American using Britain's NHS (2015) - <AUTHOR> https://www.businessinsider.in/What-Its-Like-When-Youre-An-American-Using-Britains-NHS/articleshow/46057777.cms <comment><USER3> As a Brit using the NHS I can only add that I trust, and expect, every government to make the NHS worse whilst they talk of how marvellous it is.

I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury. I'd like to see legislation to heavily penalise drug companies seeking 20,000% price increases and the like.

Both sides fiddle with it, trivially and constantly. They will even fiddle when they have won a second term or reorganised ministers - because what they themselves thought 4 years ago must have been stupid and should be immediately changed, or something.

Much of the waste is from badly thought through political fiddling, remnants of previous fiddling, and public-private partnerships stupidly chosen during a time of lowest borrowing in British history.

Neither side is honest about it however.

<comment><USER4> Imagine how well an NHS organised as it was in 1948 would function in today's world. Although there is no doubt that it could be better managed setting it in aspic will kill it surer than a nail in the back of the head. The NHS will face massive challenges in the next 30 years from demographic pressure on demand and staff, technology change and citizen behaviour and expectation. Radical "fiddling" is going to be needed to keep it alive. This is 100's bn pounds - it's the core of UK politics and it should be - we are a democracy.

<comment><USER5> Aneurin Bevan believed that the cost of the NHS would reduce over time as the population got healthier.

The current NHS budget is £125Bn/year. Many people think it is underfunded, but noone is willing to name a figure for fully funded. Is it £150Bn, 200, 500? No progress will be made, by either party, until someone stands up and does this.

<comment><USER6> >The current NHS budget is £125Bn/year. Many people think it is underfunded, but noone is willing to name a figure for fully funded. Is it £150Bn, 200, 500?

It's a moving target, because need continues to grow as the population ages. We're in largely uncharted territory, so it's difficult to make long-term cost forecasts. You could always find ways of spending money to improve a healthcare system, so it just doesn't make sense to pick a number ex nihilo. We do have other, better means of determining what a reasonable level of healthcare spending might be on a year-to-year basis.

The National Institute for Clinical Excellence have determined a cost- effectiveness threshold of £30,000 per additional Quality-Adjusted Life Year. This threshold is a little bit arbitrary, but it's a reasonable rule-of-thumb as to what treatments provide a net benefit to society. Based on this figure, we can start to calculate a reasonable overall NHS budget from the bottom-up - the NHS needs enough money to provide all the healthcare interventions that NICE has determined to be cost-effective.

In addition to cost-effectiveness, we also have benchmarks in terms of quality of care. It might not be clinically significant if someone has to wait three weeks for a GP appointment about their psoriasis or six months for knee surgery, but it matters to the patient. We know that wait times have been going up and patient satisfaction is going down, which is a reasonable indication that the system is underfunded. It wouldn't be reasonable to aim for instant care and 100% patient satisfaction, but we should at the least hope for stability rather than regression.

The question of affordability is perfectly fair, but the UK doesn't spend an exceptional amount on healthcare by the standards of equally-developed nations. As a proportion of GDP, our spending is roughly average for OECD nations. In absolute terms, we spend about 25% less per patient than Germany or Ireland. We can clearly afford to spend a fair bit more before we start feeling the pinch.

I think that it's perfectly reasonable to spend a few tenths of a percent of our GDP to try and take the pressure off the system and get the quality metrics back to where they were in 2015. If costs start spiralling out of control, then we need to have some difficult conversations about what kind of care we're going to ration, but I think that conversation is premature if we haven't first tried a modest increase in spending.

<comment><USER7> Incidentally, one of the provisions in the ACA over in the US specifically prohibits the use of QALY as a cost-effectiveness threshold. It's just one of many reasons it's so absurd for Americans to point to the NHS as a demonstration of how much more cost-effective healthcare would be if it were nationalised; something like the NHS with its cost-saving measures just wouldn't be politically viable there.

</comment></comment></comment></comment></comment><comment><USER8> By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good. By comparison to whatever the metrics of whatever government is in power at the time the NHS always looks terrible. Budgets can be set arbitrarily by the government so it's easy to make the NHS look like it is over budget (in fact all you need to do is increase the budget by less than inflation and talk about absolute numbers to fool the public and hey presto "the NHS is terribly inefficient").

The whole "4 hour" thing is mad - you should be seen in a reasonable time frame for the ailment you have. Severed hand? Go right ahead. Headache and photo sensitivity that's been going for a couple of days already? We'll be with you when we can and if things get substantially worse come back to the reception and you may be deemed more critical. Obviously I am over simplifying the matter but the NHS is staffed by competent trained professionals who should be allowed to use their own judgment as the whether someone can wait 30 seconds, or 6 hours.

<comment><USER6> >By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good.

Ish. The NHS is remarkably cost-effective, but has relatively poor survival rates for cancer, stroke and myocardial infarction. International comparisons seem to damn the NHS with faint praise - it's cheap and the patients are happy, but it's not very good at keeping people alive.

[http://www.qualitywatch.org.uk/sites/files/qualitywatch/fiel...](http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QW%20International%20comparisons%20%28final%29_disclaimer_update.pdf)

<comment><USER9> Survival rates for all those things are affected by external factors that are not in the NHS' control.

Smoking, drinking and obesity are all higher in the UK than in many other Western countries, and therefore the types and severity of these issues are likely incomparable.

Compound this with the cultural differences of the NHS (you don't go for a six-month check-up unless you're elderly, you just see a doctor when you're already ill), and the fact spending has been prioritised towards other areas (particularly paediatrics), you start to see a different story.

But there's also the fact the median age of the UK is relatively high. It's so good at keeping alive in younger years they get older and then develop cancer, stroke and heart disease/attacks later in life where they might be less survivable.

We all have to die of something. The NHS can't prevent that. What it can do is stop you having a lot of those issues earlier in life as in other countries and therefore the quality of life is improved.

If you want to see an area where it's proper shit, I would not start there: go with dental work, look at obesity prevention, etc. - that's where it's really lagging behind many other countries.

</comment></comment></comment><comment><USER10> Here in the US I had to take my son (he was 5 years old at the time) to the emergency room when he had slipped in the bathtub and hit his head which caused a huge gash right above his eye. We sat in the emergency room for 5 hours before any of the staff bothered to look at his open wound and then another 4 hours after that before they actually treated him.

The most infuriating part of the experience was the not-so-subtle attempt by the staff to see whether or not I had told them the truth about how he had sustained his injury by _constantly_ asking him to recount how he had sustained his injury instead of actually _treating_ his injury. On top of that, the staff were rude and generally dismissive when I asked how long they _thought_ it would be before my son would receive treatment.

And then of course the billing nightmare that ensued was just extra icing on the cake. The hospital was in network for my insurance (which I verified before I went and again while I was there) but the staff neglected to tell me that they were contracted through a completely different company that turns out was not in network so I ended up having to pay almost $2000 for what amounted to a few stitches for my son.

<comment><USER11> 100% f'ing right. People who think the US health care system is fantastic either (a) haven't used it much, or (b) are rich enough not to care - and in this category I'll include those with good employer-provided health care (although this number is dwindling rapidly)

</comment></comment><comment><USER12> I am a lot like the author (dual national, lived in both US and UK). One of my children was born in the US, the other in the UK. I agree with the author 100%. I would emphasize more the peace of mind that in the UK my family's health care is in no way tied to my job (I earn plenty of money and have never had trouble finding employment).

There are also huge societal benefits to socialized healthcare. There are far fewer desperate homeless people in the UK, because many homeless people in the US are stuck in that situation in large part because of some health issue. There's just a fundamental feeling in the UK that we're all going through this life together.

</comment><comment><USER13> "In the UK, I showed up at 9am and was seen instantly"

I don't think that's ever happened to me. Most likely this person was the first patient of the day, so appointment times haven't slipped yet. 30 minutes in the minimum I've had to wait in general. I've also had to wait weeks to see a GP (in the countryside).

I find anecdotal articles like this pretty unhelpful in general. We all have our own anecdotes, it's more interesting to look at the data. Comparisons between UK and US healthcare are also somewhat meaningless. They've very different systems, and their are many other countries with private and public healthcare systems that you could compare.

<comment><USER14> I'm not really familiar with NHS processes, so when it took you weeks to be seen, did someone just take your info when you walked in and say they'd get back to you when they could, or was your condition evaluated first (diagnostics run, etc) and an appointment scheduled for you for a particular date a few weeks in the future?

<comment><USER6> The former. Access to the majority of non-emergency care is gatewayed via your GP (primary care physician/family doctor) - if you need to see a specialist, you can only do so by asking your GP for a referral. You'll then wait weeks or months to see a specialist, although you may be sent for tests before then. We have a chronic shortage of GPs and the system as a whole is severely underfunded, meaning that many people have to wait weeks just to be seen by a doctor. The average wait to see a GP is 13 days, but can be much worse in some areas, especially in winter.

Some GP practices have reduced the strain by offering appointments with Nurse Practitioners, who can treat common and uncomplicated conditions. This solution is far from perfect, because there's a lot that Nurse Practitioners can't treat.

Some patients are just going to a hospital emergency department because they can't get a GP appointment in a reasonable time frame. This just increases the strain on the system, because care delivered in an ED is considerably more expensive. The four hour target is actively counterproductive; When ED managers are faced with a waiting room full of people with coughs, rashes and sprained ankles, they are forced to choose between prioritising clinical need or hitting their targets.

[http://www.pulsetoday.co.uk/your-practice/practice- topics/ac...](http://www.pulsetoday.co.uk/your-practice/practice- topics/access/average-gp-waiting-times-remain-at-two-weeks-despite-rescue- measures/20034534.article)

<comment><USER15> > Some GP practices have reduced the strain by offering appointments with > Nurse Practitioners, who can treat common and uncomplicated conditions. This > solution is far from perfect, because there's a lot that Nurse Practitioners > can't treat.

Are the NPs not permitted to treat these other conditions, or incapable? I fear there's a turf war between GPs and NPs, where GPs are worried about losing bread-and-butter work that takes little time but accounts for a large number of visits.

<comment><USER6> >Are the NPs not permitted to treat these other conditions, or incapable?

Both. They're cheaper because they've received much less training than a GP. We could allow them to treat a wider range of conditions, but there would be serious patient safety implications.

The use of nurse practitioners in primary care is relatively new and we don't have a lot of good-quality evidence on patient outcomes, so it's reasonable to act with some caution until we have better evidence. Even in their current role, they could be missing significant clinical issues that a doctor would have spotted - we just don't know at this stage. The concern isn't about the 99% of patients who have something mundane, but the 1% of patients who have something that looks mundane but is actually very serious.

There's undoubtedly some amount of territoriality on the part of doctors, but at the moment everyone is just desperately trying to cope with demand. There seems to be fairly good esprit de corps throughout the NHS, with practitioners at all levels uniting around the need to maintain good patient care against the common enemy of Jeremy Hunt.

</comment></comment></comment></comment></comment><comment><USER16> Overall this is a great compare and constrast article, but I do have one quibble with it.

> _In the US, I 've always been able to see a specialist within a few days. > Score one for America._

This is really, _really_ heavily dependent on where you live and the number of doctors and specialist doctors in the area.

I live in a mid-sized city. If I need to see a typical general practice doctor for a routine problem (coughs, etc.) I can usually be seen the same day, but I'll probably have to wait a 2-4 hours depending on when I go.

But if I need to see a specialist (allergist, dermatologist, sleep doctor, etc) and it's not a life-or-death emergency, it's usually a six-week to six _month_ wait for an opening. It literally took six months before I was able to see a dermatologist last year.

My only other option is to drive 2 hours away to the next (bigger) city that has a medical school and a large concentration of doctors. Sometimes you can get an appointment in a few days if you're willing to drive. This is actually what I've started doing when I'm referred to a specialist.

And if you live in a rural area, even routine medical care can be difficult to come by. Many towns will have a small clinic staffed by a doctor who lives in the community, but often this doctor may have rounds where he covers several communities in a geographic area. So, for instance, he may only be in the office in your nearest town Mondays and Thursdays. So if you need to see a doctor and the local nurses can't handle it, you either have to wait or drive to wherever the doctor is that day.

Where I grew up in East Tennessee, we also had a volunteer service called Remote Area Medical [0], which provided free service to very remote areas of Appalachia. I remember going to the Knoxville airport with my Dad once and seeing their DC-3 fueling up for its next trip.

[0] [https://ramusa.org/](https://ramusa.org/)

</comment><comment><USER17> So how does the US improve its healthcare system?

More interestingly, can the US political system ever enable an evidence-based debate around it?

From the other side of the pond, it feels like debates end up being emotional rather than scientific.

(I'm a Brit and love the NHS with a passion but would not claim that it's without flaw. Neither would I claim that we necessarily have more reasoned debates about issues here...)

<comment><USER18> > _More interestingly, can the US political system ever enable an evidence- > based debate around it?_

I honestly think the reason the US is slipping so much is because their political system never seems to have evidence-based debates around anything.

Worse, they have absolutely no interest what-so-ever in comparing their country and how it's actually functioning to other Developed Countries for the purposes of improvement. In fact, I genuinely don't think they care to improve anything, at all.

<comment><USER19> Funny how you you complain about evidence-based debates proceed to mischaracterize the U.S. based on your impressions.

Americans are not all of the same opinion. They do not all use the same arguments which have the same faults. In this they are like all people everywhere. Also, their political parties do not all employ the same arguments with the same faults. Arguing that everyone has the same faults is both- siderism. It is a counsel of despair. In fact, each party will use facts and international comparisons when doing so supports their preferred policy.

The Democrats have been quite fond of international comparisons in support of their efforts to improve healthcare. I struggle to find a topic on which Republicans prefer facts to mythology but they certainly grab onto a fact when it supports what they want to do. They can recognize and employ a good argument if it presents itself.

If you hear someone making a stupid argument, regarding health care or whatever, nine times out of ten it is not because they desire a worthy thing and are too stupid to get it but because they desire an unworthy thing and are crafty enough to recognize a plausible cover story. You can recognize this happening when someone drives for a constant goal but changes arguments as suits the moment. Republican arguments for lowering taxes fit this pattern as do arguments for not doing anything about climate change.

It isn't the stupidity of politicians, or even their voters, that explain American policy. It's disharmony within the nation mixed with political institutions that expect people to work toward a common purpose.

</comment></comment></comment><comment><USER20> As I'm also an American using Britain's NHS, I was pleasantly surprised to see the article mostly matches up with my experiences using local services (though as others have called out, NHS GPs and Specialists still have regular 15-30 minute delays for pre-scheduled appointments, IME)

The only downside I would call out is that I pay slightly higher taxes in the UK than I would in the US, and I imagine that part of it goes to fund NHS programs.

That said, the small increase is a relative bargain, given the the excellent level of care provided by NHS staff and the avoidance of insurance nightmares I was used to dealing with back in the states.

<comment><USER21> I'm not sure how it factors into taxes, but the US government spends more per capita on healthcare than the UK government does.

[https://visual.ons.gov.uk/how-does-uk-healthcare-spending- co...](https://visual.ons.gov.uk/how-does-uk-healthcare-spending-compare- internationally/)

</comment></comment><comment><USER22> As a point of anecdata, my dad, an American, lived in Wales the last ten years of his life. His arthritis got too bad for him to work, and the NHS took excellent care of him for years. Then he had cardiac issues and although his NHS doctor recommended heart surgery, they didn't schedule the procedure for several months and he died of a heart attack in the meantime (age 62).

Public healthcare took great care of him and then it killed him. Hard not to be ambivalent about that (though n.b. this is not an endorsement of the US system by any means).

</comment><comment><USER23> >In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle.

That is so bizarre. I'd be concerned if it takes and hour. Seriously it's called emergency room because it's an emergency, not a "it can totally wait" room.

<comment><USER24> My friend had a seizure while we were on a business trip in a suburb of London. We were taken to the hospital in ambulance, I remember we had to go through a series of 6 rooms each getting progressively smaller( first one had like 200-300 ppl) and less people. Took us about 5 hrs to get to the doctor. Doctor was patient and polite.

</comment></comment><comment><USER25> Might be of interest to discuss other systems as well. I'm somewhat familiar with the system in South Korea:

\- There's a National Insurance System that all citizens are signed up to at birth.

\- Premiums are based on income with employers splitting the cost 50:50. Low income/unemployed people go on a slightly different but substantially similar plan with no premiums.

\- Prices for procedures are nationally set and fixed.

\- Hospitals and Doctors are generally private, but must accept the National Insurance.

\- Patients pay a co-pay and doctors bill the National Insurance system for the full price.

\- The National Insurance plan only covers a set of elective procedures. Unelective procedures are payed for out of pocket, or by private supplementary insurance (which are also quite popular). e.g. if you have cancer you can go with the prescribed National Insurance treatment and it's covered, or you can go with other treatments which the private hospitals are more than happy to provide.

\- Upside: people go to the doctor early and often and as a result South Korea has some of the best medical outcomes in the world (with a few exceptions). The robust private hospital system brings in medical tourists for a wide variety of medical procedures at low prices. If you're in the Hospital and want better care than the National Insurance covers, and you have the money, your class of care options is virtually unlimited. Fewer bankruptcies than the U.S. and <7% of GDP is spent on healthcare. System is considered among the best in the world.

\- Downside: The system tends to favor simpler problems that can be handled in an assembly-line fashion. Doctors need to see huge numbers of patients to make a living, so bedside chat time is very limited (but in practice it's about as much time as I see my doctor in the U.S.). Doctors over recommend procedures and tests to get the insurance money.

\- Paradox: Because doctors are payed per procedure, but the procedures are limited, they tend to oversubscribe labs and imaging. This means that there are about 3x as many hospital beds and imaging machines than the U.S.

\- Source: Visit South Korea semi-frequently, been sick there. Even not being insured (thus paying out of pocket) the cost was far lower than my insured care in the U.S.

</comment><comment><USER26> Note that the UK _also_ has a small private system; if you're really not happy with waiting for appointments or operations you can pay to be seen. Some higher-paid jobs come with health insurance, which is really cheap because anything difficult or expensive can be shunted off to the NHS.

</comment><comment><USER27> The NHS will try many things to avoid expensive options like MRIs and more expensive medications.

For Multiple Sclerosis I was given one MRI and NO medications over the course of 12 years as I went from relapsing remitting to secondary progressive. Total postcode lottery so fuck the NHS.

</comment><comment><USER28> I have never seen such a bureaucratic/inefficiently operated institution - <USER2> there are plenty to choose from in the UK. My electricity company replaced all Vs with Ks in letters to us for 7 months. The NHS is much worse (try even getting a letter to arrive within a month - to the right address - let alone receive any medical treatment).

I have not dealt with US healthcare but having experienced other countries' I'd strongly suggest not following the UK system - other European countries certainly come to mind as working substantially better. Of course, there's a huge "Save Our NHS" push due to the number of people it employs, unions, misplaced national pride etc.

<comment><USER29> Funny how your anecdotal point is just that, anecdotal. Here's another anecdotal point for you -- Pancreatic cancer (stage 2). Diagnosed on the first visit even though a private doctor had missed it previously. Surgery in less than 5 days, excellent follow-up and post-surgery care including the surgeon having a set of non-mandatory procedures approved in record time (10mins) as a preventative step towards recurrence. Two years later, cancer free with excellent reminders and follow-ups on periodic checkups.

Your experience does not dictate the system, as doesn't mine.

<comment><USER30> So instead look at the statistics. In many sectors they are dire.

<comment><USER15> UK residents have the 20th highest life expectancy in the world. 21st for health-adjusted life expectancy. The Japanese take the top spot and live +2 years. The average American lives -2 years.

There's a lot more to health than the health care system, and this doesn't say much about how painful the process can be, but the stats look pretty good for the UK.

[https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...](https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy)

<comment><USER31> But how much of life expectancy can be attributed to the healthcare system? Maybe Brits spend more time outside, and are less stressed, etc etc. how have the rankings changed over time and what changes in the healthcare systems correlate to those trends?

</comment></comment></comment></comment></comment><comment><USER32> > Fifteen minutes to see a free doctor! It's not free, the money to pay the > hospital bills comes from taxation

</comment><comment><USER33> one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls (please no anecdotes). The US essentially funds medical innovation for the entire rest of the world. If the US goes socialized you will see almost a complete halt to medical innovation over time.

Here are 3 (not evidence based) reasons why medical care costs more in the US:

1) more administration (too many rules/regulations) 2) higher costs for the base goods (people get paid more, pharma, medical devices, etc) due to lack of price controls 3) people get more care, potentially even when it isnt going to help

[https://www.pbs.org/newshour/nation/why-does-health-care- cos...](https://www.pbs.org/newshour/nation/why-does-health-care-cost-so-much- in-america-ask-harvards-david-cutler)

<comment><USER34> I strongly disagree with your first statement. The US definitely has a high rate of innovation in medical procedures, but by no means is it Atlas, carrying the world on its shoulders. Canada which is just a single socialized healthcare system has systematically produced fantastic innovations in drugs and therapy over the last 100 years. We have dozens of research hospitals who innovate regularly. I don't have the time to spend researching every single innovation, but a small sample is included below.

There is a lot of donor money and government grant money in medical research around the world.

Research Hospitals (off the top of my head)

\- The Ottawa Hospital

\- SickKids

\- Sunnybrook Health Sciences Centre

\- Sinai Health System

\- Kingston General Hospital

Innovation

[1] [http://innovativemedicines.ca/medicines/timeline/](http://innovativemedicines.ca/medicines/timeline/)

[2] [https://legionmagazine.com/en/2009/08/eight-great- canadian-m...](https://legionmagazine.com/en/2009/08/eight-great-canadian- medical-breakthroughs/)

<comment><USER35> This is even untrue in the US. My SO works at a system of donation/endowment funded US charity hospitals where they have a history of inventing new more effective methods of treatment. Some doctors will take less money to work in an environment focused on positive patient outcomes instead of performance metrics tied to profit.</comment></comment></comment>


Shortcuts for Writing Beautiful Tech Docs Fast - <AUTHOR> https://www.gliffy.com/blog/2017/05/12/shortcuts-for-writing-technical-docs-in-30m-or-less/ <comment><USER2> Fantastic!!!</comment>


And There Goes The First Month - <AUTHOR> http://mealticket.wordpress.com/2007/02/06/and-there-goes-the-first-month/ <comment><USER2> "At the last YC dinner Joe Krauss talked about..." Okay, that's just not fair. Paul Graham _AND_ Joe Kraus? That's like cheating. How much do I have to pay to have these dinners recorded and published on Google Video? I can't be alone in being willing to pay. (Yeah..I know this is one of the big features of YC so probably not willing to allow recording...*sigh*)

</comment><comment><USER3> "Allen Morgan said that people have started forgetting that building a company takes at least 5 years." That seems awfully long. If the goal is to sell the startup before it becomes "a company", won't the average time be quite shorter?

<comment><AUTHOR> I think that's the point Allen is trying to make - if you're trying to build a sustainable company in its own right i.e. not looking to have Google acquire it, then it takes time. For example take Facebook - they have possibly the most viral product ever seen on the web and after two years they still don't know what their killer revenue stream is and neither have they IPO'ed. This stuff takes time!

</comment></comment><comment><AUTHOR> haha "that's cheating". interesting idea re the video though i think the best benefit from the speakers is being able to talk to them afterwards and ask questions/generally chat about what you're doing.</comment>


What "viable search engine competition" really looks like - <AUTHOR> http://blog.nullspace.io/building-search-engines.html

<comment><USER2> I enjoy hating on Microsoft as much as the next guy, but as far as I'm concerned Bing is basically as good as Google.

The problem for Microsoft is the same problem that faced Apple. Being "as good as" isn't enough to get people to switch. You have to be 10 times better.

Back when Google launched, it was 10x better than Yahoo. Bing seems to have quickly gotten to 1x, but hasn't moved much further.

<comment><USER3> I still regularly make searches in duckduckgo (which gets results from Bing) and then find that I have to switch Google to actually find what I'm looking for. The worst thing about this is that Google's results don't seem to be as good as they used to be, and there isn't really any other search engine that matches it yet that I've seen.

<comment><USER4> Hmmm but DDG will never be quite as good as Bing or Google simply because DDG doesn't keep any histories or track any other activity. Really good search engines get quality and relevance from all those things that DDG purports NOT to track. It's partly a machine learning problem that I just am very very skeptical DDG can get around.

<comment><USER5> I don't think this is true unless you are truly locked into your own tiny little world. All your search history really does is help Google serve up ads for you. If that's an improvement, so be it.

<comment><USER6> Many programming language related terms, movie titles, cities/postal codes, ... All those things can be judged better when the search engine has prior knowledge about you. You don't have to be "truly locked into your own tiny little world" to have previous search be a valuable predictor of what kind of results you expect.

</comment></comment></comment></comment></comment><comment><USER7> Short and very informative, though I wondered why patents are no concern for a competitor of Google (they have various broad and trivial patents on using historical data, user feedback, moderation for better search results).

As the author wrote, aiming at feature parity with Google is probably a bad idea. DDG seems to do this right: they have some better features and one distinct advantage over Google with their stance on privacy. Perhaps Google will reach a certain creepiness factor with all the collected data they're factoring into search results (e.g. I have this suspicion that content from gmail is used too) and at some point it might work against them even for the average user (or am I just biased?).

One "feature" that Google has failed to do properly is custom "site search", i.e. providing a search interface for arbitrary websites. Perhaps this is another opportunity for a new competitor or even Bing (though their "site search" was shut down in 2011 apparently), there is plenty of demand (and lots of crappy custom solutions).

<comment><USER8> Because Google usually doesn't use its patents aggressively. They will use them defensively, though, or even as a counter-attack. That's why I think it's _incredibly stupid_ of Microsoft to be attacking Google with search patents through Rockstar. If they piss off Google enough to start using their search engine patent trove against Bing, it may be game over for Bing. Microsoft should already consider itself very lucky that Google isn't as spiteful and vengeful as Apple, or Google would've used them since day one of them going after Android OEMs.

That being said, I think the only solution to beating Google is developing something disruptive, and I mean that in a very classical and traditional sense (not the way disruptive is used to mean anything these days). It means you have to build a type of a search engine (or search solution) that Google not only has no interest in pursuing (due to conflicts of interest/opposite business incentives), but probably _can 't_ pursue, or not without employing dramatic shifts in how they do search (which again, makes it even less likely for Google to pursue and try to beat this new "disruptor").

And no, don't look at Bing to provide that. They're a "direct competitor" to Google, and they will always be, because they want to be "in the exact same business" Google is, and therefore, I don't think they'll ever radically change the way they build a search engine compared to Google.

So what can such a disruptive solution be? I can't say for sure, because it probably needs more factors/benefits on its side than just one, against Google. Social "may" be a way to disrupt Google, although I think Google is already rapidly adapting to this attack vector.

I think another could be "extreme-privacy", which Google wouldn't pursue anytime soon without _really_ rethinking how its search business works.

Disruption also means attacking incumbent companies with much fewer resources through innovative business models and cost structures. Do something that would make Google's billions of investment in infrastructure _irrelevant_. A P2P search engine like YaCy or Faroo seems to be part of that solution. Perhaps what can/will kill Google is a crowdsourced super-search engine, that ends up surpassing even Google in most capabilities, because Google would be just one company, fighting against the whole resources of the world.

As in classic disruption, you also have to consider this new type of search engine will be much poorer than Google in some competition factors (at least initially). I think that is the "relevance" factor. As the op mentions, it's going to be very hard for anyone or anything to beat Google in relevance. They have too much of a headstart. But perhaps there will be such a thing as "good enough" in search, too. Maybe we're not there yet, but perhaps we will be in 5 years, or 10 years. Until a few years ago we kept wanting faster and faster Intel processors. Now we think mobile ARM processors are more than good enough for most of our daily activities.

A crowdsourced P2P search engine powered by _billions_ of people could perhaps reach that point, too, while offering some of that "extreme privacy" and other benefits that Google can't offer.

Still, how do you get that first "10 percent" of users, that end up changing the paradigm, to start using a service that's much less relevant than Google _today_? You do it in the same way other disruptive technologies win out against incumbents. You promote the _other_ benefits, that Google can't and won't match - benefits that will be important to those "first 10 percent", until you reach critical mass, and then you should be fast approaching that "good enough" relevance, too, and get even more users after that.

<comment><USER9> Voice search with punctuation. I would use Bing if it provided this. As for now I use Bing simply to make sure I'm not loading cached pages on bad connections.

</comment></comment></comment><comment><USER10> If Bing were to overtake Google and become the preferred search engine, would anything really be much different?

I'm no search engine expert but I'm pretty comfortable assuming that Bing would have(and does have)had the same issues with rap genius as Google did. The only real difference is that as the market leader Google had to publicly react to rap genius 'gaming' of their system.

I think what this shows is that yes, this is precisely a product problem because if Bing were at the top we would be having this exact same discussion only with reversed roles.

Correct me if I'm wrong but Google vs Bing is not a lot different than Coke vs Pepsi.

Until we have someone come along with a search engine which is actually a better product, market share will only really be a function of effective marketing.

That said, I think your article does a good job outlining some of the barriers that any potential competitor in this arena should be aware of.

<comment><USER11> "Coke vs Pepsi"

I want to be "A Pepper" but DDG doesn't always give me results ... Any ideas?

<comment><USER12> DDG is mineral water. Better for your health.

</comment></comment></comment><comment><USER13> I find this title to be misleading. It implies the post will demonstrate what viable search engine competition would look like, but just explains the problems that Bing is having with Google. Are we to assume that Bing v. Google is viable search engine competition?

While Microsoft's problems are real, this offers little in the way of solutions. That said; interesting read.

<comment><AUTHOR> Hmm, I didn't really say that I had the solution. If I did I'd start my own company. :) I said that I would outline the state of making search engines competitive. Here I basically focus the post around areas that are pain points for competition, which I think is pretty relevant to the writeup I set out to make.

Do you feel something in particular sucks about the article? I'm happy to change it!

That said, I use Bing as a comparison point because it's really the only other point that's comparable in terms of, like, infrastructure and stuff. It's contextualizing more than anything. I might have removed all the references to "Bing", but I don't think it would add clarity.

<comment><USER13> The article is good as is, but I'd have titled it ~'What the barriers to "viable search engine competition" really look like.'

</comment></comment></comment><comment><USER14> > IE can track, and has tracked users behavior even when they're not on Bing. > (We got in trouble for this once, hehe.)

Am I the only one concerned with both the _fact_ that IE tracks its users, and the _attitude_ of this Microsoft employee about it?

<comment><USER15> Personally, I'm amazed that they let him blog stuff in this detail about MS's search business practices. Not speaking for the org or about the official stance, but I would not consider doing so as a member of SI at Google. And I always had the intuition that MS was even more restrictive about such things. Maybe not?

<comment><AUTHOR> I didn't say anything that isn't completely public knowledge. And let's not forget that MS once employed Robert Scoble. So we can't be all bad.

EDIT: and let's be realistic. The papers on search that come out of MSR expose way more about our infrastructure than the paltry sum presented in this post.

<comment><USER15> Insiders can often link bits of public knowledge in a way that effectively discloses confidential information. Every company has a different threshold for where this is, so maybe you're on the safe side of that for your org. BTW, I'm not trying to accuse you of malfeasance, I'm just saying I wouldn't do what you're doing.

<comment><AUTHOR> Fun update, a Google executive just emailed me to say how much he liked this post.

So there's that.

<comment><USER15> Your competitor enjoys hearing about the dysfunction in your org and some back slapping about how great a job Google is doing? Surprise surprise. :P

<comment><AUTHOR> Er, what? I didn't say anything about dysfunction and I didn't pat anyone on the back. I did say things about the inherent difficulties of competing in the space though.

</comment></comment></comment></comment></comment></comment></comment><comment><USER16> I don't get the point of this post and I think that almost all the lessons the OP wrote down are wrong. Is this post an excuse why MS is performing that bad with Bing? Why is there no one from MS stepping forward and shouting, yes Bing is still behind but we will fight tooth and nail to crush Google -- no, instead some MS employee is writing a non-approved post where he gives 6 lessons why MS sucks and why life is so hard, wtf? Maybe this is the reason why MS falls behind year by year because people behind MS are too laid back and lack fighting spirit.

Nobody knows what MS is today, especially nowadays because MS doesn't have any CEO. We know that MS was the company which controlled the personal computer experience in large parts and we know that this experience was ruled by the web and by search for one decade and there is no excuse that MS totally forgot that search must be a integral part.

</comment><comment><USER17> To say nothing of the engineering challenges with crawling the entire Internet. Your first cut will likely refresh every several months or so. Remember when Google did that, back in like 2005? It was very effing hard then. Google now crawls pages newly linked from authority sites _essentially instantaneously_.

</comment><comment><USER18> Bings' lack of market share compared to Google is not because of any of the reasons listed.

It has to do with the perception people have, and the fact that they more regularly associate searching the web with Google and "googling it" vs. Bing and "binging it".

At least this is the case for average, non-hacker news people.

Why does Google have this perception? I don't know, but I will guess it likely has to do with it being the one search engine that really caught on and was able to sustain its momentum.

Competing against google would not be done by any of these incremental/less important technical metrics but more having to do with changing the notion of searching the web, and how, in a likely very niched way at first.

<comment><USER19> Public perception is also the reason that Microsoft can't hire machine learning and search quality engineers, because the question "Do you want to work at Microsoft on search quality?" starts with "Do you want to work at Microsoft?" and for many people the answer to that question is "no" regardless of the remainder of the sentence.

</comment></comment><comment> bra-ket points 1, 4, 6 from the article could have been written in 1998 as well.

how can 2 guys in a garage wipe out AltaVista, Lykos, and whoever else was doing search back then (with lots of smart people, data, resources, state-of- the-art software and user adoption to compete against)?

What is missing is a serious discussion on search quality (which made Google Google).

If Larry and Sergey started today, would they be able to compete against Google by providing better search results, or has search quality reached a "global maximum" of sorts?

Does search still suck?

<comment><USER20> AV made a substantial unforced error at exactly the wrong time which resulted in a huge drop in search quality. It wasn't as much a matter of better algorithms as one might think.

There's also a pretty big difference in scale. The AV team working on search in 2000 wasn't all that big.

</comment></comment><comment><USER21> "Bing exists than it is that it is equal to or better than Google in every way"

How is Bing better than Google (Search) in every way? With worse relevance and smaller index? Although, IIRC, Bing used to train their neural net based on Google search results to match the Google search quality (remember the 'torsoraphy' incident)?

<comment><USER22> You misread that sentence.

> it is more important that Bing exists than OTHER CONDITION

Where OTHER CONDITION is what you've quoted. He isn't calming that OTHER CONDITION is true, merely that it isn't the most important thing.

</comment></comment><comment><USER23> FTA: "social may pose an existential threat to Google's style of search"

No. Sometimes I want general information: "what is the airspeed of a laden swallow?" Sometimes I want information dependent upon the interests of the hundred or so people I know: "what do you all do in Toledo?" Sometimes I want information dependent upon my interests: "if I enjoyed 'Requiem for a Dream', what other movies should I watch?"

These things conflict: I could not possibly care less what my friends think is the airspeed of a laden swallow.

I use Google for #1, Facebook for #2, and several other sites for #3. Google has (or had) a perfectly viable business providing the best answers to general questions, and it's a shame that they're screwing it up.

<comment><AUTHOR> Hi, I'm the author.

Sorry, but you're wrong. Understanding a good amount of detail about your users, and in particular, about their social context, is a massive win for search relevance. Google invested quite a bit in acquiring Aardvark, for example.

So, even if you don't ask your friends about something, the information is still really important.

<comment><USER4> This. I think people get caught up too much in the small fraction of queries that are facts of the universe ("What's the universal gravitational constant to 3 decimal places?") versus the much much larger fraction that depends upon much larger contexts ("Movies playing in theaters nearby," or "Rock music," etc.)

</comment></comment></comment><comment><USER24> What if you made a search engine that only works on specific sites? For the most part users _don 't_ want to search the entire web for every small blog in existence, they want to go to a relatively small number of specific sites.

For example, reddit has a terrible search engine that users often complain about and comments aren't indexed at all. But searching with google often gives subpar results and they don't take into account things like upvotes at all. (I also think sites like reddit are punished by Google's algorithm pretty harshly.)

This might make the problem smaller and more tractable and a place where you could get an advantage over Google.

<comment><USER25> Yep, an effective general purpose search engine is really a collection of effective vertical (subject-intelligent) and horizontal (task-specialized) search engines.

The truth behind IBM Watson is that it's based on a methodology that makes it possible to put huge teams working on different parts of the problem without tripping on each other's feet.

</comment></comment><comment><USER16> I just checked out Bing with some well known search queries and the results are very close to Google's.

What makes me slightly uncomfortable are

\- the name and the branding. It sounds irrational but the name annoys me and I just do not want to type it. Bing doesn't sound sophisticated, smart or anything and the big picture on the landing page is unwanted and makes the product feel unfocussed. Maybe the reason is just that Bing never did something way better than Google and thus, there were no opportunities to load this name with a good reputation with some achievements.

\- the speed: Google is (or feels) still way faster here and there (when entering something into the search it instantly switch to the SERP view)

<comment><USER6> This! The branding of Bing is terrible. When I see the big picture I always think: this has nothing to do with what I'm looking for - and "what I'm looking for" should be the single most important thing for a search engine.

</comment></comment><comment><USER26> Web search with up to the top million most popular web sites removed: [https://millionshort.com/](https://millionshort.com/)

</comment><comment><USER27> Imagine if Microsoft begins saving users' information using its operating system. As result they got more information on you even than Google or anyone else.

</comment><comment><USER28> Can someone who has the page loaded add a mirror or link to a cached version?

<comment><AUTHOR> Is it down for you? It's up for me. It's static HTML hosted on GitHub Pages, so it should remain unbroken...

<comment><USER29> down for me too, can't connect

<comment><AUTHOR> Huh, weird. It would be here, if Google had indexed it yet: [http://webcache.googleusercontent.com/search?q=cache:http://...](http://webcache.googleusercontent.com/search?q=cache:http://blog.nullspace.io/building- search-engines.html/)

</comment></comment></comment></comment><comment><USER30> can you elaborate on search relevance?

is it mostly natural language processing? matching keyword queries to document corpus

<comment><USER31> Tonight I typed Eagles into Google and it showed me all the information I needed about the game that starts at 8:10 pm. That is search relevance. I've noticed Bing doing a lot of this type of thing for the past year or two but Google is definitely the master of it.

<comment><USER32> This is a great example of search result subjectivity. I don't care about football. I'm annoyed when it rudely intrudes my consciousness. If I type "eagles" into a search engine, I'm looking for the band. The football team has _no relevance_ to me, even as millions of other people tonight are probably looking for exactly what Google showed you.

<comment><USER33> Yep, and that's why it's important for the search engine to be able to collect information about you! It's not just for commercial ends like ad targeting.</comment></comment></comment></comment>


DashGum – Free Bootstrap Admin Template - <AUTHOR> http://www.blacktie.co/demo/dashgumfree/ <comment><USER3> Looks good. You might want to disable jQuery Nicescroll on Mac though as it feels really unnatural and laggy.

<comment><USER4> Came here to mention something about the scrolling as well. As soon as I noticed it (which was as soon as I went to scroll), it was the only thing I noticed.

<comment><USER5> Same here. I wish people would get over this hijacking of scroll fad. It's really annoying.

Other than that, nice theme!

<comment><USER6> I'm curious what everyone is talking about, I'm also on Mac, but I haven't noticed anything unusual about the scroll. It might have lagged a little bit initially (not really sure), but other than that it seems to be functioning normally for me.

<comment><USER7> Do you use two finger scroll on the trackpad? Instead of following your preferred scrolling speed, this plugin very quickly accelerates the page's scroll all at once on swipe, and then decelerates (like the swipe on a touch device) as the scroll loses momentum.

If you have to scroll, and are on a Mac, it will drive you mad. :)

<comment><USER6> I do, but haven't noticed that issue. The main thing I notice is that when I first navigate to the page when I start to scroll it seems like there's a delay where it doesn't respond, but then it starts working. It scrolls normally after that point though until I navigate away and then come back, then once again there seems like there's a second or two delay before it starts scrolling again.

Maybe this is related to the so called "natural scrolling" feature on Mac? I don't use that because I find it completely unnatural and it drives me nuts, so maybe it only causes that issue if you have that feature enabled?

</comment></comment></comment></comment></comment></comment><comment><USER8> This looks heavily based upon a commercial admin template by Carlos Alvarez for sale at wrapbootstrap which I found months ago... Interesting! Who was first?!

[http://www.alvarez.is/demo/dashio/dashboard/](http://www.alvarez.is/demo/dashio/dashboard/)

[http://alvarez.is/demo/dashio/index.html](http://alvarez.is/demo/dashio/index.html)

[https://wrapbootstrap.com/theme/dashio-dashboard-frontend- WB...](https://wrapbootstrap.com/theme/dashio-dashboard-frontend-WB053N683)

<comment><AUTHOR> This is from the same author [http://www.blacktie.co/2014/07/dashgum-free- dashboard/](http://www.blacktie.co/2014/07/dashgum-free-dashboard/)

Carlos Alvarez

Carlos is a self-taught designer & developer working as a freelancer since 2006. He loves creating eye-catching sites and cool user experiences. Since 2011 he develop sites using the awesome Twitter Bootstrap framework. More Here: Alvarez.is

</comment></comment><comment><AUTHOR> Download link here [http://www.blacktie.co/2014/07/dashgum-free- dashboard/](http://www.blacktie.co/2014/07/dashgum-free-dashboard/)

<comment><USER9> I saw that there is no license included. What's the status about it?

Is there by any chance a github repository for this?

<comment><USER10> Given that the author is also offering a premium (paid) version of this theme, I doubt a GitHub repository exists as this would make it harder to keep the paid version alive.

</comment></comment></comment><comment><USER11> Download link: [https://dl.dropboxusercontent.com/u/105401917/BlackTie/dashg...](https://dl.dropboxusercontent.com/u/105401917/BlackTie/dashgumfree.zip)

</comment><comment><USER12> It looks very simple & clean. One thing I noticed is the amount of in-app requests (AJAX/whatever) were giving no indication of progress, so it seemed like a lot of things were hanging.

Obviously, I attribute this to HN load, but in the real world you'd probably like to get some notice that the SPA is attempting to do "something."

</comment><comment><USER13> Loved it! Also check the panels page, nice compositions! I decided to use this in my.project. Good work!

<comment><USER14> Agreed. The panels look awesome. It's a very good looking admin theme.

</comment></comment><comment><USER15> Very nice! However, the demo and site seems a tad slow. Probably too much HN traffic :)

</comment><comment><USER16> Scroll, as others have noticed, creates an abysmal experience (Chrome on OS X).

Animation speeds are way too slow, particularly in the left menu. Creates a feeling of sluggishness.

Icons at the top of the dashboard should have some sort of text label. I don't have to wave at my car's dashboard for it to tell me that +20 means "You are going 20mph".

At smaller resolutions, those icons should take up far less space. They should either be in a 2-row grid, or all on the same row.

Square panels on the dashboard have a box shadow on hover. Not bad in principle, but this implementation doesn't look very good, and doesn't do much to highlight which panel I'm hovering (i.e. about to click on). Also, these probably shouldn't have a hover state at all, given that the use has no way of interacting with them (aside from the line graph, which should probably be in a different element).

No way to clear notifications - bad.

Hover styles on the notifications and team members implies that the whole thing is clickable - in fact, only the name is clickable, and this presents an incredibly small target.

Lock screen should just have the password field, and maybe the avatar/username, visible. Alternatively, they should slide into the existing overlay when the lock icon is clicked. Putting it in a modal is just lazy.

Lightbox for the gallery should present a larger image than appears in the grid. Right now it adds no value.

Profile page 404's.

On the bottom "Basic Table", there some actions off to the right. I have no idea what the checkmark does - a tooltip would help. Also, a tooltip on the delete letting me know what will happen would make me feel much better: "This will be deleted permanently", followed by a confirm dialog on click, or "This will go to your trash, where you can recover it later". Edit probably doesn't need one.

Todo list suffers from the same hover problem as the notifications - <USER2> state should always mean clickable. The checkbox to mark a task as done is miniscule. I'm also not sure why the todo item text is linked.

On forms, the placeholder text appears identical to user-entered text. This is a bit deceiving - make placeholder text lighter and/or thinner than user text. It should always be clear that this form field is empty. Right now that just looks like default information.

All this is not to say the overall quality is bad - it's visually appealing, and it's a great starting point. Just some things to be aware of when designing/implementing interfaces like this.

</comment><comment><USER17> Maybe I missed it (sorry!), but is their a GitHub repo for this somewhere?</comment>


Spanish startup "close to perfecting" its 3D-printed plant-based steak - <AUTHOR> https://www.euronews.com/2020/02/28/spanish-startup-close-to-perfecting-its-3d-printed-plant-based-steak <comment><AUTHOR> _Using 3D printing allows the ingredients to be laid down as a criss-cross of filaments, which imitate the intracellular proteins in muscle cells._

 _" This strategy allows us to define the resulting texture in terms of chewiness and tensile and compression resistance, and to mimic the taste and nutritional properties of a variety of meat and seafood, as well as their appearance," says Guiseppe Scionti, the founder of Nova Meat._

[https://www.bbc.com/news/business-51263266](https://www.bbc.com/news/business-51263266)</comment>


Lung Cancer Patients Live Longer with Immune Therapy - <AUTHOR> https://www.nytimes.com/2018/04/16/health/lung-cancer-immunotherapy.html <comment><USER2> I'm now 5.5 years post-treatment with immunotherapy for Stage IV melanoma and have had no evidence of disease for over four years. When immunotherapy works, it can be impressive.

For me, my treatment (adoptive cell therapy using tumor infiltrating lymphocytes) used my own white blood cells (130 billion in lab-selected and expanded form) to overwhelm the mutated cancer cells.

It was a one-time treatment (over 3-4 weeks in the hospital) with no further meds or other treatments required.

Immunotherapy has become an important tool in the future of fighting cancer, for sure.

<comment><USER3> What was the treatment like? I've heard it's similar to having the worst flu of your life * 1000.

<comment><USER2> Yes, for the two days of high dose IL-2 every 8 hours, it was pretty bad. My experience was limited to nausea, fever, sweating, and bed-shaking rigors. I've heard that some patients experience hallucinations.

Note: IL-2 was administered after I received my lab-grown white blood cells. It acts as signal to one's immune system to activate. It was used to jumpstart my immune system after it had been replaced.

<comment><USER4> I wonder how a combination of aggressive immunotherapy and "sickness" counteracting effects of cannabis (for the nausea, fever, sweating) would do in making the immunothrerapy more effective and tolerable.

<comment><USER2> Since the treatment was performed on site at the National Institutes of Health using Federal research dollars, this wouldn't have been an option. So, I have no idea.

</comment></comment></comment></comment></comment><comment><USER5> I'm a radiation oncologist specializing in lung cancer. Here's my take:

Immunotherapy is really revolutionizing the treatment of locally advanced and metastatic lung cancer. However, a "revolution" in our world is improving 5-year survival by 10-15% in absolute value. It's not outstanding, but when your baseline is around 10%, improving it by 10% means doubling it. That's why immunotherapy is being adopted so quickly despite its price.

A poster mentioned $100 000 is not a lot if it adds 10 years. It's not as simple. Right now we don't really know if we can stop the treatment. So people often receive the treatment until they progress. If it's 4 years, we're looking at $400k... The cost on society in general will have to be dealt with (and debated) at some point. I doubt insurance companies will continue paying for those treatments "forever", especially considering how prevalent lung cancer is.

Immunotherapy benefits from a great "romantic" story, which helps with its marketing like no other drug. It's your own immune system, your army, waking up and attacking the greatest villain of all; cancer. The alternative, chemotherapy, is often seen as poison. Granted, it has fewer side effects, but it has some, and they can be nasty. Basically, the immune system is in a constant state of equilibrium. You stimulate it too much and it starts attacking your own body. We're seeing some cases of thyroid problems, lung inflammation (pneumonitis), skin problems... Generally speaking though, it's better than most chemos.

Overall, it's a great treatment but obviously not perfect, crazy expensive to a point that it's likely not sustainable in the long run. Despite all of the drawbacks, it's a really exciting time for oncologists as we can finally offer more hope to our lung cancer patients.

</comment><comment><USER6> This is truly exciting and only just the beginning.

There is a host of bio-tech startups following this initial wave - with two main goals:

1., Improve the treatments to become 100% cures

2., Lower the price

This is very similar to tech and, say, the storage space. Went from 100k for a few GBs to peanuts for TBs on AWS pretty quickly. That's what momentum in a crowded space will do.

Healthcare systems around the globe will have to figure out the effects of this, similar to autonomous driving. And it is not just simple cost of treatment.

What if cancer becomes curable? What to do with all the cancer wards? Specialists in Oncology? Chemo/Radio/Surgery? The spider-web effect here is gigantic.

Sticker price for the drug vs. long term treatment (multiple chemo rounds, surgery, palliative care) if its 100k is NOTHING.

<comment><USER7> Yes, this news is exciting. But right now we're a very long way from curing cancer.

In 50% of the full range of cancer types treated so far by the drug in question, immunotherapy does absolutely nothing. And for another 25% it helps only a little. Only about 25% see a game-changing response. Even then, among high responders, most are not cured. They do live longer than if treated only with chemo. (In this study announcement, there's a 51% better survival rate after one year. That's great for those who are near death. But it offers them additional months of life, not decades.)

As of today, the fraction of patients who are fully cured of cancer by immunotherapy is unhappily small. It's also important to remember that these therapies are too new for us to know how long the positive effects will last. Will the lucky ones add months or years to their lives? We don't know. As of today it's just too soon to tell.

I do agree that the potential of treating cancer using the immune system _is_ exciting. Certainly. But right now we're nowhere near able to declare victory or start worrying about the implications of ending cancer. That's not fair to the unlucky majority of cancer patients.

<comment><USER8> _But it offers them additional months of life_

Personally, I always wonder why people go through the pain and expenses to add a few more months. Years/cure - yes, go for it. A few months? I'll take the painkillers and anti anxiety drugs, thanks - it was a good run.

</comment></comment></comment><comment><USER9> > After a median follow-up of 10.5 months, the estimated rate of overall > survival at 12 months was 69.2% in the pembrolizumab-combination group > versus 49.4% in the placebo-combination group.

Seriously groundbreaking. This is a once-in-a-decade paper. [1]

[1] [http://www.nejm.org/doi/full/10.1056/NEJMoa1801005?query=fea...](http://www.nejm.org/doi/full/10.1056/NEJMoa1801005?query=featured_home&)

<comment><USER10> There have been lots of similar 'groundbreaking' data from the various anti- PD1/-PDL1s over the pest few years. This is great, but not greater than lots of others.

</comment></comment><comment><USER11> complaints about study funding aside, checkpoint inhibitors really are stunningly effective for some cancers.

it's the first major advance we've had in oncology in maybe 25 years.

<comment><USER12> Haven't there been fairly significant advances in using specialized chemotherapies for specific forms of cancer? This at least has been my impression from a few books I've read.

<comment><USER13> More or less correct, the parent comment is nonsense. There are multiple special types of cancer that can be specifically targeted now (for example CML), though few of those are chemotherapies aside some improved targeting mechanisms via antibodies. Also, prognosis accuracy has and is improving dramatically. And there are HPV vaccinations now, targetted virus treatments comming up and so much more. Immunotherapies are great but not the first and only thing in 25 years.

</comment></comment></comment><comment><USER14> AACR meeting in Chicago is the real event. If you're a science junkie, [http://webcast.aacr.org/s/2018annual/PL01](http://webcast.aacr.org/s/2018annual/PL01)

<comment><USER14> Also from AACR: Google Augmented Reality Microscope: [https://www.youtube.com/watch?v=9Mz84cwVmS0](https://www.youtube.com/watch?v=9Mz84cwVmS0)

</comment></comment><comment><USER15> My Father is currently on a trial in Australia which combines Immune Therapy with traditional chemo treatment. The results can only be described as a miracle. He has gone from being inoperable stage IV melanoma (with the disease first being spotted in his lung, not his skin) to showing next to no evidence of the disease.

When I read many medical studies in the media, they often sound too good to be true. In this instance it is the real deal.

I hope access to this treatment becomes readily available for the rest of the public.

<comment><USER16> Not to be dismissive, but those other media stories often had someone incredibly improve their condition too and that someone would have had children to go around saying "this is the real deal" but it's still only an anecdote and it still only works on some patients. Even quack therapies have people recovering naturally sometimes. Not so say immunotherapy is quackery.

</comment></comment><comment><USER17> This is a really significant public health advance.

In the US, cancer is the second leading cause of death, and lung cancer is one of the largest causes of cancer death. Curing this disease, even in a subset of patients, is really amazing

[https://www.cdc.gov/nchs/fastats/leading-causes-of- death.htm](https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm)

[https://jamanetwork.com/journals/jama/fullarticle/2678018](https://jamanetwork.com/journals/jama/fullarticle/2678018)

</comment><comment><USER18> Thanks for sharing. I wish that instead of building destructive weapons, there was more focus was on building cures for the many diseases and fighting hunger and poverty..

</comment><comment><USER19> I remember reading this recent Financial Times article[0] about how China is innovating in the area of providing immunotherapy and other breakthrough treatments.

[0]: [https://outline.com/tdDNdd](https://outline.com/tdDNdd)

[1 non-outlined link]: [https://www.ft.com/content/30b5a944-3b57-11e8-b9f9-de94fa33a...](https://www.ft.com/content/30b5a944-3b57-11e8-b9f9-de94fa33a81e)

<comment><USER17> Right now China is playing fast-follower in general with this work, but rapidly becoming more innovative.

There are quite a few Chinese companies developing their own PD 1, PD L1 and CTLA4 inhibitors (these are the first gen immunotherapy treatments), and a lot of innovation in CAR-T cell therapy (first approved products of this type were US and European, Novartis and KITE pharma). There is less regulation of cell therapy in China, so potential for some breakthroughs.

A company called Legend Biotech in China surprised the biopharma world at a major confreence last year with breakthrough work with a cell therapy targeting BCMA.

However, the amount of US and EU investmnet in immuno-oncology is still greater than in China

</comment></comment><comment><USER20> Someone close passed away from lung cancer last year. He received immune therapy (keytruda), and while it may work wonders for others, it comes with drawbacks; My main issue was that it takes 4 to 5 treatments (with weeks between each treatment) before you even really know if it worked or not. This is valuable time that could be used to treat the cancer with chemo (which admittedly has way worse side effects than keytruda, but still).

<comment><USER21> Are there numbers that say what the success rate of immuni therapy is?

<comment><USER20> It sort of depends on what you define as success. The goal was never to "cure" the cancer, rather, to shrink the tumor.

I hesitate to assign an exact percentage to the effectiveness since there are so many factors to consider, but I remember Keytruda being reported to shrink tumors in less than a third of patients who took it.

<comment><USER9> The goal _is_ to cure, from the article, quoting the head of lung at Yale:

> "Chemotherapy has limitations. Immunotherapy has the ability to cure. I lead > the Yale lung team. We have patients on these immunotherapies alive more > than eight years."

<comment><USER20> I am sorry, that wasn't clear; That was the goal in the specific case of my family-member. The tumors would never fully disappear, and he would likely need more treatments later on.

</comment></comment></comment></comment></comment><comment><USER22> Went to a talk about immunotherapy last year, toxicity of these class of therapeutics was way better than the best other available treatment. Sadly still too nascent, but don't forget to ask for it if you can.

</comment><comment><USER23> Bad reporting - fails to explain what Immunotherapy actually is, jargons all over. Can anyone explain in simple terms?

<comment><USER24> Check out the cancer.gov page[1], which does a decent job of giving an overview. The drug in question, pembrolizumab, is a monoclonal antibody (you can tell because the name ends with '-mab'), and you can read more about how those work on this page[2].

[1] [https://www.cancer.org/treatment/treatments-and-side- effects...](https://www.cancer.org/treatment/treatments-and-side- effects/treatment-types/immunotherapy/what-is-immunotherapy.html)

[2] [https://www.cancer.org/treatment/treatments-and-side- effects...](https://www.cancer.org/treatment/treatments-and-side- effects/treatment-types/immunotherapy/monoclonal-antibodies.html)

</comment></comment><comment><USER25> Immunotherapy is not new. My mom went to Greece in 1980's and received it. It was illegal in the US then. She would go to Mexico for booster shots. I believe it really extended her life w quality. She passed in 1990 but looked good... not a bag of bones like chemo patients.

</comment><comment><USER26> Odd they don't mention the cuban work on this field.

"Researchers with Cuba's Center for Molecular Immunology have developed and approved an immunologic cancer therapy that improves survivability for certain types of cancers in some cases; as of January 2017, the drug has begun clinical trials for the treatment in the United States."

[https://www.usatoday.com/story/news/world/2018/01/09/cuba- ha...](https://www.usatoday.com/story/news/world/2018/01/09/cuba-has-lung- cancer-vaccine-many-u-s-patients-cant-get-without-breaking-law/1019093001/)

<comment><USER7> Vaxira / Racotumomab

[https://www.ncbi.nlm.nih.gov/pubmed/25420897](https://www.ncbi.nlm.nih.gov/pubmed/25420897)

[https://www.frontiersin.org/articles/10.3389/fonc.2012.00150...](https://www.frontiersin.org/articles/10.3389/fonc.2012.00150/full)

This drug has completed a limited Phase II study in 2014 (71 patients), adding about 5 months of life over the control group (11 mo vs 6 mo). Then it began a large international phase III NSCLC (lung) study which apparently hasn't ended yet.

It's approved for use in Cuba and Argentina, probably only for lung cancer.

<comment><USER26> Thanks! Weird I got down voted for my comment..

</comment></comment></comment><comment><USER27> Cuba has a lung cancer vaccine for $2. Peer reviewed. You don't hear about it. Edit: I don't even know why I go here if this site is so toxic I get downvoted for pointing out something. Enjoy your guys toxic conformation bias

<comment><USER24> The "vaccine" you refer to here is racotumomab. It's not a vaccine in the common-parlance sense ("prevents disease"), but a different immunotherapy treatment which is only approved for use in Cuba and Argentina. I'm mildly curious why it doesn't exist in the US. All of the clinical trials in the USA which I can find on that drug are either incomplete[1] or completed-but- without-results[2][3][4]. For all of those trials, "Laboratorio Elea" is the sponsor or a collaborator, so I presume they have the rights to the drug in the USA. That's apparently a company out of Argentina[5]. I don't know why they seem to have given up on getting the drug approved in USA, but wikipedia says "[a study] is underway in Argentina, Brazil, Cuba, Indonesia, Philippines, Singapore, Thailand and Uruguay", though the citation for that seems incredibly suspect[6].

[1] [https://clinicaltrials.gov/ct2/show/NCT02998983](https://clinicaltrials.gov/ct2/show/NCT02998983)

[2] [https://clinicaltrials.gov/ct2/show/NCT01460472](https://clinicaltrials.gov/ct2/show/NCT01460472)

[3] [https://clinicaltrials.gov/ct2/show/NCT01598454](https://clinicaltrials.gov/ct2/show/NCT01598454)

[4] [https://clinicaltrials.gov/ct2/show/NCT01240447](https://clinicaltrials.gov/ct2/show/NCT01240447)

[5] [http://www.elea.com/](http://www.elea.com/)

[6] [https://en.wikipedia.org/wiki/Racotumomab#Clinical_trials](https://en.wikipedia.org/wiki/Racotumomab#Clinical_trials)

</comment></comment><comment><USER28> The prohibitively expensive nature of any immunotherapy leaves me profoundly skeptical of its practical usefulness. $100,000/year? That's more than twice the median income in this country.

Is it simply that expensive to get mabs from animals, is drug development disgustingly expensive, or is there unbounded greed in pharmaceutical companies?

<comment><USER29> I've been in and out of the hospital a bit lately (broken back). That seems downright cheap. I average about $4,000 an hour when I'm in. The most recent "study" took an hour with one low paid tech using one ultrasound machine and it cost over $2,000. CT Scan? 15 minutes $7K. Heck, they charged nearly $800 to "start an IV" when they didn't even start it, it was the ambulance EMT that put it in (billed separately) they just injected morphine into it. If you don't have good insurance you are one small slip away from bankruptcy.

<comment><USER30> CT scan is less than 100$ in most places in India. It could go up to 200$ in some hospitals and is considered expensive by the patients.

<comment><USER30> And ultrasound is 10-20$. I find it seriously expensive in US. One thing is the health insurance or public backed healthcare is not widely adopted and patients still pay from their own pockets in India so charging exorbitant amounts is a big no-no.</comment></comment></comment></comment>


How to win at rock-paper-scissors - <AUTHOR> http://www.bbc.com/news/science-environment-27228416

<comment><USER2> "The game of rock-paper-scissors exhibits collective cyclic motions which cannot be understood by the Nash equilibrium concept."

This is complete bullshit. It is well understood that if your opponent is not playing an optimum strategy, you can gain an advantage by shifting away from the Nash equillibrium yourself.

Example: Image a player that always picks "Paper". By shifting away from a random choice (Nash optimum) to just always selecting "Scissors" will net you a 100% win rate.

This is a common trick utilized in poker, where good players will apply a certain playing style, while placing smaller bets, let their opponent adjust to your style and then suddenly change to a more aggressive style. You can take advantage of the fact that your opponent is trying to capitalize on your previous strategy. He has now introduced a sub-optimal element into his game, which you in turn can capitalize on.

As in the previous example, imagine we wager $1 on rock paper scissors. I pick paper for the first 100 rounds, you always pick scissors and you always win. Now we suddenly change the bet to one million dollars a hand. I change my selection to "Rock", while you play scissors, as that has given you a perfect win rate so far, and I win the money.

<comment><USER3> >This is a common trick utilized in poker, where good players will apply a certain playing style, while placing smaller bets, let their opponent adjust to your style and then suddenly change to a more aggressive style.

Pardon my ignorance of poker, but won't the opponent notice that you have suddenly raised the stake and that something could be afoot?

<comment><USER4> Playing aggressively in poker usually means betting more than your hand would otherwise dictate - but your opponent doesn't know what your hand is.

So - you play for 4-5 hours, folding on weak hands, and always raising on strong hands, and then, once people think you are a grinder, you start betting on weak hands; other players fold because they were used to you betting high stakes only on strong hands, you take their money.

<comment><USER5> To clarify for the poster who asked you the question, playing aggressively might mean better _more_ than your hand otherwise dictates, but it might also mean betting _more often_ even if you don't change your bet size.

For example, you might always fold low pairs 22-66 initially (and perhaps conspicuously reveal that you folded them) but then start raising with them later. If your opponents were paying attention, then (a) they will think you have a good hand, and may be scared into folding right now, but (b) even if they don't, they won't suspect you of having a low pair, so that if e.g. a 2-6 comes up on the board and gives you three of a kind, you have an advantage because your opponents won't consider that you have this hand.

</comment></comment></comment></comment><comment><USER6> Interesting how the pattern "rock-paper-scissors" is followed. If this is because of the name, Swedish people, for example, would follow another patterns as they call the game "rock-scissors-paper" (Sten-sax-påse).

<comment><USER7> I wonder if it has less to do with the name and more to do with which hand beats which.

That is, if you lose with a rock, you have lost to a paper, hence a paper might start looking like a better option.

<comment><USER6> Ah, that makes sense. It would lead to a lot of rock-rock etc., as the winner stays and the loser moves to the winner hand. I wonder what the players pick then? If both move up one it would lead to an even larger number of same-hand encounters.

</comment></comment></comment><comment><USER8> Is it actually a 1/3 chance of winning though? Is that including a draw as a win?

I've tried coding it up here:

[https://gist.github.com/andyhmltn/5c8c5734fe894db5aa02](https://gist.github.com/andyhmltn/5c8c5734fe894db5aa02)

Baring in mind it was a rushed 5 minute bodge-job so it could be wrong but there seems to be a massive skew towards draws

After more tests with this code it seems there's an 11% chance of winning if it's random. Baring in mind javascripts RNG

<comment><USER9> There is an equiprobability of winning/losing/draw. Your code is erroneous. You do a +1 to the random number you generate giving you 1, 2, 3. You then use that number to access an array with indexes [0, 1, 2]. You end with an undefined which screws your results.

<comment><USER8> Well if that was the case, then one result would always have 0. The indexes are used to find what something wins against

</comment></comment></comment><comment><USER10> You just have to be fast enough: [http://www.youtube.com/watch?v=ZVNnoOcohaU](http://www.youtube.com/watch?v=ZVNnoOcohaU)

</comment><comment><USER11> Or in other words "Humans are really bad at random."

<comment><USER12> The question is, are you sure that true random is always the best move? I say some random strategy, but totally random, like perfect random? I am not sure that actually has a big improvement...

<comment><USER11> If it's anything other than perfect random your opponent can figure out your pattern and use it against you.

The only time to differ from true random is if you figured out your _opponent 's_ pattern.

Which can lead to some interesting strategy of making your opponent think he figured out your pattern. Then use your knowledge of what he thinks you will do to win.

</comment></comment></comment><comment><USER13> I hope to see some replication of this. It sounds like they just looked through the numbers for patterns, instead of making a prediction beforehand and then trying to falsify it. That's fine but there needs to be replication for that kind of conclusions.

</comment><comment><USER14> TLDR: Players are more likely to pick the move that just won.

To exploit that, the best strategy would probably be to always pick the move that wasn't played. Should give you an edge until your opponent notices your pattern :)

<comment><USER15> My wife and I play RPS to determine who does things like change a diaper when we're out and about and stuff. We tie a _lot_. Far, far more than chance would dictate. We can tie for 10 in a row, quite easily, and before you jump up about how this can happen by chance, we tie in sequences a _lot_ , not just 1/3^10 times. We're trying to second guess each other.

Since humans _are_ bad at random, "just play randomly" doesn't really work; humans don't have access to "random" to play that way. So you often do get into the sorts of strategies you mention, to compensate for this.

Besides, it's more fun this way.

<comment><USER16> I played for years with a close friend in high school to decide who was driving or whatever, or just pass time. The better we knew each other (ie the longer we were playing) the more ties.

I believe there's a natural intuition for reading the expected movements of the other player, and have seen this reproduced (if anecdotally by only testing between myself and her, and not recording results) hundreds of times. Like you, 10-12 streaks of ties were not uncommon, certainly less common than statistics would seem to dictate.

somewhat relevant, there's a competitive league: [http://www.usarps.com/](http://www.usarps.com/)

I always wanted to see it in vegas: [https://www.youtube.com/watch?v=htX4T20t6lU](https://www.youtube.com/watch?v=htX4T20t6lU)

EDIT: clarity

</comment></comment></comment><comment><USER17> This article reminded me of a Rock-Paper-Scissors AI from a while back (requires Flash I think). [http://www.nytimes.com/interactive/science/rock- paper-scisso...](http://www.nytimes.com/interactive/science/rock-paper- scissors.html?_r=0)

It uses data gathered from other players. I remember playing it at the time and it was creepy how good it was at beating me. Oddly it didn't do so well this time. Maybe because I've just read that article.

<comment><USER7> AFAIR it works by storing the most likely human move for every 3 move sequence e.g. "St Pa, St Sc, St St".

If we assume most players play similarly, and don't remember much more than the last three results, this works really well.

</comment></comment><comment><USER18> If winners tend to stick with their last winning move, then shifting forward after losing is the correct strategy. Only the winners are playing irrationally here.

<comment><USER6> Wouldn't shifting backward make more sense? That way you beat the other instead of playing equal.

</comment></comment><comment><USER19> There is a 'variant' in Japan where every players start with rock, and the game starts after this first move. It's a small variation (I think it was originally aimed to synchronize more easily), but it nills the effect described in the Article for each session.

</comment><comment><USER20> How to actually win at RPS: Memorize a long, truly random sequence. That is, assuming your opponent also does. Er... now I've gone cross-eyed.

<comment><USER21> > Memorize a long, truly random sequence

> Humans are really bad at random

You could use the digits of some transcendental number, say, pi. Skip zeros, then each digit yields two moves. For the first move, lows(1,2,3) gives stone, mids(4,5,6) gives paper, and highs(7,8,9) gives scissors. For the second move use mod 3, so 0 gives stone, 1 gives paper, and 2 gives scissors.

</comment></comment><comment><USER22> >> What are your odds of winning rock-paper-scissors? Simple - one in three. At least, that's what chance predicts.

I thought the chance of winning with no prior is 1/2... Otherwise, okay, you win with 1/3, your opponent wins with 1/3, and where is the other 1/3? :) I know what the article means, but they phrase is wrongly.

<comment><USER23> The odds are 1/3 win, 1/3 loss, 1/3 tie :)

<comment><USER22> Sorry I didn't know the rules properly :) Which combination is a tie? In my version someone always wins :) ha ha

</comment></comment></comment><comment><USER24> "The only winning move is not to play."</comment>


Now You Has "King of Jazz" - <AUTHOR> https://www.criterion.com/current/posts/5511-now-you-has-king-of-jazz <comment><USER2> Criterion might just be one of my favorite companies in the world. Certainly one of two that I purchase from on a constant, consistent basis. Their releases are pretty much always well done.

<comment><USER3> Agreed. I like Janus Films also [http://www.janusfilms.com/](http://www.janusfilms.com/)

<comment><USER2> Janus is fantastic as well, as is Arrow. Always worth the price.</comment></comment></comment>