I have never understood this rationale to not do more comprehensive diagnostics. Sure, it costs more up front. But wouldn’t catching problems earlier save more money and suffering in the end?
Because none of this happens in a vacuum. The tests aren’t perfect and open to interpretation, but that’s the least of the problems here.
Sometimes no action is the correct action, but no one is going to do that. How many laws have been passed because “something needs to be done” even though nothing in the law needed fixing?
Many people, I’d say most, are not happy with inaction. Knowing something may be seriously wrong can have an enormous emotional cost for some people. Dismissing this as irrational is like saying humans are irrational. (Spoiler: they are)
Exactly, and the human "bias towards action" is amplified by legal mandate. A doctor can't recommend inaction if a pack of lawyers is lurking in the bushes waiting to pounce if the situation worsens.
Agreed. I think the article and parent comment seem to be from the perspective of someone who has never had to, say, read or interpret a chest CT. Or had to tell someone that they have an indeterminate module that may be cancer but may be nothing.
The article also seems to imply that their is one entity or person who controls all aspects of diagnosis (hence the meme at the top), from taking a history and doing a physical exam to perfectly understanding the intricacies of all additional diagnostic testing. Of course, your primary care doctor may not understand exactly what percentage of people in a low (or high) risk cohort with this lung nodule with certain specific imaging features turn out to have cancer. Hopefully the radiologist does—but they didn’t talk with the patient to assess their risk tolerance and data-collection preferences before saying “consider further evaluation with tissue sampling” in that report.
At the end of the day, respecting patient autonomy matters. It sounds like whoever wrote this article would lean towards asking their doctor to collect as much information as possible. Others wouldn’t. In a perfect world, the patient will be well informed by their doctor, be well-counseled on the risks and benefits of a test / intervention, and will be capable of understanding things like statistics well enough to come to an informed decision that works for them. In reality, that often does not happen for a number of reasons.
I get a full MRI imaging every two years so I spent a lot of time researching the ethics around it just to be prepared, and there are two things I could bring up.
First, false positives. There can be things that looks like problems but aren't, or that are problems but with complicated risk profiles around their management or resolution (especially true of aneurysms). For heavily studied situations where imaging is low risk and hugely effective with low false positive risk, most countries do have screening programs, such as regular cervical smears or mammograms for women of certain ages, as well as aortic aneurysm screening for men over 65 (in the UK, at least).
Second, psychology. A surprising (to me) number of people do not want to know about their medical status until a problem actually occurs. But then once they do know, many folks can be prone to undue worry or hastily made emotionally driven decisions that run contrary to data.
I'm going to totally make up these figures but as a demonstration of the idea, imagine that brain aneurysm scans tend to find aneurysms of concern in 5% of people and that of these 5%, 4% are likely to die within 5-10 years due to that aneurysm. Scan the entire country and you now have millions of people potentially terrified of an aneurysm that won't kill them. If an aneurysm is found and you are offered an operation with a 5% chance of mortality, are you taking it? The research I saw when I was looking into it is that, yes, most people want to get rid of the "problem", despite a higher risk of short term mortality rather than sitting it out. This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.
> Although cardiovascular disease is widely recognized as the leading cause of death, a lesser known fact is that aortic aneurysm is the 15th leading cause of death over the age of 65 years in the USA.
> This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.
Great points. Is it legal for a doctor to hide informations to its patient? such as the fact he has a seemingly "minor" aneurysm ?
> I get a full MRI imaging every two years
You might wanna study radio-protectors such as NAC. I had read it is also a contrastive agent but it's unclear to me what it help to see and what it might inadvertently hide (if anything)
That has nothing to do with NAC. NAC supposedly helps protect against possible kidney damage caused by the contrast agent, nothing to do with radiation, ionizing or otherwise.
Doesn't seem to be a clear indication that it actually helps for that, but it's used for quite a lot of other things, like treating paracetamol overdose.
I want to get regular imaging; I've never done it. I don't even have a PCP, I've been frustrated with previous PCPs not paying attention to detail or waving my symptoms as psychosomatic. I'm not sure how to assess whether a doctor ahead of time would actually be willing to work with me rather than say things that they think make me feel better. These doctors keep running me against the 99% heuristic [https://astralcodexten.substack.com/p/heuristics-that-almost...].
Now I have real money for the first time, I'm sure that makes access easier, but I'm not sure how to search and assess for quality medical care. It seems like search engines are not the way and it's mostly word-of-mouth. I guess I'll go around my office asking coworkers if their pcp is any good / has an opening...
I just want to go into a lab where I can have the imaging / diagnostics run, no question, have the ability to look at the charts myself and send them to whatever doctor -- rather than convincing a doctor to do imaging tests in the first place.
Are you in the US? How are you able to request MRI scans without an immediate cause?
1. Not doing anything in the face of “evidence” is ripe for malpractice lawsuits, rightly or wrongly
2. Not doing anything in the face of “evidence” can drive anxiety for patients and many clinicians want to be seen as having some answer or path forward, however:
3. Not all diagnostics are risk or pain free
4. Not all diagnostics are precise enough to make treatment decisions clear, correct, and authoritative - so more diagnostics will lead to more false positives which, when paired with the previous points lead to trouble for the clinician and possibly the patient.
That is one of those things that sound intuitively true, but isn't necessarily the case in practice.
One example that I am more familiar with: thyroid nodules. Recently, the medical guidelines have increased the size threshold for a biopsy, where you poke a needle in it to find out whether it is cancer or not. We could assume that diagnosing these cancers when they are smaller would always better, but that is not the case... On one end, it turns out when the nodule really is cancer, it is just as safe to wait to do the biopsy only after it has grown over the size threshold. And on the other end, the biopsies are not 100% accurate. A good percentage of the time, it can't say conclusively whether it is cancer or not. When that happens the only way to know for sure is to surgically remove the thyroid, which might result in the patient being put on lifelong hormone medication. One might think that in a perfect world we would act rationally over this uncertain information and not remove the thyroid when all it has is a small nodule with uncertain diagnosis. However, human intuition doesn't work well with percentages. When a patient is told they have a chance of having cancer, no matter how small, they will want to pursue every avenue to investigate and resolve the matter, even when the cost benefit is not worth it. When they looked into the statistics of how many people were getting thyroid surgery we could see that as imaging technology improved, more and more people had thyroid surgery, with no reduction in the number of deaths from thyroid cancer.
If a test shows "narrowed arteries" or whatever but it's not currently impacting you; inaction is an option.
Knew a fellow who was told he had a "weak blood vessel in his brain", had probably had it forever, but now he's retired they can "go in and fix it" and so he goes in for a surgery to remove a threat he was unaware of and that had not hurt him yet.
He got out after a week, never really recovered, and died within 2 months. Apparently there was another aneurysm they failed to see or fix; because it couldn't have been a direct result of his procedure.
Well there are solutions that have negligible risk of damage and potent likeliness of protection/improvement, e.g. for narrowed arteries the vasodilator tadalafil in low dose should be a net improvement.
Then you might want to combine it with a pro-angiogenic drug such as VEGF or better BPC-137.
Also even if someone seems asymptomatic it doesn't mean he is, narrowed arteries very likely to increase his aging rate and chances of death and are likely to create a nocitropic effect by creating a mini brain ischemia.
While I’m sure you know what you’re talking about, and it is very interesting, it’s poor form to suggest treatments for a cardiovascular brain conditions, after being given second hand information of a single symptom with no further history or context.
well yes I was talking in general, actually for brain aneurysms the recommendations I made are likely to increase mortality because the aneurysm has more likelihood to break with a vasodilated overflow.
Could have been; but I don't recall what it was even if i did hear it.
He explained it to me as "they said i had a time bomb that hadn't gone off yet in my skull" but he wasn't convinced until they scared his wife too. My impression was that the seriousness of the condition was debatable, that was the feeling i got from him. What he might've been told by his doctors i dunno.
Since we've accepted to let healthcare be a business, we can only blame the logical consequence of that system, health professionals are running a business, they will scare off the siblings son and grand kids of a senile elderly if they can bank 20k for some unnecessary surgery.
I imagine someone will be jumping on the occasion to point out that not all car dealers are crooks, but the rising number of anecdotes is concerning.
Brain surgery is safe and effective, and prevents severe disease and death. I encourage everyone to stay up to date on their brain surgeries. I’m sorry to hear about your friend.
Nah, we should all assume that of any and all medical interventions are unsafe and ineffective based on individual second-hand anecdotes we read in the comment sections of websites.
The phrase “safe and effective” has a legal meaning and only applies to (1) drugs and vaccines, (2) high risk medical devices, and (3) novel medium risk medical devices.
The phrase “safe and effective” notably does not apply to the practice of medicine, which is not regulated by FDA. When it comes to medical practice, you are usually speaking in the language of (CMS) quality / value - “quality adjusted life years” - and then clinical endpoints - blood pressure below X.
I know this is being pedantic, but as someone who has had an up close view of FDA regulatory policy / process from both sides of the table, it literally hurts my head to see some of the inaccurate and misguided stuff that gets bandied about on the interwebs.
My understanding is that, for typical "retirement age" humans, any major surgery (including "physically minor, but you're under general anesthesia for a while surgery) carries a high risk both of very slow recovery, and of very slow or obviously incomplete recovery of pre-surgery mental capabilities.
I had a brain surgery (craniectomy to remove a colloid cyst in the interventricular foramen of Monro) at 22, and while I was home from the hospital after 2 days it took over a month to get back to normal. It'd surely be hellish after retirement age. Anything with general anesthesia is high-risk, no matter how minor the rest of the procedure.
> What? If the harms of the biopsy outweigh the benefits, don’t do the damn biopsy!
But you’ll get sued if the scan suggests something but you don’t follow up and do the biopsy, and it turns out to be cancer. The author doesn’t seem to realize this is all happening against the background of potential litigation.
To paraphrase the author's point -- the doctor could have a policy to intervene only if the screening produces _flagrantly_ worrying results, and continue to not intervene in cases where the results are merely mildly worrying. Technically, this might lead to strictly better outcomes at the ensemble level.
But any patient likely 1. doesn't care about ensemble performance 2. will get stressed out at the mildest indication of concern 3. induce a concave payoff for a trigger-shy doctor (no credit for correctly not intervening, and massive discredit for incorrectly not intervening).
One reason behind why doctors can’t simply do tests then not follow up is simply medical malpractice suits.
Often times, once you do the test you’re locked into figuring out everything even to the detriment of the patient for fear of getting your license revoked.
The NHS has gone the other way and wont run diagnostic tests it really needs to. The end result is growing legal action over failure to diagnose conditions. Long covid is diagnosed in just 28,000 patients and yet the office for national statistics says by the symptom studies 1.8 million have it. There is no where I know of, certainly not on the NHS, where you can get a test for microclots, a condition found in the bulk of Long Covid cases and easily treatable but doesn't show up in normal clotting tests. You can get micro clot tests throughout a lot of Africa but such is the reluctance to run tests in the UK no labs have bothered. Its something we have known can be tested and treated for 17 months at least.
Be careful about reducing the testing just because it drives over treatment because under treatment is quite deadly, cheaper maybe but also has a serious impact of life expectancy and disease burden. Life expectancy is dropping in the UK and disease burden is one of the highest in the western world and growing. The grass isn't greener on the low test and treatment side, health care is still increasingly expensive and the results are worse.
You’re willing to trade off a few extra deaths if you can save a certain amount of money. Hell NICE in the UK put a very firm GBP figure on the value of a life-year.
It works great at a population level since you maximize outcomes and keep costs low.
But that isn’t that comforting when you’re the poor bloke who dies from lung cancer that could have been detected early but NICE said the 50GBP test isn’t cost-effective.
People point to the US, but every country in the world is struggling with healthcare costs and how to contain them. As technologies develop, costs will only continue to rise - the question is how to control costs and get the maximum benefit.
From my own experience it's typically done a few ways: 1) the government decides what treatment will be paid for and which ones won't [this works pretty well since patients don't know what they're missing], 2) the government simply caps a budget and pushes treatment decision down - doctors and hospital are forced to make trade-offs. Countries that do #2 often have long wait times for elective procedures - that's the cost control mechanism.
The US does neither one of these very well (but does them to some extent, but it's unevenly applied), so costs are very high (in addition to other factors). But if one wants universal care and a manageable healthcare budget, you need to say "no" to some things that would otherwise still benefit the patient.
And yet I seem to remember we were told government would not be making vital healthcare decisions like the greedy private sector corporations. That was supposedly a chief selling point to government managed care.
To be honest, this seems to be the best approach. The public system provides a baseline level of care based on a set budget. Individuals are free to seek additional care at their own expense.
Compare the UK vs. US [0]: life expectancy is higher in the UK _and_ expenditure is lower. As much as people love to dunk on the NHS, population-level optimization works.
I am in a similar boat, I feel healthy but I would like to do a full body and blood checkup to know if there's anything coming down the line or if anything's out of order at the moment but I do not yet know.
Is it better to know? To not know? To know when it's the moment? BTW I'm in Italy so it wouldn't even be that expensive to do every couple years.
That's all nice but we used to recommend systematic PSA screening for all males over 50. We later realized that there was a lot of false positives and that the intervention often brought more risks than it cured actual cancers. So it's only recommended for patients with risk factors.
Now, consider the GP who has healthy 50yo, does a PSA anyway and it's positive. The GP could still decide not to act. But the patient is not so likely not to do anything. Or even understand the odds. At that point, if the patient dies, the GP is likely to get sued because he should have acted. Even if over all of his patients, not acting was more efficient. If the GP decides to act, however, regardless of whether the patient survives, he won't be blamed for it. So doctors have a nasty incentive to act.
What about the other extreme, let everyone do all the tests imaginable? Or course it doesn't make sense. The balance is on how mych evidence available before a test is suggested. Evidence is the incident rate among the population and the false negative rate(specificity). I'm using very loosely defined terms here because I'm too lazy to quote the definition. But no need false dichotomy.
There is an easy fix but nobody would stand for it: do full longitudinal surveillance of all tests. That is, the gent with the “narrowed” arteries could be followed to see if it becomes a problem (a lot of the metrics are, to simplify, fairly arbitrary and based on a small observational n). Perhaps he does have a stroke, perhaps not.
Of course no one would stand for such an intrusive system. But over time it would improve diagnosis.
anonymised data about prescription correlations and symptom metrics is the #1 missed opportunity of mankind progress.
The tragic fact is, for most drug we have zero clue what they're doing to your body after a 6month-1 year period, nor do we know what do the combinatorial explosion of polypharmacical interactions do.
There are people currently living the dream of increased lifepsan/healspan by getting lucky on that pharmacological lottery ticket and other (most) are living the invisible damage nightmare.
There’s a baseline issue here which is insurance companies and actuaries.
If you can afford to be outside the insurance system in the US you can get excellent care. That can include having tests done that aren’t covered by insurance and avoiding tests that an insurance company would normally require just for CYA reasons, but aren’t worth the risk.
But the incentives of the insurance-driven care are not aligned with optimal patient outcome.
in countries that have public paid medicare (such as France) it really shows that it leads to a strong lag in adopting modern medical practices and drugs.
I'm not advocating against free medecine, however this limitation should be more highlighted than it currently is. Too many people think they're getting the best treatment..
The patient should have a right to be an early adopter if he wants to. Besides, drugs will never leave alpha status if we never let them flow on the market. Although yes obviously a gradually titrated A/B testing scheme would be much more reasonable than the current illegal/legal shift. Moreover cf my other comments, anonymised statistics are needed.
I hear this repeated a lot but it’s not necessarily true.
I had an experience with a doctor who was supposedly so prestigious that she didn’t accept insurance. I ended up going to two appointments where she did nothing but push for redoing some tests in her expensive laboratory at a cost of $5000. She couldn’t explain why her lab was different and eventually admitted that they used the exact same equipment as my previous (insurance-covered) test.
When I declined and tried to leave she offered me the “discount” of $1000 off for new patients. It was really just one big push to funnel people through her expensive lab combined with a fancy office and nice bedside manner.
Don’t assume that just because someone is outside of the insurance system they’re going to provide superior care.
You got scammed. Sounds like you know that. I’ve seen functional medicine docs like this too, it’s a part of their business model to sell you overpriced supplements that they get kickbacks from.
Just because they don’t take insurance doesn’t mean they don’t have their own ethical sketchiness. However, just because there are bad non-insurance docs out there doesnt mean there aren’t excellent, ethical ones of the type OP described.
My wife gets to visit them a lot due to a skin cancer episode, and her former practice was swallowed up by some private equity dermatology group. I learned about their operations via a case study published one of their vendors - a commission/incentive management software platform. Up to 70% of provider pay is about pushing magic goop for your face.
> a doctor who was supposedly so prestigious that she didn’t accept insurance.
It seems like there's a problem right up front: prestige.
My main doctor doesn't accept insurance though she will give you a form with the diagnosis codes marked if you want to submit it yourself. She simply doesn't want to deal with the paperwork. There's none of the fancy "concierge" and "membership" bullshit, much less "prestige". She just has an ordinary doctor's office, and doesn't own a lab or anything.
But in exchange for filing the insurance form if I remember to: the longest I've had to wait to see her when I was sick was a couple of hours, I can bring my dog with me to my visits, and she and I pass scientific papers back and forth when determining treatment. But the main advantages of "no insurance" are that we have lots of time for a visit (if needed) and nobody looking over her shoulder for prior auth or such. It's a much more collaborative model.
Unfortunately I don't think this model scales, but my exposure to the more formula-driven mass medical system has been discouraging.
Why would I not? He attends board meetings, restaurants (when I sit outside) and is with me pretty much 24 hours a day. He use to go into the office back when I did that.
More generally I had read on HN a while ago that this is the reason why doctors don't do a Full-body radiography/scan. Because many humans have bugs/anomalies that are mild/non-issues but are ambiguous and anxiety prone. The latter (and most salient reason tragically) is that the doctos by covering much more data, would become legally responsible for not seeing (e.g. a tumor found in a place that wasn't the tissue/region target of the original investigation)
I find those really sad and I want to have a whole body radio (and disclose that I take the anxiety cost willfully and that I abandon my right to sue the doctor for this specific radio), is it possible? Is there a place where this can be done?
It’s just a full-body MRI. Costs a couple thousand dollars. Would put it in the category of neat curiosity and possibly useful as a baseline or if you have surprise cancer or something. But totally unnecessary and to be avoided if you’re prone to medical anxiety.
> 1000 dollar per hour seems like a non-reasonable price
MRIs are expensive machinery that take highly-trained and well-paid technicians to maintain and operate. The imaging process takes an hour alone; start to finish, it's a two-hour process that is far from just pushing a button.
> one should have a legal right to command a MRI scan without paid analysis
I don't think there is a law, in America, prohibiting MRIs without expert analysis. But one, that's useless. And two, the people who don't think it's useless are the ones most likely to misinterpret the data and cause problems for the MRI provider.
> Result: How much does an MRI scan cost in India? The average cost of MRI scan in India is usually between Rs. 1500 to Rs. 25000.
> Query: Rs. 25000 in US dollars
> Result: 25,000 Indian Rupee equals 321.02 United States Dollar
...so ok, there's a chance the first answer is wrong and/or there's some factor I'm missing, but assuming it isn't one must again ask the question: Why does an MRI cost $5k?
For the record, asking specifically about a full body scan did not change the price:
> Query: cost of an full body MRI in India
> Result: [...] And the full-body scan cost you between INR 18000 to INR 25000 in India.
Where did $5k come from? I said a "couple thousand dollars," though looking at my e-mail it was $1,500. A 4 to 5x cost differential from India to New York City seems explicable.
$5k is a number that's been thrown around in this thread so I guess it stuck in my head.
> A 4 to 5x cost differential from India to New York City seems explicable.
Then please explain it, because you seemed to be saying that this expense was inherent to the machine and had little to do with cost of related labor. If that was the case, one wouldn't expect an MRI in India to cost 1/5th as much.
I also doubt it would be any less expensive here in south central Wisconsin than it is in New York City.
> this expense was inherent to the machine and had little to do with cost of related labor
The machines are expensive. They also vary in strength, with scanners in e.g. the Philippines and Malaysia being of considerably lower strength than is common in America [1]. (I couldn't find data for India. There are certainly no 7T scanners there; I believe most are 1.5T and below. In New York, it was a 3T.)
Between that, which might be a 2 or 3x differential between a low and high field strength scanner, and the cost differential of "highly-trained and well-paid technicians [needed] to maintain and operate" [2], 4 to 5x seems explicable.
answering you next comment since HN has a lag..
I don't think american radiologist read this paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265198/ but hey one can hope the myth that occidentals are better trained, it might be actually true who knows
The question that needs to asked though is: what would you do with that information? Would you be willing to undergo biopsy (which is the standard for diagnosis) knowing there is a non-zero risk of complication. What if the biopsy is not conclusive? Do we then do a major surgery which includes risk of death? Imaging is NOT diagnostic for tumors. For most lesions, you have to take tissue samples.
> what would you do with that information?
Well for starters anyone should check he has the right number of each organ, and at the right place (not ectoplasmic), and that their shape and volume is not pathologic.
You should also check your bones joints to check wether you have metallic accumulation or not.
It's not just about tumors. In any cases, there are generally many possibles diagnosises that do not involve a biopsy, such as blood/urine/lymph/fecal biomarkers, and DNA testing. In some cases you might even consider biofluorescence.
Secondly, if a thing look like a tumor, I would study the risk and if very low I would proceed for a biopsy (risk seems OK) or otherwise use anticarcinogenic drugs.
I would not proceed to a risky surgery unless necessary though, especially in an era where potent anticarcinogenic exists such as PNC-27
> Full-body radiography/scan. Because many humans have bugs/anomalies that are mild/non-issues but are ambiguous and anxiety prone.
These scans aren't magic. Most of the time you need a "contrast agent" to find things.
That means an injection (and attendant infection risk) and circulation of a strange substance in your body. In the case of Gadolinium, there's about a 1 in 1000 reaction risk. So, you don't want to go injecting that into people without a good reason.
One slightly reasonable common argument I hear for reduced medical diagnostics is: “we don’t have the resources; it’d overwhelm the medical system”. While this may be the case for some tests, there are probably a great number of tests that could be scaled to be done yearly on the whole population.
> While this may be the case for some tests, there are probably a great number of tests that could be scaled to be done yearly on the whole population.
Isn't this already the case? Tests that are considered worth doing regularly even without extra symptoms are done regularly. E.g. mammograms and colonoscopies/stool tests.
(I'm ignoring your focus on "yearly" since really you care about "regularly" given that yearly is totally arbitrary and timing that makes sense is clearly dependent on the tests in question.)
No. Not all screenings/tests are done, even when it's super low cost and non-invasive. For example, one factor that is used to determine whether to screen for certain types of cancer is "Possible harms from follow-up procedures". [1] Another factor that is taken into account it the chances of a false positive. [1] Both of these factors are irrational, since more information is strictly optimal given a rational agent. They should not even merit consideration in choosing whether to undertake a screening (this information should only be used after a screening is done, to determine follow-up action).
In my opinion, the only justifiable factors are probably along the lines of:
- invasiveness (e.g. if it's non-invasive or minimal cost)
- benefit to the patient if detected
- cost relative to other screenings/actions that can be done for the patient
> For example, one factor that is used to determine whether to screen for certain types of cancer is "Possible harms from follow-up procedures". [1] Another factor that is taken into account it the chances of a false positive. [1] Both of these factors are irrational, since more information is strictly optimal given a rational agent.
Your entire argument here seems to require patients to be rational agents. They aren't.
> Your entire argument here seems to require patients to be rational agents.
Yes, my argument does rely on patients being rational agents.
> They aren't.
That may be true, but it's certainly paternalistic (in the formal, definitional sense) to act as if they are not rational agents and withhold information/reduce autonomy. This is a case of pure paternalism (again, in the formal philosophical sense).
Different ethical systems, of course, make different judgements on whether this behavior is moral. It's also up for debate whether this is a desirable feature of the medical system.
> That may be true, but it's certainly paternalistic (in the formal, definitional sense) to act as if they are not rational agents and withhold information. This is a case of pure paternalism (again, in the formal philosophical sense).
Call it whatever you want. Idealizing patients as rational agents instead of considering how they are in reality results in worse outcomes. If your goal is to actually help people, you should base your arguments on how things are in reality instead of some idealized dream world.
> If your goal is to actually help people, you should base your arguments on how things are in reality instead of some idealized dream world.
That's a fair position (you seem to be a utilitarian), and probably quite defensible. But, one could argue that patient choice is an important feature for our medical systems to have. I certainly want to be able to refuse medications that my doctor recommends (e.g. opioids) or seek alternate advice/second opinions. My cost-benefit analysis equation is probably not the same as my doctor.
To be clear, I'm not talking about an "idealized dream world", as you put it -- I'm talking about patient autonomy in the real world, even if it means allowing patients to make what seems like a suboptimal decision.
I made that point because I argue that patient autonomy is important. Further, I argue that in order to protect patient autonomy, information should not be withheld from the patient. Accordingly, the patient should be given everything necessary to enable them to make optimal choices as a rational agent. Not providing low-cost, minimally-invasive screen tests to the patient, under the premise that the patient is an irrational agent, reduces their autonomy insofar as it limits their decision-making capacity. I argue that there is no compelling justification to do this for low-cost, minimally-invasive screenings. Furthermore, assuming that the patient is rational and finding ways to advance the rational patient's well-being protects patient autonomy. Therefore, the only justifiable factors that should be considered when screening patients that preserve patient autonomy is what I stated here: https://news.ycombinator.com/item?id=31450997
Does the position seem clear now? I apologize if this line of reasoning was not clear earlier.
> Not providing low-cost, minimally-invasive screen tests to the patient, under the premise that the patient is an irrational agent, reduces their autonomy for no justifiable reason.
The reality that patients are irrational agents _is_ a justifiable reason.
> Therefore, the only justifiable factors that should be considered when screening patients that preserve patient autonomy...
Your position is clear. I disagree. I think given real constraints (economic, legal, psychology of patients/doctors/etc.) focusing on overall quality of outcomes makes most sense. You can disagree if you want, but don't pretend it's not justifiable.
edit: Besides all the tests are available to you. You can pay them if you'd like. Given they are low-cost (at least those you're focusing on here) it really isn't a burden on you to get the tests done yourself.
- Physicians want to avoid getting sued
- Physicians want to get paid , just like everyone else.
- The payor in the system is not the patient, but a faraway entity removed from the situation on the ground.
In such instances, all 3 factors influence a decision.
If a decision to perform procedure X is close to 50/50 (test/no test)
Do you think "no test" will win ?
Now put that in the macro context of millions of patient visits.
now, since we are talking diagnostic testing, you may need to be tested at a hospital. So now, you are voluntarily exposing yourself to a hub of tired doctors/bureaucracy/germs.
I was squarely in the author's camp and am now a little less so having seen the impact of false positives on my family. Anxiety is real and harmful, and humans are generally very bad at responding to tiny, explicit risk of big harm (small nodule in lung that may be cancer or not, covid, vaccine side-effects, shark attacks).
From what I understood about how the system works in most European countries:
A test has a specific sensitivity and a rate of false positives. So for screening (CT in this case) you would want a high sensitivity and low cost, while the false positives would not be your priority. The positives should go through a confirming test (biopsy in this case) with a high specificity. Here cost and sensitivity are usually secondary.
Now insurers look at the screening tests rate of false positives. If they deem it too high, they don't want doctors to do those tests on a population with a low probability of having the condition you are screening for (low base rate). If the patient belongs to a subgroup shown to have a high enough base rate of a condition, then it makes sense to do the screening.
Then you have different patients, some want to get one MRI each year, some only want to run diagnostic after they experience symptoms. I believe most doctors respect that individual risk tolerance within the given framework.
Now the thresholds obviously should be revised regularly as cost, test properties and even base rates of diseases change, but I don't see a systemic defect here, my blind spot?
The big problem with testing is that it assumes the human body can be averaged.
We are not.
One person's natural lump is another's cancer.
One person's low heart rate is another's natural genetic gift.
Modern medicine , particularly compensation, wants to put everything in neat black/white boxes.
Which is why tests are more dangerous than they seem.
You are not average, and you shouldn't compare yourself to any perceived average because the human body is not average.
You should compare yourself to you, and that's all the doctor should use.
> And I’ll wearily pretend to accept that people are emotional and couldn’t understand Bayesian reasoning or false positives and so we need to worry about stressing them out (#2).
> Why are we taking as given that a net-negative decision to do a biopsy will be made
The author should stop wearily pretending that anxiety isn’t a common result of a positive test, and recognize that the average person is not comforted by a Bayesian analysis when their health could be at risk.
If continuing to a biopsy is as common as the author says (I don’t have any data on it), that suggests anxiety IS a common response and we can’t simply wish it weren’t the case. Mental health is health.
Thanks for saying this. There was an article the other day here on HN about someone totally obsessed with “fulfilling“ his iphone app’s health “objectives”.
Anxiety is one of the worst outcomes of over-diagnostics.
This. I don’t want to know there’s a nodule and then hear “but it could be nothing. Don’t worry about it.”
Because then suddenly, I’ll become hyper aware of every potentially significant symptom and have to resist the urge to constantly google and check if there’s a chance it might indicate something. Is that pimple a pimple? Hey, I don’t remember my neck feeling this lumpy. Boy, I sure do seem to have sinus issues a lot. Are these joint aches normal? Etc, etc, etc.
As a kid, I felt absolutely invulnerable to worrying about my health. The first time I experienced true health anxiety is when my doctor pointed out a mole on my back and said “do you want to check this mole for cancer?” to which I replied, “oh, I guess so?”… only he didn’t. Because he checked with insurance, and insurance came back negative on it.
I am still in my 20s. I’m not in the best health, but my everyday life is pretty uninhibited by health issues. I don’t wake up with coldsweats. So yeah, it could happen to me, but frankly it’s worth being skeptical at my age.
But when the doctor pointed out that mole, they shattered the mental barrier I had between myself and cancer patients. I knew mentally that of course it could happen to me, but I had absolutely no idea that the signs of it could literally be hiding on my back, and I would be none the wiser. I googled and I learned a whole lot, and my intuitions were very wrong. In fact, I had many symptoms that can indicate various cancers. I heard stories about pimples that were not pimples, back pain that was not back pain, etc. people living normal lives who just went in for a checkup and suddenly faced certain death.
I’ve mostly snapped out of the hypochondria mindset, but still today I wonder about some symptoms in a way I never would’ve before. My life is altered by this one thing a doctor said off hand.
And for what it’s worth, I’m not saying he should not have done that. Insurance should’ve covered the biopsy just in case. I’ve outright noticed that sometimes, doctors will slightly edit your responses to things to get insurance to OK a diagnostic, and I think it’s in some part because they know that if you don’t get that peace of mind it could be damaging. Being hyper aware of your heart beat or super concerned about sleep apnea is not as bad as suffering from actual disease, but it’s certainly it’s own kind of hell.
It’s weird to me because much like cancer patients, I viewed myself as separate from hypochondriacs and immune to it as a whole. A lesson learned the hard way, and now I feel a twinge every time I see a new headline about cancer or hypochondria.
Could having doctors refuse to run diagnostics also lead to anxiety? It has for me personally but I may not be the typical patient. Some people want zero information about medical issues. They just want to leave all of it to the doctors, no desire to research their condition or understand the details; just trust the doc. I am the sort of person if my mechanic tells me I need an expensive repair, I want to know why. Once I had a dr tell me that I was wrong to feel less anxiety after getting an abnormal brain scan, than I would have felt had I not had the scan at all. It was an absurd conversation and very clear to me that the dr was more invested in his opinion on the matter than he was in listening to my reasons why the scan was reassuring to me. It was an mri, so no radiation. But he insisted that my anxiety would be worse having had the scan than if I hadn’t. A bizarre moment. Anyway, maybe doctors sometimes get too stuck on their own opinions and don’t fully appreciate that there are more than one type of patient? Some people like to change their own oil, some do not. Doctors may also underrate the anxiety of having no clear diagnosis when life changing problems occur. One size fits all mentality is probably wrong.
Did you offer to pay for the MRI cash (roughly $5k I would bet)?
Because to me this sounds more like "your insurance won't pay for it because it is not an indicated study by ACR criteria."
I hear that spending hours on the phone trying to justify a test to an insurance company is no fun, and I bet the task is not made any easier if you don't actually believe that the study will help the patient.
HMO so yes, costs are a factor. But it was a small cost relative to repeated doctor visits, hospital costs, etc… MRI for massive HMO are not $5000 due to economies of scale. The dr in this case was angry because the MRI revealed brain tumors which needed to be monitored.
$5k would be the estimated outside-of-insurance cost to you, to avoid spending hours of the MD trying to justify the study with the insurance.
Meningiomas by chance?
Has the monitoring improved your health? I'm not sure whether I would be more or less troubled if I had symptoms with an unclear cause vs a possible cause but unclear management plan. I suppose this will be highly variable.
For anyone looking at self pay for an MRI in the US, there's an organization that offers that and other imaging services for the uninsured at $325 or less. https://radiologyassist.com/MRI.html
This article is rather funny because it misses out on key facts of how doctors practice medicine these days.
I listen to my supremely well educated plastic surgeon wife regularly discussing and giving guidance to office staff around patients in their private practice. Their general approach is to get patient statistics, and that is all, without the aggregated vital signs. I asked her once, "Why don't you get the patient vital signs too?"
Her response was unexpected, "If we get patient vital signs, we immediately become liable for patient overall health. Our malpractice insurance is specific to the practice of medicine for plastic surgeons, and plastic surgeons only. Our front office staff are normally front office only, or aspiring doctors on a break between their undergrad and entry to medschool. Our practice uses no Nurse Practicioners, Physician's Assistants, or nurses. We're not set up, or staffed appropriately to deliver general medical care."
Conclusion 1: Medical care is characterized by liability control; there are logistics/staffing aspects to medicine around specific types of care.
Medical Diagnosis we think of as scans, remote tests. You get a CAT scan, you get an MRI, or X-ray, bam, 15 seconds, 5 minutes, or an hour later (after waiting in a hospital for hours) you're done and some radiologist or other specialist is interpreting the results and you have a diagnosis. That is true in some cases, but not others. If you get a positive mammogram, or a suspicious lump what is the next step? Welp, that is regularly one of two things - a needle biopsy, or an investigational biopsy. Needle implies small, thin, fairly painless. Not this needle - instead imagine a needle designed for tissue harvesting, like a horse sized needle. This big giant thing needs to go into your breast to suck up enough of the suspicious lump for a pathologist to examine it. Alternatively, you could have an investigational biopsy where a surgeon takes a small amount of tissue from inside your breast with a scalpel. Investigational biopsies via scalpel can be a big scam too, where a car accident occurs, a cut tendon in the hand, and the surgeon decides to open up the arm past the wrist to visualize all the soft tissue up the arm. Lucrative billing enhancements.. But, when it comes to breasts, we know that certain life changes predispose towards a positive mammogram for a limited time window. Stopping breast feeding being the foremost change that can cause suspicious lumps.
Conclusion 2:
Diagnostic tests can be quite painful, and, at the wrong time, quite unneeded. Some of them are damaging. Good medicine is about as much when to intervene, and when to test, just as much as it is about when not to intervene and when not to test.
Not for the reasons central to the article, but my favorite is the No HPV Test For Men stance. Because men usually don't have symptoms and have far less risk of cancer than women..... Just take 10 seconds to ponder how myopic that is. But that's how the medical establishment thinks about health care.
This is so true. And I think we need more Bayesian models in Hospital IT systems to help with this. The probability needs to be updated, you shift to a new population with new evidence. It seems so clear, yet somehow it is so intuitive. Why? In many respects, Bayesian reasoning is just what we do, but then sometimes it fails us. We are just not good at accepting risks of any kind I think. Better to not put ourselves into this position seems to be the reasoning. Avoid that "The test told you so!" feeling...
> If you do a CT scan and it shows a mass, you’ll order a biopsy.
> But because that patient was low-risk, the harms of that biopsy will outweigh the benefits.
> Thus, you shouldn’t do the CT scan.
> What? If the harms of the biopsy outweigh the benefits, don’t do the damn biopsy!
I'm not sure what the point of doing the CT scan if we're not going to act on its result.
Sure, you gain the confidence that everything's gucci if it turns negative. Is that really worth the stress of the test going positive and the not doing the biopsy? Seems dubious to me.
In a "perfect world" we'd all get routine checks, this would have two advantages:
* Most illneses are easier to treat and have better long term outcomes in terms of morbidity, when they are detected early / in a asymptomatic stage.
* We could collectively use the data collected from scanning "healthy" people, and adjust our bayesian priors so that we can more accurately adjust our diagnostic measures. E.g. common virus infections can give you brain lesions visible in MRI scans. However since MRIs are expensive we rarely scan healthy people so every lesion in an MRI is an immediate supicion of MS or other neurodegnerative diseases.
We simply don't have good baselines for this.
The latter would allow us to look at all the indicators more holistically to make a well balanced judgement if more invasive diagnostics are warranted.
I think the author is correct in the acedemic sense, but ignorant of the reality of healthcare.
If a doctor receives a test result that shows a suspicious mass, then neglects to order a biopsy to investigate further, there are 2 rough outcomes.
1. It was nothing
2. It was cancer
If it turns out to be (2), the doctor and the practice/hospital/whatever gets sued for malpractice.
On a more ranty note, why does everyone think they are better at other people's jobs than those people are? Where is the basic trust in the other? You think a doctor in the United States after ~15 years of school doesn't know that most biopsies turn out to be more harmful that useful? Come on. Restore some basic trust in other's competence.
This is the reality. In fact, the situation is getting even more complicated as direct-to-consumer screening becomes more popular (e.g. full body MRI scans). Companies that are selling the health screenings are only incentivized to sell as many screenings as possible. Scans inevitably result in benign incidental findings far more often than they identify real health problems. Then the patient is directed to a specialist who is uninvolved with the screening company. The specialist is incentivized to aggressively investigate the finding out of fear of malpractice and due to pressure from the patient. Nobody has ever thanked their doctor for inaction. The end result far too often is a series of expensive and painful procedures with a large dose of anxiety. Of course screenings also save lives, but nobody is responsible for ensuring the benefits outweigh the harms at the macro level.
I don't think any actor in that chain is malicious, it's just an example of poorly aligned incentives. Screening companies, doctors and patients all believe they are making the most optimal choice.
Presumably the patient can decline the biopsy? What happens to liability in that case? Does the doctor then have to decline to work with that patient further? What happens to liability if the doctor doesn't fire the patient? I agree there needs to be trust somehow, yet it seems practitioners hands are tied from a level above to toe the line for liability reasons rather than patient outcome. Is a doctor able to take into account all extenuating circumstances of a patient or only those predefined on a checklist passed on by a murky review process? What happens to patients who do research and find alternative (maybe better) opinions, well are they in network? Can a network have differing opinions among its practitioners?
Generally there would be no potential medical malpractice liability if a patient declines a medical procedure. That happens all the time.
Physicians can fire patients, although they seldom do so because of declining a medical procedure. Professional ethics and state laws generally require the physician to first hand off the patient to another physician first; they can't just drop someone with zero notice.
There is generally no mandated checklist, at least not from a legal standpoint. Some healthcare provider organizations do require their employees to follow certain written standards of care. Medical societies also publish evidence-based care guidelines. Compliance is voluntary but gross deviations could be factor in liability cases or in actions by state medical boards.
Insurance reimbursement is an entirely separate issue. Every insurance plan has a different network of providers and different rules about which services are covered under various circumstances.
Also the author seems to entirely ignore patient psychology. Sure in some parallel universe where patients can be told "so we found something weird on your lung don't know what it is and don't really care" and just accept it, then maybe doing the unnecessary tests doesn't matter (ignoring extra costs of course which _do_ matter). But we don't live in that universe. Ignoring how patients actually behave and pretending they are just perfectly logical is basically malpractice in my opinion.
Amusing Idea: Let people apply for "Always Full Diagnostics" status, and accept ~0.01% of the population. The "lucky" AFD's would get every test, scan, biopsy, follow-up, exploratory surgery, etc. that was remotely plausible. The anonymized results from all those (mostly unwise) things would be a gold mine of public health data. And I suspect there'd be more than enough obvious adverse outcomes to convince most of the other ~99.99% that "more is better" does not apply to medical diagnostics.
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[ 4.1 ms ] story [ 153 ms ] threadSometimes no action is the correct action, but no one is going to do that. How many laws have been passed because “something needs to be done” even though nothing in the law needed fixing?
Many people, I’d say most, are not happy with inaction. Knowing something may be seriously wrong can have an enormous emotional cost for some people. Dismissing this as irrational is like saying humans are irrational. (Spoiler: they are)
The article also seems to imply that their is one entity or person who controls all aspects of diagnosis (hence the meme at the top), from taking a history and doing a physical exam to perfectly understanding the intricacies of all additional diagnostic testing. Of course, your primary care doctor may not understand exactly what percentage of people in a low (or high) risk cohort with this lung nodule with certain specific imaging features turn out to have cancer. Hopefully the radiologist does—but they didn’t talk with the patient to assess their risk tolerance and data-collection preferences before saying “consider further evaluation with tissue sampling” in that report.
At the end of the day, respecting patient autonomy matters. It sounds like whoever wrote this article would lean towards asking their doctor to collect as much information as possible. Others wouldn’t. In a perfect world, the patient will be well informed by their doctor, be well-counseled on the risks and benefits of a test / intervention, and will be capable of understanding things like statistics well enough to come to an informed decision that works for them. In reality, that often does not happen for a number of reasons.
First, false positives. There can be things that looks like problems but aren't, or that are problems but with complicated risk profiles around their management or resolution (especially true of aneurysms). For heavily studied situations where imaging is low risk and hugely effective with low false positive risk, most countries do have screening programs, such as regular cervical smears or mammograms for women of certain ages, as well as aortic aneurysm screening for men over 65 (in the UK, at least).
Second, psychology. A surprising (to me) number of people do not want to know about their medical status until a problem actually occurs. But then once they do know, many folks can be prone to undue worry or hastily made emotionally driven decisions that run contrary to data.
I'm going to totally make up these figures but as a demonstration of the idea, imagine that brain aneurysm scans tend to find aneurysms of concern in 5% of people and that of these 5%, 4% are likely to die within 5-10 years due to that aneurysm. Scan the entire country and you now have millions of people potentially terrified of an aneurysm that won't kill them. If an aneurysm is found and you are offered an operation with a 5% chance of mortality, are you taking it? The research I saw when I was looking into it is that, yes, most people want to get rid of the "problem", despite a higher risk of short term mortality rather than sitting it out. This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.
I was not aware of this. non-surgical interventions: https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_C...
> This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.
Great points. Is it legal for a doctor to hide informations to its patient? such as the fact he has a seemingly "minor" aneurysm ?
> I get a full MRI imaging every two years
You might wanna study radio-protectors such as NAC. I had read it is also a contrastive agent but it's unclear to me what it help to see and what it might inadvertently hide (if anything)
Doesn't seem to be a clear indication that it actually helps for that, but it's used for quite a lot of other things, like treating paracetamol overdose.
bruh radiations induce oxidative stress and free radicals which is the major cause of damage, which the antioxidant GSH (NAC) prevents/reduce
Now I have real money for the first time, I'm sure that makes access easier, but I'm not sure how to search and assess for quality medical care. It seems like search engines are not the way and it's mostly word-of-mouth. I guess I'll go around my office asking coworkers if their pcp is any good / has an opening...
I just want to go into a lab where I can have the imaging / diagnostics run, no question, have the ability to look at the charts myself and send them to whatever doctor -- rather than convincing a doctor to do imaging tests in the first place.
Are you in the US? How are you able to request MRI scans without an immediate cause?
1. Not doing anything in the face of “evidence” is ripe for malpractice lawsuits, rightly or wrongly
2. Not doing anything in the face of “evidence” can drive anxiety for patients and many clinicians want to be seen as having some answer or path forward, however:
3. Not all diagnostics are risk or pain free
4. Not all diagnostics are precise enough to make treatment decisions clear, correct, and authoritative - so more diagnostics will lead to more false positives which, when paired with the previous points lead to trouble for the clinician and possibly the patient.
One example that I am more familiar with: thyroid nodules. Recently, the medical guidelines have increased the size threshold for a biopsy, where you poke a needle in it to find out whether it is cancer or not. We could assume that diagnosing these cancers when they are smaller would always better, but that is not the case... On one end, it turns out when the nodule really is cancer, it is just as safe to wait to do the biopsy only after it has grown over the size threshold. And on the other end, the biopsies are not 100% accurate. A good percentage of the time, it can't say conclusively whether it is cancer or not. When that happens the only way to know for sure is to surgically remove the thyroid, which might result in the patient being put on lifelong hormone medication. One might think that in a perfect world we would act rationally over this uncertain information and not remove the thyroid when all it has is a small nodule with uncertain diagnosis. However, human intuition doesn't work well with percentages. When a patient is told they have a chance of having cancer, no matter how small, they will want to pursue every avenue to investigate and resolve the matter, even when the cost benefit is not worth it. When they looked into the statistics of how many people were getting thyroid surgery we could see that as imaging technology improved, more and more people had thyroid surgery, with no reduction in the number of deaths from thyroid cancer.
No? That's even shown clearly in the anecdotes of the original blog post.
Knew a fellow who was told he had a "weak blood vessel in his brain", had probably had it forever, but now he's retired they can "go in and fix it" and so he goes in for a surgery to remove a threat he was unaware of and that had not hurt him yet.
He got out after a week, never really recovered, and died within 2 months. Apparently there was another aneurysm they failed to see or fix; because it couldn't have been a direct result of his procedure.
Well there are solutions that have negligible risk of damage and potent likeliness of protection/improvement, e.g. for narrowed arteries the vasodilator tadalafil in low dose should be a net improvement. Then you might want to combine it with a pro-angiogenic drug such as VEGF or better BPC-137.
Also even if someone seems asymptomatic it doesn't mean he is, narrowed arteries very likely to increase his aging rate and chances of death and are likely to create a nocitropic effect by creating a mini brain ischemia.
https://en.m.wikipedia.org/wiki/Cerebral_arteriovenous_malfo...
He explained it to me as "they said i had a time bomb that hadn't gone off yet in my skull" but he wasn't convinced until they scared his wife too. My impression was that the seriousness of the condition was debatable, that was the feeling i got from him. What he might've been told by his doctors i dunno.
I imagine someone will be jumping on the occasion to point out that not all car dealers are crooks, but the rising number of anecdotes is concerning.
The phrase “safe and effective” has a legal meaning and only applies to (1) drugs and vaccines, (2) high risk medical devices, and (3) novel medium risk medical devices.
The phrase “safe and effective” notably does not apply to the practice of medicine, which is not regulated by FDA. When it comes to medical practice, you are usually speaking in the language of (CMS) quality / value - “quality adjusted life years” - and then clinical endpoints - blood pressure below X.
I know this is being pedantic, but as someone who has had an up close view of FDA regulatory policy / process from both sides of the table, it literally hurts my head to see some of the inaccurate and misguided stuff that gets bandied about on the interwebs.
But you’ll get sued if the scan suggests something but you don’t follow up and do the biopsy, and it turns out to be cancer. The author doesn’t seem to realize this is all happening against the background of potential litigation.
But any patient likely 1. doesn't care about ensemble performance 2. will get stressed out at the mildest indication of concern 3. induce a concave payoff for a trigger-shy doctor (no credit for correctly not intervening, and massive discredit for incorrectly not intervening).
Be careful about reducing the testing just because it drives over treatment because under treatment is quite deadly, cheaper maybe but also has a serious impact of life expectancy and disease burden. Life expectancy is dropping in the UK and disease burden is one of the highest in the western world and growing. The grass isn't greener on the low test and treatment side, health care is still increasingly expensive and the results are worse.
You’re willing to trade off a few extra deaths if you can save a certain amount of money. Hell NICE in the UK put a very firm GBP figure on the value of a life-year.
It works great at a population level since you maximize outcomes and keep costs low.
But that isn’t that comforting when you’re the poor bloke who dies from lung cancer that could have been detected early but NICE said the 50GBP test isn’t cost-effective.
Or even make a certain amount of money: https://www.openthebooks.com/substack-investigation-faucis-r...
From my own experience it's typically done a few ways: 1) the government decides what treatment will be paid for and which ones won't [this works pretty well since patients don't know what they're missing], 2) the government simply caps a budget and pushes treatment decision down - doctors and hospital are forced to make trade-offs. Countries that do #2 often have long wait times for elective procedures - that's the cost control mechanism.
The US does neither one of these very well (but does them to some extent, but it's unevenly applied), so costs are very high (in addition to other factors). But if one wants universal care and a manageable healthcare budget, you need to say "no" to some things that would otherwise still benefit the patient.
It would be awesome if in cases like this, the doctor would suggest the patient to pay this 50GBP out of their own pocket.
[0] - https://ourworldindata.org/grapher/life-expectancy-vs-health...
There are a million factors that go into life expectancy other than just the healthcare system.
Is it better to know? To not know? To know when it's the moment? BTW I'm in Italy so it wouldn't even be that expensive to do every couple years.
This machine will tell me how I feel better than I can do it myself. This secondhand abstraction is more reliable than my firsthand observation
Now, consider the GP who has healthy 50yo, does a PSA anyway and it's positive. The GP could still decide not to act. But the patient is not so likely not to do anything. Or even understand the odds. At that point, if the patient dies, the GP is likely to get sued because he should have acted. Even if over all of his patients, not acting was more efficient. If the GP decides to act, however, regardless of whether the patient survives, he won't be blamed for it. So doctors have a nasty incentive to act.
Of course no one would stand for such an intrusive system. But over time it would improve diagnosis.
How exactly would you follow? Stress testing, angiography, cardiac MR, CCTA??
If such a correlation were found, more intervention would indicated, if not, then not.
It’s a pretty slow process, but outcome is what really matters, and even if slow it would be faster than doing nothing.
If you can afford to be outside the insurance system in the US you can get excellent care. That can include having tests done that aren’t covered by insurance and avoiding tests that an insurance company would normally require just for CYA reasons, but aren’t worth the risk.
But the incentives of the insurance-driven care are not aligned with optimal patient outcome.
I had an experience with a doctor who was supposedly so prestigious that she didn’t accept insurance. I ended up going to two appointments where she did nothing but push for redoing some tests in her expensive laboratory at a cost of $5000. She couldn’t explain why her lab was different and eventually admitted that they used the exact same equipment as my previous (insurance-covered) test.
When I declined and tried to leave she offered me the “discount” of $1000 off for new patients. It was really just one big push to funnel people through her expensive lab combined with a fancy office and nice bedside manner.
Don’t assume that just because someone is outside of the insurance system they’re going to provide superior care.
Just because they don’t take insurance doesn’t mean they don’t have their own ethical sketchiness. However, just because there are bad non-insurance docs out there doesnt mean there aren’t excellent, ethical ones of the type OP described.
My wife gets to visit them a lot due to a skin cancer episode, and her former practice was swallowed up by some private equity dermatology group. I learned about their operations via a case study published one of their vendors - a commission/incentive management software platform. Up to 70% of provider pay is about pushing magic goop for your face.
It seems like there's a problem right up front: prestige.
My main doctor doesn't accept insurance though she will give you a form with the diagnosis codes marked if you want to submit it yourself. She simply doesn't want to deal with the paperwork. There's none of the fancy "concierge" and "membership" bullshit, much less "prestige". She just has an ordinary doctor's office, and doesn't own a lab or anything.
But in exchange for filing the insurance form if I remember to: the longest I've had to wait to see her when I was sick was a couple of hours, I can bring my dog with me to my visits, and she and I pass scientific papers back and forth when determining treatment. But the main advantages of "no insurance" are that we have lots of time for a visit (if needed) and nobody looking over her shoulder for prior auth or such. It's a much more collaborative model.
Unfortunately I don't think this model scales, but my exposure to the more formula-driven mass medical system has been discouraging.
It’s just a full-body MRI. Costs a couple thousand dollars. Would put it in the category of neat curiosity and possibly useful as a baseline or if you have surprise cancer or something. But totally unnecessary and to be avoided if you’re prone to medical anxiety.
Why such scaling with the size? Pure greed? The guy has mostly to push a button..
2) one should have a legal right to command a MRI scan without paid analysis.
MRIs are expensive machinery that take highly-trained and well-paid technicians to maintain and operate. The imaging process takes an hour alone; start to finish, it's a two-hour process that is far from just pushing a button.
> one should have a legal right to command a MRI scan without paid analysis
I don't think there is a law, in America, prohibiting MRIs without expert analysis. But one, that's useless. And two, the people who don't think it's useless are the ones most likely to misinterpret the data and cause problems for the MRI provider.
> Result: How much does an MRI scan cost in India? The average cost of MRI scan in India is usually between Rs. 1500 to Rs. 25000.
> Query: Rs. 25000 in US dollars
> Result: 25,000 Indian Rupee equals 321.02 United States Dollar
...so ok, there's a chance the first answer is wrong and/or there's some factor I'm missing, but assuming it isn't one must again ask the question: Why does an MRI cost $5k?
For the record, asking specifically about a full body scan did not change the price:
> Query: cost of an full body MRI in India
> Result: [...] And the full-body scan cost you between INR 18000 to INR 25000 in India.
Where did $5k come from? I said a "couple thousand dollars," though looking at my e-mail it was $1,500. A 4 to 5x cost differential from India to New York City seems explicable.
> A 4 to 5x cost differential from India to New York City seems explicable.
Then please explain it, because you seemed to be saying that this expense was inherent to the machine and had little to do with cost of related labor. If that was the case, one wouldn't expect an MRI in India to cost 1/5th as much.
I also doubt it would be any less expensive here in south central Wisconsin than it is in New York City.
The machines are expensive. They also vary in strength, with scanners in e.g. the Philippines and Malaysia being of considerably lower strength than is common in America [1]. (I couldn't find data for India. There are certainly no 7T scanners there; I believe most are 1.5T and below. In New York, it was a 3T.)
Between that, which might be a 2 or 3x differential between a low and high field strength scanner, and the cost differential of "highly-trained and well-paid technicians [needed] to maintain and operate" [2], 4 to 5x seems explicable.
[1] https://researchonline.lshtm.ac.uk/id/eprint/6700/1/IL9.pdf
[2] https://news.ycombinator.com/item?id=31449409
Disclosure: I'm a pathologist.
BTW it's very cool that this is a thing> https://www.nlm.nih.gov/research/visible/getting_data.html
These scans aren't magic. Most of the time you need a "contrast agent" to find things.
That means an injection (and attendant infection risk) and circulation of a strange substance in your body. In the case of Gadolinium, there's about a 1 in 1000 reaction risk. So, you don't want to go injecting that into people without a good reason.
Isn't this already the case? Tests that are considered worth doing regularly even without extra symptoms are done regularly. E.g. mammograms and colonoscopies/stool tests.
(I'm ignoring your focus on "yearly" since really you care about "regularly" given that yearly is totally arbitrary and timing that makes sense is clearly dependent on the tests in question.)
In my opinion, the only justifiable factors are probably along the lines of:
- invasiveness (e.g. if it's non-invasive or minimal cost)
- benefit to the patient if detected
- cost relative to other screenings/actions that can be done for the patient
Everything else seems strictly suboptimal.
[1]: https://en.wikipedia.org/wiki/Cancer_screening#Risks
Your entire argument here seems to require patients to be rational agents. They aren't.
Yes, my argument does rely on patients being rational agents.
> They aren't.
That may be true, but it's certainly paternalistic (in the formal, definitional sense) to act as if they are not rational agents and withhold information/reduce autonomy. This is a case of pure paternalism (again, in the formal philosophical sense).
Different ethical systems, of course, make different judgements on whether this behavior is moral. It's also up for debate whether this is a desirable feature of the medical system.
Call it whatever you want. Idealizing patients as rational agents instead of considering how they are in reality results in worse outcomes. If your goal is to actually help people, you should base your arguments on how things are in reality instead of some idealized dream world.
That's a fair position (you seem to be a utilitarian), and probably quite defensible. But, one could argue that patient choice is an important feature for our medical systems to have. I certainly want to be able to refuse medications that my doctor recommends (e.g. opioids) or seek alternate advice/second opinions. My cost-benefit analysis equation is probably not the same as my doctor.
To be clear, I'm not talking about an "idealized dream world", as you put it -- I'm talking about patient autonomy in the real world, even if it means allowing patients to make what seems like a suboptimal decision.
You can do this.
> I'm talking about patient autonomy in the real world, even if it means allowing patients to make what seems like a suboptimal decision.
Patients are allowed to have these tests done against the recommendations of doctors (of course the costs might not be covered by insurance).
So I'm not really sure what you're arguing anymore...
Does the position seem clear now? I apologize if this line of reasoning was not clear earlier.
The reality that patients are irrational agents _is_ a justifiable reason.
> Therefore, the only justifiable factors that should be considered when screening patients that preserve patient autonomy...
Your position is clear. I disagree. I think given real constraints (economic, legal, psychology of patients/doctors/etc.) focusing on overall quality of outcomes makes most sense. You can disagree if you want, but don't pretend it's not justifiable.
edit: Besides all the tests are available to you. You can pay them if you'd like. Given they are low-cost (at least those you're focusing on here) it really isn't a burden on you to get the tests done yourself.
I'll note that I never "pretended that it's not justifiable". I did explicitly say earlier:
> That's a fair position (you seem to be a utilitarian), and probably quite defensible.
I'm disengaging, for now, since it seems like we understand each other's position, and we had a productive, lively discussion.
- Physicians want to avoid getting sued - Physicians want to get paid , just like everyone else. - The payor in the system is not the patient, but a faraway entity removed from the situation on the ground.
In such instances, all 3 factors influence a decision. If a decision to perform procedure X is close to 50/50 (test/no test)
Do you think "no test" will win ?
Now put that in the macro context of millions of patient visits. now, since we are talking diagnostic testing, you may need to be tested at a hospital. So now, you are voluntarily exposing yourself to a hub of tired doctors/bureaucracy/germs.
That starts looking like madness , for sure
A test has a specific sensitivity and a rate of false positives. So for screening (CT in this case) you would want a high sensitivity and low cost, while the false positives would not be your priority. The positives should go through a confirming test (biopsy in this case) with a high specificity. Here cost and sensitivity are usually secondary.
Now insurers look at the screening tests rate of false positives. If they deem it too high, they don't want doctors to do those tests on a population with a low probability of having the condition you are screening for (low base rate). If the patient belongs to a subgroup shown to have a high enough base rate of a condition, then it makes sense to do the screening.
Then you have different patients, some want to get one MRI each year, some only want to run diagnostic after they experience symptoms. I believe most doctors respect that individual risk tolerance within the given framework.
Now the thresholds obviously should be revised regularly as cost, test properties and even base rates of diseases change, but I don't see a systemic defect here, my blind spot?
We are not.
One person's natural lump is another's cancer.
One person's low heart rate is another's natural genetic gift.
Modern medicine , particularly compensation, wants to put everything in neat black/white boxes.
Which is why tests are more dangerous than they seem. You are not average, and you shouldn't compare yourself to any perceived average because the human body is not average.
You should compare yourself to you, and that's all the doctor should use.
> Why are we taking as given that a net-negative decision to do a biopsy will be made
The author should stop wearily pretending that anxiety isn’t a common result of a positive test, and recognize that the average person is not comforted by a Bayesian analysis when their health could be at risk.
If continuing to a biopsy is as common as the author says (I don’t have any data on it), that suggests anxiety IS a common response and we can’t simply wish it weren’t the case. Mental health is health.
Anxiety is one of the worst outcomes of over-diagnostics.
Because then suddenly, I’ll become hyper aware of every potentially significant symptom and have to resist the urge to constantly google and check if there’s a chance it might indicate something. Is that pimple a pimple? Hey, I don’t remember my neck feeling this lumpy. Boy, I sure do seem to have sinus issues a lot. Are these joint aches normal? Etc, etc, etc.
As a kid, I felt absolutely invulnerable to worrying about my health. The first time I experienced true health anxiety is when my doctor pointed out a mole on my back and said “do you want to check this mole for cancer?” to which I replied, “oh, I guess so?”… only he didn’t. Because he checked with insurance, and insurance came back negative on it.
I am still in my 20s. I’m not in the best health, but my everyday life is pretty uninhibited by health issues. I don’t wake up with coldsweats. So yeah, it could happen to me, but frankly it’s worth being skeptical at my age.
But when the doctor pointed out that mole, they shattered the mental barrier I had between myself and cancer patients. I knew mentally that of course it could happen to me, but I had absolutely no idea that the signs of it could literally be hiding on my back, and I would be none the wiser. I googled and I learned a whole lot, and my intuitions were very wrong. In fact, I had many symptoms that can indicate various cancers. I heard stories about pimples that were not pimples, back pain that was not back pain, etc. people living normal lives who just went in for a checkup and suddenly faced certain death.
I’ve mostly snapped out of the hypochondria mindset, but still today I wonder about some symptoms in a way I never would’ve before. My life is altered by this one thing a doctor said off hand.
And for what it’s worth, I’m not saying he should not have done that. Insurance should’ve covered the biopsy just in case. I’ve outright noticed that sometimes, doctors will slightly edit your responses to things to get insurance to OK a diagnostic, and I think it’s in some part because they know that if you don’t get that peace of mind it could be damaging. Being hyper aware of your heart beat or super concerned about sleep apnea is not as bad as suffering from actual disease, but it’s certainly it’s own kind of hell.
It’s weird to me because much like cancer patients, I viewed myself as separate from hypochondriacs and immune to it as a whole. A lesson learned the hard way, and now I feel a twinge every time I see a new headline about cancer or hypochondria.
Because to me this sounds more like "your insurance won't pay for it because it is not an indicated study by ACR criteria."
I hear that spending hours on the phone trying to justify a test to an insurance company is no fun, and I bet the task is not made any easier if you don't actually believe that the study will help the patient.
Meningiomas by chance?
Has the monitoring improved your health? I'm not sure whether I would be more or less troubled if I had symptoms with an unclear cause vs a possible cause but unclear management plan. I suppose this will be highly variable.
I listen to my supremely well educated plastic surgeon wife regularly discussing and giving guidance to office staff around patients in their private practice. Their general approach is to get patient statistics, and that is all, without the aggregated vital signs. I asked her once, "Why don't you get the patient vital signs too?"
Her response was unexpected, "If we get patient vital signs, we immediately become liable for patient overall health. Our malpractice insurance is specific to the practice of medicine for plastic surgeons, and plastic surgeons only. Our front office staff are normally front office only, or aspiring doctors on a break between their undergrad and entry to medschool. Our practice uses no Nurse Practicioners, Physician's Assistants, or nurses. We're not set up, or staffed appropriately to deliver general medical care."
Conclusion 1: Medical care is characterized by liability control; there are logistics/staffing aspects to medicine around specific types of care.
Medical Diagnosis we think of as scans, remote tests. You get a CAT scan, you get an MRI, or X-ray, bam, 15 seconds, 5 minutes, or an hour later (after waiting in a hospital for hours) you're done and some radiologist or other specialist is interpreting the results and you have a diagnosis. That is true in some cases, but not others. If you get a positive mammogram, or a suspicious lump what is the next step? Welp, that is regularly one of two things - a needle biopsy, or an investigational biopsy. Needle implies small, thin, fairly painless. Not this needle - instead imagine a needle designed for tissue harvesting, like a horse sized needle. This big giant thing needs to go into your breast to suck up enough of the suspicious lump for a pathologist to examine it. Alternatively, you could have an investigational biopsy where a surgeon takes a small amount of tissue from inside your breast with a scalpel. Investigational biopsies via scalpel can be a big scam too, where a car accident occurs, a cut tendon in the hand, and the surgeon decides to open up the arm past the wrist to visualize all the soft tissue up the arm. Lucrative billing enhancements.. But, when it comes to breasts, we know that certain life changes predispose towards a positive mammogram for a limited time window. Stopping breast feeding being the foremost change that can cause suspicious lumps.
Conclusion 2: Diagnostic tests can be quite painful, and, at the wrong time, quite unneeded. Some of them are damaging. Good medicine is about as much when to intervene, and when to test, just as much as it is about when not to intervene and when not to test.
Literacy is a skill.
See above.
> But because that patient was low-risk, the harms of that biopsy will outweigh the benefits.
> Thus, you shouldn’t do the CT scan.
> What? If the harms of the biopsy outweigh the benefits, don’t do the damn biopsy!
I'm not sure what the point of doing the CT scan if we're not going to act on its result.
Sure, you gain the confidence that everything's gucci if it turns negative. Is that really worth the stress of the test going positive and the not doing the biopsy? Seems dubious to me.
* Most illneses are easier to treat and have better long term outcomes in terms of morbidity, when they are detected early / in a asymptomatic stage.
* We could collectively use the data collected from scanning "healthy" people, and adjust our bayesian priors so that we can more accurately adjust our diagnostic measures. E.g. common virus infections can give you brain lesions visible in MRI scans. However since MRIs are expensive we rarely scan healthy people so every lesion in an MRI is an immediate supicion of MS or other neurodegnerative diseases. We simply don't have good baselines for this.
The latter would allow us to look at all the indicators more holistically to make a well balanced judgement if more invasive diagnostics are warranted.
If a doctor receives a test result that shows a suspicious mass, then neglects to order a biopsy to investigate further, there are 2 rough outcomes.
1. It was nothing 2. It was cancer
If it turns out to be (2), the doctor and the practice/hospital/whatever gets sued for malpractice.
On a more ranty note, why does everyone think they are better at other people's jobs than those people are? Where is the basic trust in the other? You think a doctor in the United States after ~15 years of school doesn't know that most biopsies turn out to be more harmful that useful? Come on. Restore some basic trust in other's competence.
I don't think any actor in that chain is malicious, it's just an example of poorly aligned incentives. Screening companies, doctors and patients all believe they are making the most optimal choice.
Physicians can fire patients, although they seldom do so because of declining a medical procedure. Professional ethics and state laws generally require the physician to first hand off the patient to another physician first; they can't just drop someone with zero notice.
There is generally no mandated checklist, at least not from a legal standpoint. Some healthcare provider organizations do require their employees to follow certain written standards of care. Medical societies also publish evidence-based care guidelines. Compliance is voluntary but gross deviations could be factor in liability cases or in actions by state medical boards.
Insurance reimbursement is an entirely separate issue. Every insurance plan has a different network of providers and different rules about which services are covered under various circumstances.