Caltrops - We Love Katamari





	[quote name="saltlord"][quote name="blackwater"][quote name="saltlord"]The difference between a chinese liver and a russian one, or between my brain and yours, are all potential facts according to academics. It's of interest to prescribers what your metabolism's gonna do and if it can be predicted in a way that saves people suffering on the wrong drugs, it should and policy should reflect it. With cheap testing. Like the pharmacogenomic testing I took.[/quote] Actually, there are already activists working on trying to stop hospitals from using race to give better medical treatment. A few weeks ago I found a twitter post from one of them bragging about causing some hospital or other to stop considering race when treating liver issues. Sorry, I can't find the link now.[/quote] Those activists are either dumb or obviously right on a case by case basis. I'm talking about a debate within the scientific community about complex genome interactions, not operational clinical practices. The science for that is still coming in and will be for a while. I've followed enough of it to know. However, at the end I pivoted rather abruptly to what IS currently possible: said testing. [quote][quote name="saltlord"]Not all doctors believe in the testing, but then some doctors are fucking cranks that believe prozac doesn't have side effects (my personal experience) or that they should marry their kids or whatever the fuck.[/quote] As I recall, Scott's position was that genetic testing wasn't that helpful when prescribing anti-depressants. I think the reason boiled down to the testing being only moderately accurate, and also expensive. Keep in mind that the alternative, just trying different courses of anti-depressants on a patient until one "clicks," is pretty easy to do.[/quote] Well, you unintentionally pushed my jeep button. Here we go. It's easy to prescribe a few meds until one 'clicks' (not what they do, treating people is far less precise than building ikea shelves) in that it's easier than arguing with an insurer through paperwork, but this is what we call medical paternalism, which is just advocate language for doctors being shitty to patients because insurers, certifiers, boards, pharma, thought leaders, and the industry are shitty to patients. The shit rolls downhill, so they don't do the tests. By which we mean tell an admin to order them after having like one conversation with a PGx test sales guy and then charging their patient. As for price - the comprehensive panel testing options I've seen are less than $200 over the counter (subsets for one condition are often less), and decidedly less than that for a medicaid patient whose insurer bargains down a provider, which is more than the $6 for a prozac script fill at walmart but far less than the cost of a malpractice or wrongful death suit when you fail to predict a suicide, which happens often enough to be a professional hazard of telling someone you'd rather they go through two to eight months per drug on one to six drugs in order of decreasing likelihood to work (this is the standard protocol, they actually do this to people whose families could sue in case of suicide). Smart doctors have realized the risk of this is serious enough to write their ER notes <a href="https://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html">as if the patient has already died</a>. Also you own the results forever and they apply to a lot more drugs than just what your shrink might write for. It's not like your genes are gonna change. It is a poor doctor who can neither do the cost/benefit on such a test nor sell one to a patient. Accuracy is another question altogether. PGx tests are plenty accurate at predicting what you can metabolize, given your metabolism isn't in a dogshit state (for which refer patient to metabolic specialists and take thorough history), your drug-drug interactions aren't set up poorly (for which there are free tools provided to doctors to do regimen component comparisons that they often don't use because of time constraints, ignorance, inertia, favoritism, and in a few cases I've had the displeasure to observe, straight-up fucking laziness), and you're getting your knowledge of pharmaceutical compounds from a useful source (the pharmacist at every CVS has four years of school for this, nearly all MDs have six months, and pharma sales reps have a deck of power point slides). Maybe Scott could be better at his job, though most MDs aren't going to need to be - 60% of depression cases likely respond to standard doses of prozac. Then there's the other 40%, and so on for other disorders. This is why medical advocates exist, but we're a weird breed. Also, all the information throughput doctors have is controlled by their work environments, which are plenty shitty, and mostly controlled by pharma and insurance and the law. Pharma does not fucking want you to fail to sell their new favorite compound because you have a procedure for finding an ideal, low-cost fit first. Pharma especially doesn't want you knowing what does and doesn't work for punching holes in their marketing and pays buckets of money to 'thought leaders' in clinical professions to make this happen even when it stands to get sued hard for it later; this last couple years they got hit for selling an AIDS drug that did kidney and bone damage and knowing about it when a safer alternative existed but who cares, prescribe Truvada until the cost of the recalls and lawsuits is comparable, Fight Club style. What they do to negotiate drug prices is largely out of sight and mind to doctors because it is negotiated with insurers - the clinicians I work with routinely don't know as much about per-dose cost as my pharmacy contacts do. [quote][quote name="saltlord"]The debate about policy needing to be driven by modern day genetic research is gonna go on long after they disprove the bell curve once and for all (now THAT'S racist shit). This guy had a dumb, premature notion - I'll wait until I have evidence to judge how it materially affected his patient-oriented behavior as a clinician.[/quote] Debate? There is no debate. If you breathe a word about genetic differences in IQ in public, you will lose your job and be cancelled. You're allowed to talk about genetic differences in liver function or whatever for now, but that may soon be unacceptable as well. There is a huge amount of evidence for genetic variation in intelligence, but it certainly doesn't matter in the current political climate. What is in the process of happening is that we're going to stop doing any kind of standardized testing in order to sweep the gaps under the rug. The process started in the 1970s with <a href="https://nationalaffairs.com/publications/detail/the-dead-end-of-disparate-impact">Griggs v. Duke Power</a>. It's going to finish soon with <a href="https://mitadmissions.org/blogs/entry/a-special-announcement-about-sat-subject-tests/">the end of the SATs, ACTs, for admissions to college.</a>[/quote][/quote]Since you keep going off in this direction, it doesn't matter to me what the pop culture cranks out on twitter about race science, you're bringing this back to that instead of talking about the international medical community studying genetic factors in anatomical differences and that is far more interesting to me. Mostly because if I take Feynman's wife-beating ass down a peg by giving him blood pressure problems so bad he can't do his job or be gregarious, he cannot function in any fashion that is measurably intelligent without the right medication and that medication might be selected genetically. Everything else is whatever. If you're bemoaning the end of college admissions, I'm perfectly fine with decommodifying education and forcing the work of sorting the wheat from the chaff back onto academic advisors and professors instead of letting them coast on tenure and fuck around while student selection is run by the college's marketing team.[/quote]