months-old internal note EoLing the Linux port, directing people to use the obtuse CLI instead. No problem— we're all technical people here, right? Problem. The API used by the GUI client supported necessary functionality the CLI didn't. That alone rendered the Linux initiative dead-in-the-water for most technical workers who'd benefit most.
I'm sure the manager who canned the Linux client was solving a very real problem, but a) a decision directly affecting company-wide strategy getting lost in the ether, and b) nobody checking to see if these big overtures were even basically feasible, embodies their organizational shortcomings. (I might have gotten some of the details wrong— it was a long time ago— but you get the gist.)
That's almost certainly why they're getting sued for purportedly blatant age discrimination, too. Managers in the middle with too much sway to have that little top-level visibility solving their problems using means that end up screwing lots of people.
That they style themselves as a technology-focused business consulting company rather than just a tech company is pretty rich.
IBM has acceptable tape systems.
Would be nice if they did not keep changing tape buffer sizes/times and other conditions without properly advertising the changes, but LTO is bad at scale so they have that going for them.
Another insult to the injury: they were doing e-commerce with WebSphere Commerce series as early as 1998, yet they could not even go beyond the limited presentation-controller-db tiered architecture, and could never imagine something like shopify.
The tech sector prints money. Large companies can leech off past heroics built by former employees for decades, even if the current employees are incompetent. A zombie company if you will.
I don’t think “doing cool engineering” has anywhere near as much to do with staying in business than you think it does. And IBM of all tech companies is the one that always was more about suits and sales than technology.
They have a very big consultancy business. Probably has a much better brand name than say Tata consulting. Plus their products like db2, websphere or openshift have thousands of businesses locked in.
IBM identified back in the 70s their core asset and were very explicit about what it was. "No one gets fired for buying IBM." Their key strategy since then has been to monetize this asset in a variety of creative, and mainly very effective ways.
Thinkpads were a great example of this. Laptops which promised decent quality and support for a high price. When the laptop market was demystified and commodified, IBM correctly got out of it - for a decent price.
If some random start-up, or even Google, had built Watson, it would have correctly been seen as a gimmick. Instead it sold literally billions of software consulting to people who thought they needed AI but actually just needed a search box with dynamic autosuggestion. Would you rather get some junior guy to hack something together using open source tools, or would you rather pay IBM 50 times as much? If you chose the former, you're simply not in the target market.
The hybrid cloud is exactly the same game - as is made quite clear in that ad, it's pitched at middle management who don't want to look like chumps for ignoring the cloud, but don't want to fuck up by moving to it.
Reputation is a difficult asset to monetize - effectively you make money from it by degrading and then destroying it. After all, if you carry living up to your good reputation, you're not extracting any advantage from it. IBM can't sell their reputation or their name to the highest bidder. All they can do is keep trawling for business lines where it gives them a comparative advantage.
It's easy to see this as unscrupulous - but their customers genuinely do get a benefit from the confidence they have in IBM.
I imagine IBM quantum computing will go to same route. IBM has become a husk of its former self — mostly marketing, and generally 5-10 years behind the cutting edge.
Anecdotally, the main business value I've seen from ML/AI tech has been in cases where
1. A basic solution shipped and made a ton of money e.g. Ads, Search, recommendations etc.
2. It is financially feasible to have a dedicated team(s) make small incremental progress on these solutions. Even very small gains are beneficial.
3. The business perceives a threat if they fall behind in this area.
The thing is that the gains on the basic solution (heuristics, off the shelf pre-trained CV model, open voice recognition) are pretty small, and if the threat of others making progress goes away - the inferred value of further investment will probably vanish as well.
Other applications which put the AI in the driver's seat (sometimes literally) seem far from production - or if they do work, then they work reasonably well using an alternate approach from what you might expect.
The only real business problem is they didn’t program Watson to do what the Healthcare industry actually wants — make more $$$$$. The last thing they want is a computer that can actually diagnose people and provide effective solutions.
> The last thing they want is a computer that can actually diagnose people and provide effective solutions.
Intimately knowing the non-profit side of the healthcare system as well as the construction and operation of data science systems, I wholeheartedly disagree with your assertion and your conclusion as being a general takeaway.
The parent comment assumed that everything in healthcare is profit-motive driven. However, there are large portions of the healthcare industry that are non-profit, that are transparent in their funding and their costs, and that are looking to implement AI to improve healthcare outcomes. Parkland Health and Hospital System, Harris Health System, University Health System are some that I am more familiar with that run with this (PHHS recently achieved HIMMS Level 7 certification, for example). These are social safety-net hospitals and healthcare systems -- they care for everyone regardless of ability to pay. They focus not only on emergency and inpatient care, but also ambulatory care, primary care, and even fund (at arm's length) community (non-profit) medicaid insurers.
On a more subjective side, I've seen a lot of folks out to make a buck, but the non-profit healthcare side has been much more focused on patient outcomes.
I have no idea what they got for the money they spent. Merge Healthcare was the most miserable work experience I have ever had. They had patents, I guess, but the actual technology was garbage. And the owner was…a piece of work, let's say that.
The inefficiencies are where all the money is made. After all, patients don’t pay and they certainly don’t pay for results.
Patients may pay for insurance, and buy the right to not worry. Insurance delivers peace of mind by with appointments, papers, and pills. Look at all the bureaucracy and money, it must be fancy and effective. In the course of producing these papers are human doctors, nurses, coders, etc. They sometimes feel a sense of human decency and help people pro bono.
Because they were indicative of Ferro’s “leadership”: flashy branding gimmicks, with nothing to back them up.
Like when he bought an orange Tesla roadster to bring to trade shows. He’d just pop an orange car in the middle of the booth. What’s that got to do with health care? I dunno.
(And this was all a while ago, but this job just always stuck in my craw, because it made “Silicon Valley” feel like an understated documentary and not a parody.)
710 comments
[ 4.1 ms ] story [ 331 ms ] threadIBM created a machine that could win at Jeopardy, not a universal expert or problem solver.
Say what you want about Google, but they didn't claim to solve any practical problems by creating AlphaZero.
IBM is its own category of tech company really… Oracle would fit the bill better.
https://www.youtube.com/watch?v=71DVIWZnOho
[0]: [Why Cities Keep on Growing, Corporations Always Die, and Life Gets Faster] https://www.youtube.com/watch?v=jOnWowd-7HQ
Anything "Watson" (together with 95% of that company - optimistically) is marred too deep in bureaucracy and yes men to do anything productive and innovative.
Basically, I don't see that Google has any incentive to break out its profits by line of business unless someone forces them to. They're better off if you just look at a black box of ad revenue and say "yeah it's all profitable, so ads are as strong as ever."
However, many jurisdictions ban them outright claiming that they a form of gambling and challenging the unregulated nature of questions leading to misaligned incentives (“When will that building burn down?”).
Yet despite these issues, the scheme can offer a neutral ground for betting against overhyped technologies or registering dissent against the policies of authoritarian regimes.
Cryptocurrency based prediction markets further protect the participants by masking or hiding their identities.
The combination of these features makes prediction markets an effective way to deliver global-scale censorship-resistant voting to the masses.
[1] https://en.m.wikipedia.org/wiki/Prediction_market
Your argument isn't with me, it's with whoever decided a prediction market should be illegal. Go change that person's mind.
The blockchain only knows about things on the blockchain itself. So someone has to do the actual data entry into the blockchain, and that person is the weakest link in any 'prediction' scheme.
Probably could be accomplished without crypto, but it can also be accomplished on some blockchains with minimal additional investment.
Watson Health seems to have been focused on selling the narrative of AI in healthcare, even though the technology wasn’t there.
The divestiture is only for IP also, and it seems most people in the group will be laid off.
The solutions we built were generally pretty good and our clients were happy, but the Watson part was never anything more than marketing,
I think somebody thought if they "humanized" AI by making it seem like it was a character, it would make AI seem all that much more closer to the dream.
On the face of it, not a horrible idea, but applied to what was essentially a bunch of separate algorithms.. pretty misleading, but that's just an opinion.
Sounds like another health care company where the exec just got convicted.
AI in general is very over stated. When it works it’s great, when it doesn’t (which is often) then you lose all trust in it.
"The plane lands safely 99% of the time" is an impressive demonstration and a completely worthless product, but if that's all you have then what can you do other than launch it?
Every single one.
So it says something about AI more than companies.
The definition of "reliable" here is also important. Usually this devolves into a series of moving goal posts ending with "if it can't do everything perfectly all the time then it's not real!"
Seems pretty obvious that anything that would do that is not human-like intelligence, and probably the search results should be taken with a handful of salt even if they stuck some impressive natural language generation after it.
Guessing "what are trousers" for king of Egypt isn't in itself an indicator the whole Watson system is flawed. Although you're right: it's an indicator the intelligence is non human-like.
Just like, from Watson's perspective, a human named John making hilariously bad guesses related to coin flips isn't in itself an indicator that John isn't intelligent either.
Just that there are some categories of knowledge or application of that knowledge that some systems are bad at handling.
Yes, it's almost perfectly dual: the things we do easily, without thinking, are hard for machines. Many things that we can only do with years of training, machines do effortlessly.
I think technology like Watson has a bright future when applied in the right way, but I think it's counter-productive to wrap it in anthropomorphic marketing, and especially to give it these direct natural language interfaces. Because that makes people misunderstand what it is.
AIs don't seem to have that "gate," and to a human, it does make them appear to be very 'foolish' machines.
My mom worked for a GP for about 20 years, and it seemed to me that most of what made that guy a doctor was bedside manner + being able to remember a lot of things. But GPs often make astounding amounts of money while leaning heavily on their staff to actually handle patients and keep the business running. I thought it could help drugs get a little cheaper too, because there wouldn't be any point in the pharma companies sending out salespeople to do lunch seminars to convince the GPs to prescribe this or that drug (this still happens).
Maybe this will still happen, but it doesn't seem imminent anymore.
My impression is that accompanying a patient is super important, it helps to understand illness, to have a plan in case of more complex treatments, etc.
Then my doctor has the ability to know me and gauge my health. She's also very good at probabilities and detecting when something really goes wrong.
I'm sure that being able to do that require a lot more than numbers.
(I'm studying data sciences, I trust them, but my guts tell me that diagnosis is in a whole different ballpark)
There are some people who will never, ever complain about anything. When they complain of severe abdominal pain, for example, you pull out all the stops immediately to figure out what's wrong, because it's probably really bad.
On the other hand, there are hypochondriacs and people will low pain tolerance. While they can certainly also become seriously ill -- and one must never forget this -- the tempo and pace of workup and order of intervention is markedly different, absent other information that shifts the pretest probabilities.
That’s me. I really, really appreciate a GP that both understands that I’m not doing it on purpose, and can reassure me that nothing is wrong, or figure out that we actually do need more testing this time.
Unfortunately it’s been years since I had one like that :/
I wouldn’t eliminate GPs from the process, but many people actually would like to hear what the robots have to say about their medical conditions. Having second opinions of this sort available might lead to better patient outcomes.
There isn’t enough humanity in healthcare to begin with. Replacement of doctors with AI sounds pretty horrific. General practice isn’t where healthcare costs are going bonkers, and it seems weird to want to cost-cut something that actually kind of works in favor of bullshit.
Know what would be a great use of AI? Something real like analyzing all of the telemetry in EMRs to provide better guidance to doctors to proactively guide people. Some CVSHealth chatbot telling me whatever is a waste of time.
I actually suspect it would be trivial to beat my doctor after 5 years of higher frequency full blood panel data collection.
10 full blood panel samples a year, have 20 million people do that for a data set we can do classification on. I think my doctor is kind of out of business then.
Will never happen in my life though with health insurance and health bureaucracy.
https://www.ondemand.labcorp.com/lab-tests/comprehensive-hea...
Yes, of course, hospital care would be better in many ways if we did have somebody who statefully understood particular patients’ needs.
But what I’m saying is, the GPs in hospitals could be replaced with stateless diagnostic AI without making hospital care any worse than it is now. And hospital care is a large part of the medical system, so only replacing diagnostics there (while leaving primary-care GPs alone) would still be a major optimization, freeing many doctors to provide better care, go into specialties, etc.
That's rarely (if ever) a 1:1 ratio. That attending physician is almost certainly juggling multiple patients. Same with the rest of the care team. There's a reason why the first thing one does when approaching a patient bed is to look at the chart.
> Some things can be documented in the patient chart but there are always gaps.
Then those gaps need closed, stat. Once those gaps are closed...
> Clinical decision support systems for partially automating diagnosis could potentially be helpful in some limited circumstances but the ones built so far mostly don't work very well.
...then this will improve considerably. Garbage in, garbage out.
And in most routine cases the diagnosis is the easy part. The hard stuff is actually working with patients and doing the hands-on procedures, which won't be significantly automated in our lifetimes.
Pattern recognition algorithms do have some promise for computer assisted interpretation of things like medical images and ECG waveforms where the input data is already in digital form. We can't rely exclusively on algorithms for patient care, but if the physician reaches a conclusion different from the human physician, then it's probably worth taking a deeper look and getting a second opinion.
...which is why we shouldn't be wasting such valuable resources (people with an aptitude for medicine) on doing such an easy, routine task all day long, no? It'd be like if chefs spent most of their time hand-grinding spices rather than cooking.
> A skilled, experienced clinician can intuit a great deal from subtle signs like skin color, breathe sounds, tone of voice, small movements, etc. / Pattern recognition algorithms do have some promise for computer assisted interpretation of things like medical images and ECG waveforms where the input data is already in digital form.
You're seemingly contradicting yourself here: you're saying that the places where ML shows the most promise, are exactly with the tasks that would best replace the things doctors are doing. The only reason that ML can't do those things, is that people aren't putting data like "a video exam of the patient by a nurse" into the chart where the diagnostic algorithm can see it / be trained on it.
This is incorrect. Doctors are assigned to patients, and if there is a complication any time or day or night the doctor is contacted to decide what to do. The entire point is so that there is one person who is familiar with the patient, who is also responsible if anything goes wrong. I don't know how malpractice would work with an AI, but given the number of malpractice cases yearly in the US it'd either be sued out of viability or have to be provided with legal immunity(possibly the worst scenario IMO)
There are researchers that conduct experiments to produce meaningful data and extract conclusions from that data. Then there are expert panels that produce guidelines from the results of that research. Most diagnostics and treatments are prescribed following decision diagrams that doctors themselves call... algorithms!
There are several limitations that prevent us from applying other AI techniques to the problem. Off the top of my head:
- We do not have the technology for machines to capture the contextual and communication nuances that doctors pick up on. There can be a world of difference between the exact same statement given by two different patients or even the same patient in two different situations. Likewise, the effect of a doctors' statement can be quite literally the opposite depending on who the patient is and their state of mind. One of the most important aspects of the GP's job is to handle these differences to achieve the best possible outcomes for their patients.
- Society at large is not ready to trust machines to make such intimately relevant decisions. It is not uncommon for patients to hide relevant information from their doctors, and to blatantly ignore the recommendations from them. This would be many times worse if the doctor part wasn't human.
- We cannot apply modern inference techniques (e.g.: deep learning) to the global problem because we have strict rules that prevent medical data collection and analysis without a clear purpose. Furthermore, these techniques tend to produce unexplainable results -which is unacceptable in this field-. As a result, there's not enough political capital to relax those rules.
I mean, China will likely do it, as long as they can capture high quality data, so there's that.
A computer cannot perform that role with the current paradigm of AI, even the worst and most arrogant doctor is more qualified leader than any computer.
Those are both people problems. Tech can't solve many people problems, especially something as entrenched as healthcare. Isn't it huge, something like 10% of the US economy?
…turns out, it’s $2.7tr!!! [2]
[1]www.tradingeconomics.com [2]https://www.statista.com/study/15826/health-care-and-social-...
To put this further into perspective: the US military budget is immense, as we know… and it clocks in at 3.7% of GDP [1]
[1] https://www.statista.com/statistics/266892/military-expendit...
If politicians are willing to pork and barrel over a random soy farm employing 2000 people, for sure they're not going to throw away, say, 5% of the US GDP and possibly 5% of all employment in the US.
I don't know how you're going to get out of it...
[1] "There were 22 million workers in the health care industry, one of the largest and fastest-growing sectors in the United States that accounts for 14% of all U.S. workers, according to the Census Bureau’s 2019 American Community Survey (ACS)."
https://www.census.gov/library/stories/2021/04/who-are-our-h...
It is happening. They are called physician assistants and nurse practitioners, "supervised" by a doctor. I assume going forward, they will take more and more of the usual pink eye/ear infection/flu and other common work that does not require 6 to 8 years of post bachelor education.
Corps can pay less, and since they have a tenth of the education, they order tons of profitable tests, consults, and scans because they don't know otherwise.
I don't know if 500hrs of shadowing after a 2yr part-time online only program that you don't need any nursing degree or experience to enter would count as highly trained or skilled. Here's a list of direct entry nursing masters programs - https://nursinglicensemap.com/nursing-degrees/masters-in-nur...
Here's Johns Hopkins doctor of nursing practice program's curriculum - https://nursing.jhu.edu/academics/programs/doctoral/msn-dnp/... - where more than half of your classes are not medicine related and which requires an astounding 1000 clinical hours and less than 10 credits a semester before you can call yourself "doctor". Most medical students will have 1000hrs after 3 months in 3rd year, where they will be expected to diagnose and come up with treatment plans vs just shadowing, and they still have 9 more months of 3rd year, 4th year, and a minimum of 3 more years in residency. Doctors will likely end up with a minimum of 15000 hours of training. The difference really is that large, and I feel bad for the patients and for the NPs who have no idea how deficient their education is. PAs have 2000hrs of clinical experience. Here's a chart - https://i.imgur.com/Cj5z4f8.jpg
I don't have anything against NPs when the supervision is close, but more and more doctors are put into positions where they are acting as liability sponges for de-facto independent NPs/PAs.
Here are a few studies - (CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625
Comparing urgent care visits between MD/DOs and Midlevels. Doctors saw more complicated patients, addressed more complaints and deprescribed more. https://link.springer.com/article/10.1007/s11606-021-06669-w
NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullar...
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696
The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)...
Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m...
Honestly, if not for the weirdness of the US system, mid-level providers shouldn't exist. But we are where we are. There absolutely is no room for independent practise for mid-level providers.
Hence the purpose of managed care organizations (MCOs, health insurance companies) employing people to approve and deny (or design systems that approve or deny) payment for unnecessary tests, consults, and scans. And in a taxpayer funded system, the government employs people to performs the same roles.
https://www.chcs.org/its-not-just-risk-why-the-shift-to-valu...
It’s a very polarizing topic in medicine that patients generally aren’t privy to. Especially for resident physicians who often make half as much as these midlevels yet have more education, there’s a lot of bitterness. The federal government is ultimately to blame… having a fixed number of residency spots to artificially limit the supply of new physicians is terrible, and this is the predictable result.
I think hospitals support inefficient midlevels because they can bill patients for the increased resource usage, but it’s not good for the system overall when unnecessary scans and consults are done, and more complex patients don’t get comprehensive care. Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.
There already was a tiered system, with rich people being able to buy concierge medicine and getting preferred treatment based on who knows who on the hospital's board or if their name is on a wing of the hospital.
The change now is a more visible and more granular price segmentation.
Healthcare providers with greater proportion of NP/PA will be selling for cheaper, so MCO will sell access to only them in their lower price plans, and healthcare providers where you get to see doctors will be in higher price plans.
This already happens, especially with many healthcare providers not accepting lower reimbursed Medicaid patients.
Basically, they are watching their expected wealth / purchasing power be reduced.
All this, and if you don’t complete your residency, you have no prosperous future as a doctor. You might re-match to another residency if you’re very lucky. The hospitals know this and act accordingly. Residents and even medical students paying tuition (!) were assigned to treat COVID patients and couldn’t really decline without risking the future they’re heavily invested in.
Keep in mind, the federal government pays ~150k per year to the hospital for having the resident. Yet the residents are often more indentured workhorses than trainees. It’s not uncommon for entire departments to run overnight with only residents, but no attending physicians.
Now imagine being in this situation, and not being allowed into the “providers lounge” because you’re a resident. Or using a broad-spectrum antibiotic instead of something more specific and being scolded for poor antibiotic stewardship, while the NP who has “completed their training” can’t even properly decide antibiotics are indicated some of the time. And if that NP were ever treated the way a resident is, they could go get a job at the hospital on the other side of town and start in a week.
I agree that Congress should increase funding for residency programs.
https://www.ama-assn.org/education/gme-funding/ama-seeks-mor...
There’s definitely a trade off between resources devoted to education vs. acceptable risks from failed procedures, missed/delayed diagnoses, and increased utilization of imaging and referrals (and the physician radiologists and others who participate in that - it goes full circle). Physicians now are probably on one extreme end of that, and midlevels on the other.
On the topic of servicing rural areas… the problem is that nobody with better options (which includes midlevels) wants to live in these places. These educated, high-earning people want to live in urban areas, and they can. CMS has tried to incentivize this with billing by offering higher reimbursement rates to rural places that have a midlevel on staff. That’s about it, though.
Or the problem is that people are not offered enough money to make the sacrifices they would make by living in rural places.
If midlevels can successfully detect complicated cases to a supervising physician, and handle a whole lot of other care independently... and the net result is equivalent outcomes... this isn't a massive win? You've conserved the really expensive and contended resource for where it's needed and not made anything worse...
#1 - Funky/misleading statistics - Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients. It's not claiming that of any randomly selected patient, regardless of who they see, the outcome is the same. Therefore, if uncomplicated patients saw physicians, outcomes for the physicians could improve. In primary care managing hypertension or diabetes, this isn't as pertinent. For something like anesthesiology, it's more so counting how many times shit hits the fan, and brain cells die when the anesthesiologist takes time to be summoned.
#2 - They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here! The patient no longer has use of their interphalangeal joints. The physician would probably try to shine a light through it, note the patient's Scandinavian ancestry and family history of plantar fasciitis, and tell them to live with it and come back if it changes.
No resources were saved here, but the patient's DASH score (disability of the arm, shoulder, and hand) is still 0 so the outcomes are the same.
This happens all the time.
#3 - Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.
#4 - It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor... in many places, that doesn't necessarily need to be an anesthesiologist, and the surgeon performing the procedure can suffice. The AANA recently changed its name to the "American Association of Nurse Anesthesiology"... It used to be "Anesthetists". The CEO and president (two different people) of the American Nurses Association both refer to themselves as "Doctor" in a healthcare setting even though one holds a DNP and the other a PhD. It's pervasive.
The studies I've seen have compared practices where NPs are seen first vs. physicians are seen first.
> They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here!
Your claim is this kind of excessive testing and referral doesn't happen with physicians? Do you have some kind of evidence this is more common with NPs?
This kind of overtesting leading to unnecessary procedures and bad outcomes has been pervasive through care in the US. Don't blame it on NPs.
> Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.
Ditto
> It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor...
Welp, we're not creating anywhere near enough residencies to create enough physicians to do the work, so I'd suggest we'd figure out ways to either do that or use people with lower levels of training well (preferably both!).
The private ones might the ones in the public system at least in my country need to see a patient every 10 minutes to keep their heads above water.
It's funny because it's the complete opposite of what family medicine was supposed to be. The doctors were supposed to live and work in those towns so they could get to know the population and form stronger bonds with the community. Instead, they either burn out quickly or move on to far better working environments, specialization or not. Some of these public healthcare units don't even have sinks you can use to wash your hands.
That sounds like a lot of professions, engineering management included :-)
I've been to private practices where every day at lunch or near end of day there would be some drug rep with food for all the staff.
And a psychiatrist that had stacks of free samples of drugs.
Even contact lenses are marketed with free samples.
Sure, there may be some excesses (although the truly major perks like entire vacations dressed up as a "conference" no longer exist), but I would much rather have doctors be aware of new drugs and yes, subject to marketing pitches, than have these drugs languish (eventually leading to drugs not being created) because nobody knows about them.
https://www.isms.org/CME/Medical-License/License-Requirement...
[1]: https://www.mbc.ca.gov/Licensing/Physicians-and-Surgeons/Ren...
Even if a practitioner took it seriously and wanted to get a real education about actual medical issues, they aren't going to find coverage of brand new drugs in an educational setting unless it was arranged by the drug companies themselves.
https://www.netce.com/specials.php?productid=MD22X,MDSUB
But.... journal publishers exploit their monopolies, and conferences are funded by corporate sponsors. So perhaps they're not so different.
With some other mechanism that doesn't have major conflicts of interest? Like, I don't know, attending to actual courses, like any other profession that requires continuing training.
They are supposed to study. Continuously.
Merck, Dec 2021: https://www.nejm.org/doi/full/10.1056/NEJMoa2116044
AstraZeneca, Jan 2022: https://www.nejm.org/doi/full/10.1056/NEJMoa2112431
https://www.ahajournals.org/doi/pdf/10.1161/HYPERTENSIONAHA....
There are courses available if you wish to be taught. There are events where people present new developments. There are paid sites like UpToDate. Even textbooks eventually get new editions and there's always plenty of fundamental science in them that doesn't change
The authors have no conflict of interest to declare, but declare lecture honoraria or consulting fees as follows: T.U., Bayer, Boehringer Ingelheim, Hexal, Vifor Pharma; C.B., Servier, Menarini, Merck Pharma, Novartis, Egis, Daichy Sankyo, Gilead; N.R.P., Servier, Pfizer, Sanofi, Eva Pharma; D.P., Torrent Pharmaceuticals; M.S., Medtronic, Abbott, Novartis, Servier, Pfizer, Boehringer-Ingelheim; G.S.S., AstraZeneca, Menarini, Pfizer, Servier; B.W., Vascular Dynamics USA, Inc, Relypsa, Inc, USA; Daiichi Sankyo, Pfizer, Servier, Novartis, Menarini, Omron; A.E.S., Omron, Novartis, Takeda, Servier, Abbott.
I thought we were talking about direct marketing by pharmaceutical company representatives by the way. It is of course impossible to separate modern medicine from the pharmaceutical industry since many therapies depend directly on them. It's still the doctor's job to figure out which medicines are actually good and what's merely some salesman's product.
Scientific articles are published and read by the community. There are, for example, social media and messaging groups where doctors will post and discuss articles, including their methododology and limitations. There's always the possibility that the study could actually be relevant.
Drug company representatitives talk to doctors in private in order to try and convince them to prescribe drugs. Like all marketing, there's an inherent dishonesty to it. You always assume they're overstating the positives, downplaying the negatives and ignoring alternatives. Doing this is actually the doctor's job. It's our job to pick these claims apart and figure out what's true and what isn't so that patients don't have to do it.
Doctor-drug industry relationship is at its healthiest when they're just giving doctors free samples of the drugs they were already going to prescribe anyway. Doesn't change the doctor's conduct and helps patients with free medicine. Doctors are already going to prescribe angiotensin receptor blockers for hypertension, drug company representatives won't change that. They can and should provide free samples though, free medication helps everyone.
Everything a drug company does is ultimately about selling more drugs. It's not limited to the drug reps.
> they're overstating the positives, downplaying the negatives and ignoring alternatives
Again, not at all exclusive to drug reps. This behavior can be traced all the way back to Phase I of the clinical trial.
Your position in this thread makes no sense. I stated the drug reps help doctors stay up to date on the latest drugs and treatments, you disagreed and said doctors should "study. continuously." What should they study? Articles sponsored by the drug companies. How can you square that? Further, I'm sure you're aware that only a tiny percentage of doctors actually read the fancy journals and fewer understand the statistics and the details (perhaps those are the docs who sit around on the message boards you mention). For the other 90+%, the drug reps are the conduit who deliver relevant info to doctors. Ate they aggressive? Yes. Sneaky? Sometimes. Ultimately, do they help doctors discover drugs that help their patients? Unless you believe the drugs being approved by the FDA are ineffective, the answer is yes.
No conflict of interest, except they're directly paid by drug companies. That's the sort of thing you'd expect to see in a banana republic, not established medicine. It should call the integrity of the entire system into question, frankly.
Do you really want to ban all interactions between researchers/clinicians and drug companies?
These COI disclosures also strike me as hard to interpret. It’s certainly possible that some of these people are deeply invested in a company and are pushing its particular therapy hard to buy a new boat or something. However, I’d bet many of them are $250 to participate in a focus group, or free conference registration to be in a panel. It’s important to know who’s buttering the authors’ bread, but it’d be helpful to know how much it’s being buttered too.
This document https://www.researchamerica.org/sites/default/files/Policy_A... states that in 2017 private industry spent $121 billion on Medical & Health R&D Expenditures in 2017 compared to $39 for the federal govt ($32 of which is NIH). $121 billion in a single year -- I honestly assumed the number was in millions till I re-read it.
This article https://www.baltimoresun.com/health/bs-hs-trial-funding-2015... says "Industry funds six times more clinical trials than feds"
You are probably right that the drug companies are (not surprisingly) focused specifically on drugs while NIH research is more general and widespread. But that is still a very large difference.
I mean, yeah? If a shoe company required you to buy a shoe before trying it on without free returns, the shoe may as well not exist.
In my experience at a specialized neurology practice: they wait outside until the doctor is free, then knock on the door and ask if they have a moment. They would almost always get straight to business, never wasted more than half a minute of people's time socializing.
Right, but there would be a lot of point in making deals with whoever builds Watson-like devices, to turn them ever-so-slightly more likely to prescribe one drug over another or make one diagnosis over another. It might even be cheaper than hiring and sending out a bunch of salespeople.
If we want to reduce costs, we need to move to lower level providers like a LPN or CRNP. Most people coming into a GP have the flu or an ear infection or .... and that can be handled by them. There will be one MD and to handle complicated cases and to supervise. We've already switched so that intake is done by CNA making $15/hour. In the US at least working at FAANG pays far more than being a GP.
Not just FAANG, either.
The assertion by grandparent poster that GPs are "astoundingly" well paid is bonkers.
According to the Bureau of Labor Statistics, the mean salary of "family and general practitioners" in May 2020 was $214,370 [1]. This figure includes salaries from GPs throughout the country (i.e., not just in the Bay Area).
You can also look at median salaries. According to the BLS, all ten of the occupations with the highest median incomes in the U.S. are medical occupations [2]. "Family medicine physicians" are 10th on this list.
[1] https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...
[2] https://www.bls.gov/ooh/highest-paying.htm
Many specializations come with very low job opportunities, being a GP is very stressfull: low paid assembly line type of work, a GP is expected to see 6 patient per hour, do home visits, follow up with patients and hospitals, and run a practice, manage employees, follow lots of trainings, etc. Having your own practice as a GP is not very popular any more, a lot of GP just want to freelance part time, not having the additional stress of running a practice.
At some point, the (possibly subpar) GP will be a costlier decision (whether in dollars/time/frustration).
Just like grocery stores having 10 self-checkouts and 1 cashier.
Perhaps this indicates a major gap in your visibility into and understanding of modern medical practice?
> My mom worked for a GP for about 20 years, and it seemed to me that most of what made that guy a doctor was bedside manner + being able to remember a lot of things.
"being able to remember a lot of things" -- Yes, absolutely. This is an area where AI-assisted decision support (like Watson) could be, and I hope will be, extremely valuable.
OTOH, you also rightly recognize bedside manner -- as anyone who has been a patient or a patient's family caregiver will attest, this is an essential component of core, and I think likely also the healing process. We won't get this from a machine until there is a true general purpose AI, at which point I expect an AI singularity anyway.
But consider that there are other factors of the practice of general medicine that you haven't even touched upon. For example, liability: In the office you envision, where Watson/AI makes medical decisions and these are executed by other roles like nursing, where does ultimate responsibility (and legal liability) lie? Remember that Watson outputs probabilities -- suppose the following:
Chance of disease X: 89% Chance of disease Y: 10% Chance of disease Z: 1%
If disease X, intervention A has an 80% probability of success. However, if disease Y, intervention A has an 80% probability of harm.
(before you object that this is contrived, this represents a realistic situation I encountered recently, where intervention A is high dose steroids)
Now, will we put the onus on the patient to select an intervention? I don't think that would be very popular. While I certainly do not advocate paternalism, when faced with difficult decisions quite many people openly defer to their physician.
> But GPs often make astounding amounts of money
I suppose this could be true for some definitions of "astounding," but it's generally accepted that GP/"primary care physician" pay is essentially the lowest of all specialties , which is a major contributor to lack of access to primary care in industrialized countries (while you'll not have a hard time finding a private pay dermatologist, for instance)
ANd on top of this, we are posting on HN where a mid level software engineer total comp can EASILY outpace the average US primary care physician salary.
> while leaning heavily on their staff to actually handle patients and keep the business running.
Do not all professionals and business executives rely on highly trained staff as force multipliers? This is a fundamental principle of the advancement of human economies. It is grossly inefficient to operate with individuals as "jack of all trades" when they can instead each become specialized to support a bigger or broader goal.
By "leaning heavily on their staff to actually handle patients and keep the business running" are you suggesting that the primary care physician should be performing check-in, insurance verification, rooming, vitals measurement, blood draw, medication administration etc? That is a certain recipe for massively decreased throughput and shortages/decreased access to primary care.
> I thought it could help drugs get a little cheaper too, because there wouldn't be any point in the pharma companies sending out salespeople to do lunch seminars to convince the GPs to prescribe this or that drug (this still happens).
This has been massively curtailed for 20+ years, at least in the US. I am not sure about other countries. But overall I think this is a seriously minor portion of the (exorbitant) price of medications in industrialized countries.
In any case, I doubt it would make much of an imp...
Most of what the doctor is doing is a type of modern shamanism though. Person doesn't feel good, so the doctor orders a useless test, test comes back negative so the person feels better. Then we complain health care cost too much.
10 full blood panel samples a year with other bio-metric data and a data set of 20 million people to do classification on would crush the doctor over time.
This bullshit health system though makes it impossible to have any real innovation at a mass scale. We will never have personal higher frequency medical data in my lifetime that would actually hugely improve the system and cut most of the cost out.
Every dollar spent coming up with the next automated imaging diagnosis model would be better spent on a model that encourages people to get up and exercise 5x/week, quit smoking (or never start), and get their colonoscopy. Once the patient is presenting to the doctor with heart failure, coronary artery disease, carotid stenosis, COPD, colon cancer, etc. the battle is already lost.
Complain all you want about the healthcare system holding data back. You don't need the healthcare system to make the biggest impact on people's health.
—- I’ll add that your shamanism comment sounds like the typical bs that the 20-something software engineer, who thinks they know everything because they make more than 100k a year and have never had to go to a doctor for anything other than strep throat or generalized anxiety disorder let alone spent anytime in a hospital other than to visit family members, that are everywhere on this site loves to say about physicians or other healthcare workers to shit on them.
Person doesn't feel good. Mild flu-like symptoms. There's a good chance that the patient will get better if I do literally nothing. However, I also know that it could be X, Y, Z... So I order a test to prove that it's not those diseases because if it turns out to be them it would make me guilty of gross negligence.
Concrete example: symptoms of hypothyroidism are similar to depression, therefore you must rule out hypothyroidism in order to diagnose depression.
> 10 full blood panel samples a year
Why? Where's your evidence that this waste of money will benefit anyone? Even yearly screenings are sometimes questioned in medicine and they do have evidence backing them up showing reductions in mortality. What are you even trying to find?
Also, because we haven’t done this at scale, we don’t know the true baseline for most people who may have something on the blood panel samples but never get tested because they are asymptomatic. So then we have this whole group of people with recommended treatment because of the results, even though they are asymptomatic. And they are treated, which then leads to increased costs and side effects…
And now we’ve effectively increased medical costs and decreased quality of life for asymptomatic patients. BUT - if we do it with just a drop of blood, we might be able to start a startup and raise some funding… We could call it Thermos or something…
There are just too many unknowns and fiddly things going on with human bodies
edit: Haha, I guess Tex's sibling comment makes a good point though..
I’ve seen this in Japan (ish), but in the Netherlands it’s definitely the GP’s doing most of the job. The assistant just does bookings and waves me in when it’s my turn.
Come up with a way for better patient outcomes to result in higher profits and you'll see advances in patient care real damn fast.
I have other solutions, but there's no point in listing them because nobody will implement them (for the same reason that one won't be: profits over patients)
Sure, that, and recognizing patterns and adjusting medication and being able to use good judgement for when to escalate to a referral for a specialist. But that's a lot!
I actually go to a teaching hospital for my primary care. It means I get seen by residents, and almost always also by very experienced teaching doctors. It ends up meaning that I get more time and attention by people who are actively learning and trying hard to do the right thing. The trade-off is there's no long-term trust relationship, but I am OK with that. I've also experienced care from elderly family doctors who run a "one-man-band" with a nurse and a receptionist, they're nice but I think I get better care at a teaching hospital.
That’s exactly right, but there’s nothing wrong with that.
A good doctor’s memory of patients spanning decades of a career and all of the various treatments that they did or did not respond to is very valuable. It’s a good thing that they offload as much as possible to other people so they can focus on doing what they do best.
As lame as it may be, but I just used the McDo kiosk for the first time.
Why? I'm a very infrequent customer at McDo and have 0 knowledge of options and combos, but also remember the mutual annoyance when previously asking for menu details from a min-wage clerk.
In a perverse way, the kiosk gives that power to choose back to me, the customer. At the same time relegating the supposedly more able humans to even less meaningful role.
This worked quite right in this case. I can see this approach applicable as well for some medical need that could be mapped onto a sequence of a "few" choices.
This could be resulting in some assistive pre-screening report.
Well, that's the stuff the assistants do at the beginning of a doctor visit. Not that different from a slot-operated scales of ancient times.
But in the end, I still want to see an immediate human responsibility in such transaction. By the same token, a GP won't be leaning heavily on such "assistive report" and would still go on and ask all of the questions again, as trained, as allotted, as billed.
Each doctor visit begins as a custom solution, no matter how cookie-cutter it turns out to be at the end. That's what we expect and that's what it ends up being billed to us.
I could see them making a comeback with crypto but not the way we think about it today. Instead, inter-enterprise operations infrastructure.
It turned out that under the hood they were just using conventional distributed database technology. All marketing in order to get multiple companies to work together on shared systems.
Not quite, check out Corda's R3 project - it's already being widely used in enterprise and projects are being built on top of it.
https://www.businessinsider.com/ibm-watson-office-tour-2016-...
Medical diagnosis is a trivial problem for machine learning to beat humans. Humans are terrible at this.
The problem is there is not even the concept of high frequency medical data. Imagine machine learning in quant stock trading with samples once a year. Of course it isn't going to work.
The problem is all in the externalities. Doctors don't want AI. They can see the automation path and their bank account change down the line quite clearly. Not to mention most doctors don't know anything about data science so how can you have any faith in the algorithm prediction? No one wants to be the test case and then get a law suit. "I was just following what the computer said was correct". Wrong answer, pay up.
The real irony to me is in a 100 years people look at the current medical system as complete quakery. Literally have everything right now to build medical super intelligence but stuck with the human doctors doing the exact same things from 50 years ago.
If drives me crazy that I can't make my own decisions about my own health, even for trivial cases. I've spent countless hours and dollars going to pointless doctor visits just to get a routine refill. Literally the conversation at most of these visits is as simple as me telling the doc that everything is fine with $medA, lets just keep it the same; followed by the doctor saying sure and writing me a new script. Such a massive inefficient waste of time.
If I had the ability to order my own tests, blood work, and adjust the dosages of my meds I could do it a hell of a lot better than the doctor I see every 6-12 months. Antibiotics are the some of the worst with this. The doc literally doesn’t even look at me, I just describe my symptoms and they go “yep sounds like an infection” — like Gods almighty you could be a web form. And it would would actually cost my insurance less which is even more infuriating.
Specialists I have found are actually useful and so I can’t really bring myself to hate that Tier 1 MDs act as a screen for people whose time is valuable.
Hundreds of thousands, no, potentially millions of people have decided to take hydrochloroquine and ivermectin as a treatment for Covid. The people who believe that they're in a position to dictate their own medical treatment are the ones who most often are "totally ignorant".
Yes, it's more expensive in isolation - in the best case scenario - to have someone competent see a doctor for a refill. But it's a hell of a lot cheaper than the rare case of someone saying "I have self-diagnosed as needing hydrochloroquine for my Covid" and then dying from an overdose after they passed out and their family took them to an expensive emergency room. Your experience is not universal.
But this is why the current crop of AIs (which Watson itself might NOT be part of) is problematic : they're too much black boxes.
So they directly clash with the laws that assume on one hand perfect transparency of the tools used, and on the other perfect responsibility of the people using them.
How long before the use itself of a neural network is deemed to have been illegal because it broke one of the laws mandating the explanation of the algorithm that has been used to make a decision to the person that this decision targeted ?
Eventually, way down the line, this might involve giving some kind of civil status to computer programs so they can actually be made responsible.
- 2022-01-05: "Scoop: IBM tries to sell Watson Health again" https://www.axios.com/ibm-tries-to-sell-watson-health-again-...
- 2022-01-07: "IBM reportedly shopping Watson Health just as healthcare gets hot" https://techcrunch.com/2022/01/07/ibm-reportedly-shopping-wa...
A lot of the hope seemed to be in document summarization from the latest medical literature, plus integrating patient data from electronic medical records.
The autopsy of this could be interesting. Some of the critiques against using electronic health records previously was that many of them were designed for medical billing (I don't have a good link, but Eric Topol's "Deep Medicine" has some notes on this problem https://www.basicbooks.com/titles/eric-topol-md/deep-medicin...).
I think I understand why (because AI as a term is overloaded by marketing teams), but the inclination is to paint with a broad brush is still inaccurate here.
https://youtu.be/uClWlVCwHsI
Tesla’s safety claims are wildly overstated, as documented here:
https://news.ycombinator.com/item?id=26855608
In aggregate, Tesla’s FSD is demonstrably not up to the task. “Limited driver assist” is a much more fair assessment of what their software is actually capable of than the “full self driving” branding.
Tesla's marketing is extremely disingenuous, IMO. The name of your product creates expectations in peoples' minds, and sure, you can absolve yourself of liability by putting in the fine print "this isn't anywhere close to true FSD and your car might not be powerful enough to support it by the time we get there, so you gotta keep your hands on the wheel," but that doesn't make it right.
If they called it "advanced driver assist" or something similar, I'd be fine with it (it is more advanced than traditional driver assistance tools like cruise control and lane departure warnings, after all). But I doubt they could get people to pay $10k or whatever the current price is if they were more honest. Instead, they would prefer to earn more money by slapping that FSD label on it and letting people immediately turn their brains off.
Perhaps most importantly, all legal responsibility falls on the driver, regardless of the fact that the car can cause accidents faster than a human can realistically react even if paying perfect attention.
https://www.jurist.org/commentary/2021/09/william-widen-phil...
I have decent amount of hope for AI, but corporate greed, hype by practitioners, a general explosion of various edTech companies hyping up the hype to drive online course sales and general excess of VC money is driving an embarrassing amount of AI failures.
I am sure that any fad now and in the future, will have a similar cycle.
https://en.wikipedia.org/wiki/AI_winter
https://en.wikipedia.org/wiki/Gartner_hype_cycle
As far as I’m concerned the only cool engineering thing IBM does anymore is POWER, which has a sort of unique memory architecture but otherwise is well behind everyone else.
What else did they do in my lifetime? They took a profitable RedHat and gutted it, they took the best Laptop line and sold it to Lenovo and almost ruined it, they tried to be a front runner in ML but blew their budget on marketing (remember Watson on Jeopardy?)
The final straw for me was watching football with a techhy friend and a commercial for IBMs “hybrid cloud” came on. There’s some executive mulling over whether to “go to the cloud” or whether to go with on premises, and they have a eureka moment where they learn about IBM hybrid cloud and they go into a board meeting and save the day. We both just burst out laughing.
IBM doesn’t make stuff anymore. That’s the core problem.
A huge part of it was the incompetence with which IBM pushed us to use Watson modules in our products, which I could see 6 years ago were worse than open source AI options and had no application to Weather Underground's services. They were basically toy projects being advertised as ground-breaking AI. I'm not surprised at all to see Watson finally collapsing under the weight of its vacuous claims.
They were media events that lead to powerful media events, which in turn lead to investors pumping money into the stock price. Shareholder value is the only real profit. Watson being on Jeopardy no doubt garnered investment dollars from thousands of wealthy retirees. Those toy projects earned their keep many times over.
https://www.macrotrends.net/stocks/charts/IBM/ibm/market-cap
It is even worse than it looks considering the opportunity cost of not sticking the money in basically risk free and cost free SP500 ETFs. Even Warren Buffett took a huge bath on IBM.
But as someone who doesn't know the tech, but worked in the media side as a vendor at the tail end making marketing materials for IBM during their "Internet of Things" craze, I couldn't help but feel, as a laymen, so excited at what IoT (and other crazy developments like Watson) could be, because apparently IBM at the time was hitting up a buncha different vendors and just blanketing a certain sector of the marketing industry with jobs. Any colleagues I talked to were on some IBM marketing job or another.
Fast forward to about 7 years later, and I still have no clue what IoT is or does, but I sure saw a buncha marketing material flood mainstream media for a minute, with IBM saying it'd be revolutionary!
Just makes me think about web3/ crypto/ NFT's, how it's coming down hard with media campaigns, claims, yada yada. Definitely seems about hype & optics, just like IBM in their IoT media carpet bombing era.
That can't be the reason. Over the last 5 years, IBM underperformed the S&P 500 by 16%/year.
A shame…
Those were the days…
Fun fact: a few years back Amadeus employees were in the top 15 of k8s contributors by company.
If this is surprising to you, you have no idea.
It's a 24/7 business as a start. Multiple flights, multiple fares, multiple ways of booking a flight, airline agreements, etc
Modernization for these systems was probably long overdue.
https://www.ibm.com/ibm/history/ibm100/us/en/icons/sabre/
https://arstechnica.com/science/2022/01/the-most-important-c...
There was a project they did not want to do. To avoid saying "no" and risking the relationship they quoted what they thought was an outrageous price, expecting to loose. The customer said yes. They had underestimated how much IBM had been gouging them for so long.
"How do you get to tokyo from paris", the cheapest, the shortest time, the least layovers, add a stop in X, etc. Not that easy.
Then you have to remember all the stuff under the hood like how are you caching all that information, how do you actually register the sales of all those tickets. Are they in your flight alliance? Are they goign through your regional airline systems too?
I would never want to touch that stuff. Way too hard. Way too many legacy systems powering it too, probably.
See also: https://franz.com/success/customer_apps/data_mining/itastory...
Which is now owened by google and probably powering google flights lol
Not to mention the uptime requirements and other SLAs in place (which probably are all different for each contract they sign)… yup. It’s probably a monster.
No one talks about Oracle. But they're still around. We did a major tech project to migrate off of Oracle after an acquisition of a large org that was running it.
It was a year-long effort to migrate. But it was worth it since Oracle renewal costs were going to be nearly 50% of our IT budget.
b) Large global talent pool of Oracle experts.
c) First-class professional support.
Not everyone is looking to innovate on their database. Many just want something that is reliable and easily supported.
Ah, this was a sarcastic comment! It was, right?
https://youtu.be/0EL3ZkcMNS4
This commercial still makes me laugh. The way she finishes his sentence with “our digital transformation” is the kicker.
https://petri.com/blockchain-bust-microsoft-joins-ibm-with-b...
Genius!
The solution is 100x faster, cheaper, more secure, immutable, less prone to fraud and limited in supply.
It’s a very simple calculation.
whut
I never need to transfer money quickly between accounts — it’s never once been a problem to wait a couple days. And sure there are real economic problems with printing money, but again, the government does a decent enough job at keeping the dollar stable that it doesn’t affect me.
And there’s the fact that the US gov has tons of power to maintain the validity of the fiat dollar through legislation, and as a backup they have the use of force through police and jail (in the case of tax evasion, or avoiding the laws). Then there are international alliances, and there’s the largest military in the world also with a strong interest in maintaining the dollar’s value.
So I’m not worried about the value of the US dollar in the long term — at least I certainly trust it more than a purely technical solution with none of the US Gov benefits.
Faster: I don’t have any problem with speed of USD transactions. In fact, most transactions are faster than crypto via credit cards or cash.
Cheaper: there are $0 transaction fees for cash, and low fees for credit.
Secure: US laws do a decent enough job
Fraud: crypto exchanges get hacked and there is often no recourse — if my credit card is stolen, there are laws that protect me
Limited supply: by definition, that makes the currency deflationary, which is horrible for a growing economy. And it’s obvious in bitcoin. Nobody spends money today if it’ll be worth more tomorrow — that’s why everyone just buys and holds bitcoin as an investment, not uses it as a currency
It might not matter to you that sending cross border transactions have very high fees, because you live in a first world country and are rich, but 99% of the world aren’t as rich as you.
NYC Covid pass was build on blockchain. Such a goddamn pointless waste of time
The whole rest of the universe needs software too. Most companies are grossly incompetent to develop it themselves. Most are things that SWEs of the type which visit HN would never, ever want to work on. IBM does that adequately well. That's "services."
If I need a tool built which will manage workflow at a management consulting firm, a custom tool for managing cases at a law firm, or some custom supply chain kludge -- the 99% of other "boring" software -- and I happen to know nothing about technology, who do I turn to?
IBM isn't a bad choice. It's a major step up from Indian firms in terms of both price and quality. It has significant in-house technology to leverage. It's a safe choice. It will usually do better than in-house IT.
I recently evaluated the business of a company which builds ships. They developed software in-house with an IT staff who weren't qualified to tie their own shoelaces. They had huge military contracts. They didn't subcontract to IBM, but it wouldn't have been a bad choice.
A serious insult because it'd be much more true would be to look at it's OD, culture and demise since Gerstner. Gerstner wasn't happy with a lot of IBM slop, paper pushers, and corporate BS either. That'd keep it on track rather than spurious comparisons.
Gerstner layed of somewhere around 20% of work force, sold off tons of ibm art, real estate etc because IBM was lost ... And losing money. That says something. Spurious comparisons don't.
Labeling IBM bad because it out sources to India is a vieled insult to indians and it's culture I guess. If that's the position -- not mine --- have the galiteantry and courage to just say so.
I'm reminded of the Futurama line: do you idiots where you're from? Nobody nowhere can say no to that. American culture, OD, and common sense when it's not losing money, playing golf, splashing around shareholder cash on art or tieing up innovation in BS (all of which IBM did pre Gerstner and was called out for) expects problems fixed, brings out the best in all comers, and expects comers to be value add. Thosr that cant play that game are out.
Regrettably this has one dark corner. Management isnt so good at overseeing itself. So in really bad situations they are good at shifting blame. Well nobody said it'd be easy. Let's start by not gossiping however.
I would put the IT services business of Accenture, Cap Gemini, and IBM in the same bucket as the rest of the Indian firms.
I'm not sure what your point is here, but based on Forbes 2000 for 2020 via Wikipedia [1], by market cap Tata Consultancy Services and Reliance are both larger than IBM. Both have grown faster than IBM since 2020. In terms of companies overall a number of other Indian companies are larger than IBM.
If you look at infotech alone, Tata Consultancy Services is the one bigger than IBM, and Infosys (>50% of IBM market cap), HCL Technologies and Wipro are all larger than 1/10th of IBM.
[1] https://en.wikipedia.org/wiki/List_of_largest_companies_in_I...
Tata is nearly half a century older than IBM. IBM is older than the TCS subsidiary, sure - TCS is "only" 54 years old. But I have no idea why that matters to your argument as it's still not clear to me why you were making the comparison.
That said, IBM does today have more employees in India than in the US, and IBMs current CEO is Indian-American, born in India and educated in part at an IIT so I can see why some would describe it that way. To me at least there's no value judgement - positive or negative - attached to that. It seems like you took offence at the comparison of IBM to an Indian company, and I can see why you'd think so in context, but I don't see why that justifies downplaying the success of companies like TCS.
> Like I said show me an Indian company that was a tech giant for analysis on the way down.
I still have no idea what you intend this to mean. TCS is a tech giant. It's the largest IT service company in the world.
As for Tata being no IBM, you're right, Tata Group is older and several times the size of IBM. The Tata Consultancy Services subsidiary alone is larger than IBM, and Tata as a whole employs about twice as many people as IBM, most in TCS. IBMs original business was thematically closer to what they still do today, I guess, but only marginally.
>I still have no idea what you intend this to mean. TCS is a tech giant. It's the largest IT service company in the world.
What is so tough here understand here? I've done IT for 30 years. I don't think I've used a gadget, O/S, compiler, cloud resource, dev-ops, or distributed algo from Tata once. IBM? All day long. I consulted at AT&T ... man the number of things they made I used was insane.
Moreover, given time all large companies cycle between running on all 8 cylinders to periods where marketing, paper pushers, corporate culture BS, losing contact with customers and customer satisfaction, poor quality erode the top/bottom line, lead to a loss of market power, pricing power, and so on.
Tata, assuming it ever had the towering heights IBM hit on all fronts, may be big now. But wait around long enough and Tata like most large human organizations will fall from grace too. And I bet, at it's core, outsourcing will not be found to be root-cause; related perhaps but certainly blaming the outsiders isn't wisdom. So as I said, then re-said, and say again show me one of those Indian companies *who are on a down cycle now*. The way I have contextualized it here makes for a relevant comparison.
While I'm at it: I'll say again unlike posters earlier up, I refuse to crap on IBM because it out-sources to Indian companies. Like anywhere some Indian companies suck. Some don't. Some may be on a high cycle like Tata. Those in the US doing the outsourcing maybe already sucked before outsourcing began. It's those kinds of spurious insults which are not appropriate and not my position.
[0] https://newsroom.ibm.com/2021-11-03-IBM-Completes-the-Separa...
Will it be? Don't they outsource a lot of their subcomponents to Indian firms?
- A US intermediator can know the climate in India and navigate the cultural differences because they do this day in day out.
- A US tech company can properly vet whom they're subcontracting to because they have engineers in-house
- A US tech company will have a contract in US jurisdiction. If there is e.g. a data leak, there is liability through US courts. A step down from that, a US company can have US-based oversight and escalation mechanisms
- Social networks and relationships matter too. If you're working with Bob from the golf course, and his company messes up, you'll see Bob again next month at the golf course and chew him out.
... and so on.
I'm not suggesting you or I (personally) should subcontract through IBM, but for a US-based non-tech firm, it can make a lot of sense.
To flip this around, whom would you rather hire to do your accounting (presuming you're not an accountant and know nothing about accounting):
- A US company which outsources to India
- A random company in India
I would go for the former, since I know there would be liability if they messed up, and they'd make sure the US tax code was properly complied with. There's nothing wrong with the latter, but I'd have no way to vet them, and if they messed up, no recourse.
Having been there, I can say that IBM is no different than the other Indian tech firms like Infosys, Wipro, HCL and other. Infact, there is a rotating door of employees among IBM and other Indian firms.
1. Since the last 5 years, IBM has more employees in India than in the US or any other country [1]
2. Secondly IBM pays more that the Indian companies in India to poach employees but shortchange their US counterparts. [2]
Infact, the only difference between IBM and other firms is that the initial sales procoess is handled by American counterparts. Once the sales piece is done and the actual project starts, it is replaced by the offshore team.
[1] https://www.zdnet.com/article/ibm-now-has-more-workers-in-in...
[2] https://www.postbulletin.com/opinion/ibm-to-give-raises-to-i...
Oh, my sweet child. You might be surprised to learn that IBM and those SWE boiler rooms like WiPro are basically the same.
They had apparently been doing some "cleanup" and somehow our site number got on to a list. All our servers, attached volumes, subnets, load-balancers were deleted.
My boss and I spent the next 30 hours applying terraform and rebuilding anything not automated.
Would not recommend IBM Cloud. We are moving off in next 6 months.
> IBM will not be allowed to enter any new contracts with the State Government until it improves its governance and contracting practices.
With that ban _still live today_, it astonishes me that any corporation would trust the organisation to actually carry through with their obligations. You have to really, really, royally screw up for a government body to consider you anathema.
The old adage of "No one was ever fired for hiring IBM" is no longer true or reasonable.
[0] https://statements.qld.gov.au/statements/72961
I mean, yes, but also think about how long a government can afford to have their lawyers pursue a case like that. If you don't have those kind of resources, it's a lot riskier.
When we opened the initial ticket, the IBM engineer kept saying "you should ask X why they deleted your stuff". Eventually after attaching the LinkedIn page for the IBM SRE in the audit logs, they realized something was screwed up on their side.
Few weeks later, massive layoffs, that triggered the warn act. So now I know how IBM works, see first hand meeting, after meeting being totally worthless. I would say stay far away from anything the touch. Just be glad you could move off their platform and not stuck using their platform with their CICD ... else you would be in living hell.
Weird experience.
Turns out sitting on my ass and listening to something useless pays the same.
It isn’t always a power move, even if HN wants it to be; and yes, I realize that’s an unpopular opinion here.
Then he mentioned the 'merger of equals' and I thought 'this isn't good news'
Narrator: It wasn't.
Started looking for a new job that same minute...
Two years ago I had to help a customer debug some weird nginx behaviour, resulting in their traffic spiking at ten times the expected rate. The IBM/Softlayer VPN required that I used Internet Explorer, but it still failed to work. We spend three month with IBM and IBM Cloud consultants to make it NOT work.
IBM destroy everything it buys. They have POWER, their mainframes and associated software left. How that keeps them afloat is a mystery.
As an example, most network or server changes you made through the API resulted in an automated email saying your sales representative would be in touch about your order, followed a minute later by an automated email saying the change was done at $0 charge.
* Bring in Deloitte, McKenzie, or other consulting group.
* Gut the acquired company to reduce costs.
* Fold newly acquired divisions into existing mediocre division.
* Service gets run into the ground without the original people who made it great.
* Eventually the service degrades and customers leave, business line stops generating profits
* Company goes through the process again.
Nice payday for the founding team and the ticking time bomb is paid for out of bigcorp’s wallet. They go on to great new things and the eventual demise of their garbage pile will be blamed on bigcorp.
Not to say that large companies don’t destroy value - they absolutely do, frequently - but that the main error they make is not being able to appraise which startups are smoke and mirrors and which are legit. The rest of us are not so great at it either.
This seems like just another argument for limiting startup acquires. Perhaps if a big exit wasn't the goal, the company would focus on more long term viability.
Anyway, I don't think they big companies care as much about whether they destroy value, as long as they destroy a potential competitor.
Startup acquisitions, in the absence of astoundingly deep due-diligence should probably be placed in portfolios where a 5:1 failure rate can be tolerated. I’m not sure how such an acquisition would be compensated.
It's not easy to know when is the right time to jump your old trusted provider. At the beginning of the acquisition not much happens. Things degrade slowly because employees take the burden of doing the job for two people. But nobody can be subjected to the stress for too many years.
Big corporations create nothing, only abuse the good faith of employees and the cost of moving providers of small companies. I have seen that happening in tech. When small innovative companies grew they got enough economic power to not have to innovate anymore. Purchase small good companies and drain them is the new business model.
And it's a shame, there was a time that liked IBM, and others.
Marketing aside. Lets not forget how cool that was. It was a great public demonstation that AI / ML is possible now.
/lol
I always answer, "Sure, we could, if you're fine with not other progress getting made towards your business objectives for 6 months."
I set up briefings to Gartner Analysts seeking to get our consultancy on a quad early in the mobile era.
One of them was on the earliest examples of hybrid HTML / native views in iOS. One of our engineers was implementing them in the Apple Store app.
IIRC, Gartner was not ready to split out boutique mobile dev but getting an earworm into an analyst with influence over a quad is still valuable.
I presume there is chatter on potential forming of quads before they make print.
Working these executive-influential information sources, and our firm continuing to land major app dev contracts led to an acquisition by Deloitte Digital.
https://www.ibm.com/investor/att/pdf/IBM-2Q-Earnings-Press-R...
But when I left to go back to school "global services" a business to business consulting division was the big up and coming division. It seems that division is where IBM decided to go. Honestly they'll just sell to some big businesses so likely you'll never hear about what they're doing.
I'll agree they seem to have lost their way. Its a shame really. They did some good things: I remember a lot of the engineers there would travel to schools and promote engineering careers.
Then Covid hit, nobody wanted to fly, and $BIGCO took an earnings haircut and decided to cut back. My friend had to let dozens of people go. It ended up costing him his company because he'd neglected bringing other work into the pipeline.
Coworker dad went from being a millionaire to living in a truck this way too.
Let the big fish swim together.
They still do stuff but it's hard research and niche so business wise it won't make them short term success. You mention power but they also have a good hand in Quantum Computing.
which may take over the world, but is presently at the stage "call me when it can reliably factor 35"
They make money on those who have more than they know what to do with.
Case in point: I spent six months in a project, which at its peak had about forty people working on it. Eventually it was scrapped and replaced with a solution from IBM, which in turn ended up... not being used at all.
Overall it was a hilarious waste of everyone's time, but somehow that was okay.
I understand why you're saying this. I have no idea either. However, open their 10-K and you'll find out how they make money. In fact, while their revenue and profits are declining, they still make more than $70B in revenue a year with a profit of about $4-5B, so their ability to stay in business is higher than many tech companies that are not profitable.
Extremely reliable, and extremely good at what they do. They sure are expensive.
A lot more companies should adopt them.
Yet its going the way.
They run at scale at a lot of companies.
AS/400 / iSeries was awesome at least in the beginning.
I think it may be discontinued now.
Those machines were extremely reliable and well made.
Often companies who had bought one had no idea where it was. Someone had set it up for them 7 years ago and after that nobody paid attention.
Some places were better and did proper backups. Which means stuff the right tape of a rotation into the slot.
They would also call home to tell IBM of a proper that is developing and they would send a tech out to switch the parts prior to anyone using it had any problem.
(and that is when the machines were sometimes hard to find. One was buried in a closet, with tons of paper cases, paper archives. stack buttom up to the floor.
IBM is a sale driven organization. I.e. sale first - tech after. so it cannot be judged as an high tech company, I.e. on the tech.
A point of reference is SUN - which was tech first - sale after.
Another point of reference is HP. HP was tech first, but turned into sales first.
There's your answer.
I know they bought Red Hat but I didn't hear that they gutted it. Can you expand on that?
Source: I work at Red Hat.
It's a bit of a strange comment considering it blames IBM for Lenovo's management of the Thinkpad line and a commercial that they later realized (but still haven't corrected themselves) was actually an HPE commercial [0].
[0] https://news.ycombinator.com/item?id=30047062
Before IBM purchase: Travel to clients, build and/or fix their things, suggest improvements.
After IBM purchase: Travel to clients, build and/or fix their things, suggest improvements.
At least from my side of Red Hat I've experienced zero changes in how I go about my work. In fact, my schedule is even more packed now, we can barely keep up with the demand. As far as I can tell IBM has left us alone to do our thing. Maybe it's different for other departments.
The kinds of places where HN devs would say your career goes to die, along with your soul.
They will do the stuff the internal teams at those companies pass on.
They probably could just run much of the business just on the licencing fees they get. If you think they are not doing anything you're likely not their target customer.
I don't think they do either, judging by my experience working there as an upper-level-support technician 15 years ago.
It seemed like the organization was book-ended with decent brains: engineers and front-line managers were decent to fantastic, and the upper-management seemed to be decent at the time. However, both ends seemed to be choking to death on a hundred layers of middle management. 7 years after Office Space was released and I actually had three(3) managers. Three! I had a technical manager with whom I had bi-weekly meetings where we talked about nothing, a non-technical manager with whom I had monthly meetings where we talked about nothing, and the head of my department who was the only one who meaningfully managed me in any way. (And he was absolutely fantastic.)
For example— they made some big announcements about their impending migration from windows to linux for everybody from admin assistants to sales to developers. Exciting! I loved that linux was getting more professional credibility, and my product ran on Solaris, so having a local UNIX environment would reduce some of the cognitive load for networking, scripting, etc. etc. There was no internal mandate to start the migration yet, but I was too eager to wait. I found the official image on the intranet and started writing documentation for my coworkers. It was pretty smooth! The complex GUI apps like the Lotus suite worked great! Well, as great as they did on windows, anyway. The installer was quite polished! I was excited!
I had one more thing to install— the ancient, internal defect and ticket tracking clients used by every technical worker, product designer, all of their managers, etc. Neither the intranet page for the clients nor the Linux image docs had any info. Hours later, I found a months-old internal note EoLing the Linux port, directing people to use the obtuse CLI instead. No problem— we're all technical people here, right? Problem. The API used by the GUI client supported necessary functionality the CLI didn't. That alone rendered the Linux initiative dead-in-the-water for most technical workers who'd benefit most.
I'm sure the manager who canned the Linux client was solving a very real problem, but a) a decision directly affecting company-wide strategy getting lost in the ether, and b) nobody checking to see if these big overtures were even basically feasible, embodies their organizational shortcomings. (I might have gotten some of the details wrong— it was a long time ago— but you get the gist.)
That's almost certainly why they're getting sued for purportedly blatant age discrimination, too. Managers in the middle with too much sway to have that little top-level visibility solving their problems using means that end up screwing lots of people.
That they style themselves as a technology-focused business consulting company rather than just a tech company is pretty rich.
Thinkpads were a great example of this. Laptops which promised decent quality and support for a high price. When the laptop market was demystified and commodified, IBM correctly got out of it - for a decent price.
If some random start-up, or even Google, had built Watson, it would have correctly been seen as a gimmick. Instead it sold literally billions of software consulting to people who thought they needed AI but actually just needed a search box with dynamic autosuggestion. Would you rather get some junior guy to hack something together using open source tools, or would you rather pay IBM 50 times as much? If you chose the former, you're simply not in the target market.
The hybrid cloud is exactly the same game - as is made quite clear in that ad, it's pitched at middle management who don't want to look like chumps for ignoring the cloud, but don't want to fuck up by moving to it.
Reputation is a difficult asset to monetize - effectively you make money from it by degrading and then destroying it. After all, if you carry living up to your good reputation, you're not extracting any advantage from it. IBM can't sell their reputation or their name to the highest bidder. All they can do is keep trawling for business lines where it gives them a comparative advantage.
It's easy to see this as unscrupulous - but their customers genuinely do get a benefit from the confidence they have in IBM.
1. A basic solution shipped and made a ton of money e.g. Ads, Search, recommendations etc.
2. It is financially feasible to have a dedicated team(s) make small incremental progress on these solutions. Even very small gains are beneficial.
3. The business perceives a threat if they fall behind in this area.
The thing is that the gains on the basic solution (heuristics, off the shelf pre-trained CV model, open voice recognition) are pretty small, and if the threat of others making progress goes away - the inferred value of further investment will probably vanish as well.
Other applications which put the AI in the driver's seat (sometimes literally) seem far from production - or if they do work, then they work reasonably well using an alternate approach from what you might expect.
Intimately knowing the non-profit side of the healthcare system as well as the construction and operation of data science systems, I wholeheartedly disagree with your assertion and your conclusion as being a general takeaway.
Here is insight into how non-profit and community health programs are funded: https://www.parklandhospital.com/financial-summary
Here is a section of Healthcare new dedicated to AI/ML implementations and other related events: https://www.healthcareitnews.com/topics/artificial-intellige...
Here is CMS's directive for hospital price transparency: https://www.cms.gov/hospital-price-transparency
The parent comment assumed that everything in healthcare is profit-motive driven. However, there are large portions of the healthcare industry that are non-profit, that are transparent in their funding and their costs, and that are looking to implement AI to improve healthcare outcomes. Parkland Health and Hospital System, Harris Health System, University Health System are some that I am more familiar with that run with this (PHHS recently achieved HIMMS Level 7 certification, for example). These are social safety-net hospitals and healthcare systems -- they care for everyone regardless of ability to pay. They focus not only on emergency and inpatient care, but also ambulatory care, primary care, and even fund (at arm's length) community (non-profit) medicaid insurers.
On a more subjective side, I've seen a lot of folks out to make a buck, but the non-profit healthcare side has been much more focused on patient outcomes.
https://www.reuters.com/article/us-merge-healthcare-m-a-ibm/...
I have no idea what they got for the money they spent. Merge Healthcare was the most miserable work experience I have ever had. They had patents, I guess, but the actual technology was garbage. And the owner was…a piece of work, let's say that.
https://www.npr.org/2018/12/12/675961765/tribune-tronc-and-b...
Patients may pay for insurance, and buy the right to not worry. Insurance delivers peace of mind by with appointments, papers, and pills. Look at all the bureaucracy and money, it must be fancy and effective. In the course of producing these papers are human doctors, nurses, coders, etc. They sometimes feel a sense of human decency and help people pro bono.
Was it the orange ties?
Because they were indicative of Ferro’s “leadership”: flashy branding gimmicks, with nothing to back them up.
Like when he bought an orange Tesla roadster to bring to trade shows. He’d just pop an orange car in the middle of the booth. What’s that got to do with health care? I dunno.
(And this was all a while ago, but this job just always stuck in my craw, because it made “Silicon Valley” feel like an understated documentary and not a parody.)