Completely anecdotal, but very infrequent checks of my blood pressure over the years would always flag high and it would always be written off as a temporary stress spike at getting it taken. Otherwise I was completely healthy and had no complaints so it was ignored.
It turns out that I had crisis levels of hypertension for years, and all of those aberrant readings were actually my normal. When I finally got it diagnosed and treated -- purely thinking it might relate to sporadic mid-sleep headaches/sicknesses [1] -- discovered that years in that state had pushed my kidneys to the cusp of kidney disease, which is something that doesn't heal.
Check your blood pressure regularly. Get an Omron unit and it even logs it into a little app. Treat it early because the damage accumulates for decades.
[1] That turned out to be a newly developed absolute intolerance for alcohol. A single beer or glass of wine with dinner would have me sick all night.
Interestingly, the scenario is somewhat discussed in the article:
"...Rivero used as an example a request he receives frequently: to check the cholesterol of young people with no risk factors. “Checking a 32-year-old man with no history of sudden death or hypercholesterolemia in the family is pointless,” and can result in prescriptions for medication of questionable usefulness and that is not without risk in the event of minor changes..."
Cholesterol numbers are but guides/risk factors on your health risk. They do not necessarily mean that you will suffer from atherosclerosis the precursor to heart disease.
That was my argument to my primary care doctor. He then arranged for a CT scan of my arteries that showed there was significant blockage. I'm now on statins for the rest of my life to keep cholesterol in the blood down and hopefully keep the arteries from getting completely blocked.
And your primary care physician did the correct thing which was to scan your arteries for damage. Also statins work by helping over a long period of time - so chances are if you are good with the sides (if you have sides) and you have a bunch of risk factors makes a lot of sense. Not a physician FWIW.
I get the logic, but … isn’t this failure mode the fault of the doctor, for overreacting to a minor issue/non-issue, rather than the patient for getting yearly checkups?
It may be a failure of the doctor, but we want to measure mortality in our world, not a magical one where doctors are perfect.
The takeaway here can and should be that interventions are started too soon, but that's a more difficult change than for healthy people to just reduce testing.
Doctors are generally instructed to aim for optimal outcomes.
Suppose 98% of people taking a drug as prescribed live longer, but 2% don’t use as described and they offset the gains. Should the drug be prescribed or not?
Similarly, what if people who do annual checkups and get good numbers take worse care of themselves because their numbers are healthy?
The issue is that doctors are biased to seeing a biased sample of human who are encountering problems. So in a way, they have to overreact always since the number of patients NOT having issues and seeing them due to the yearly checkups are way less than the number of people who are having problems.
The problem might go away if somehow we got a significant percentage of the general population to do health checkup, balancing out the unhealthy population (in meeting doctors). But that is nigh impossible, and might just overwhelm the whole doctor system altogether
I'm a bit mind boggled there is even a human involved here.
Lab results + Patient data = Diagnosis + Prescription
Why is there a Physician deciding if medicine is needed? The patient data from the original visit + lab should be enough, not sure why a second visit is needed. (This is only a problem because Physicians make somewhere between $250-$500/hr, if we had a market drive supply of Physicians, I don't think this question would be important)
I think that in that case, the issue is not that patient had checkup, but that standard reaction to high cholesterol is wrong. Having it checked up less often may help the patient, but real fix for healthcare system would be to not prescribe this medication in this situation.
The vast majority of common statins are off patent and extremely inexpensive. Pharmacies often offer them at around $5/month, without insurance, usually free with.
The 'better' cholesterol drugs like the PCSK9s are expensive, but insurance almost always demands a first-line (cheap) drug be tried first for typical hypercholesterolemia.
I had my family test their blood sugar because we had a test kit sitting around. That's how we found out my youngest was at the beginning states of type 1 diabetes. If we hadn't checked her sugars, she would have undoubtedly been admitted to the hospital under DKA and had a traumatic introduction to her condition.
As it was, nobody, not the local doctors nor the children's hospital in the local metro center, had any idea of what to do with her. We had to repeat our story numerous times and she was admitted for no reason for three days because that was their protocol.
So i think the whole idea is bullshit. Test early, test often and let the practices catch up to the new amount of information.
But this thought process begs the question: what if this person is the one who STARTS the history of high cholesterol, and subsequent increased heart-related mortality. Or following it the other way, only people with a history of this are at risk? It is statistical: there could be a person with no history who is at risk, the probability is lower, but nonzero.
As others are pointing out, cholesterol is a lab indicator not a symptom or disease out right. Cholesterol numbers are a proxy for risk for a negative event, but only a weak proxy. If you're otherwise healthy and don't have a family history of cardiac events then your cholesterol numbers probably don't matter. Trying to control those numbers in the absence of other risk factors presents other risks. Cholesterol medicines aren't without side effects, so you're best off not taking them if you don't need them.
Higher compared to what? Have you established what your healthy baseline cholesterol level is, or are you just assuming that whatever the literature uses as its favourite test demographic accurately captures your age/metabolism/lifestyle?
Cholesterol is a prime example; The leading medications deteriorate muscle and reduce mobility; where increased mobility decreases the risk of cholesterol illness via inreased arterial plasticity.
And where dietary cholesterol has been proven to not be directly related, you're fighting your liver and genetics.
I find this to be dubious and honestly a little insulting. Here in the UK there is a not insignificant number of people that die from cancers because their local health practice ignored or even refused to listen to a patient.
The idea of a yearly checkup is totally foreign here unless you are going private.
Do annual checkups involve blood tests where you are? I've only had blood taken as part of one once, and that was in direct response to a new diagnosis of a health condition in a grandparent.
Of course, blood and urine. I do them every six months, even though my insurance only covers once a year, I'm happy to pay out of pocket for the second.
I think the idea is this: even accurate tests have false positives. For patients in a low-risk group, virtually all positive results in the checkup will be false positives. When the low-risk group is large (the entirety of a nation's healthy 20-30 year olds), the number of such false positives will also be large.
The positive results, regardless of whether they are true or false, will have some sort of follow-up. Maybe a second, more invasive test, maybe even starting on a drug straight away if the numbers look bad. And like for any medical procedure, there is a chance that this follow-up will harm this person's health: they will get an infection from a badly done second test, they will have an adverse reaction to the drug, etc.
And the question is whether it is ethical or worthwhile to expose patients to the risk of harming their health through the follow up, given that the chances of them having the condition (and thus of the follow-up being at all useful) are extremely low regardless of what the checkup result says.
> whether it is ethical or worthwhile to expose patients to the risk of harming their health through the follow up
So you seem to be saying that, in certain cases, if you have a positive test result, then the expected value of taking certain follow-up actions is negative. It follows that a rational actor, knowing this, would not take those actions in that situation. Then isn't the solution for doctors to update their procedures so that they don't take those follow-up actions in those situations (and explain the odds to patients who care)?
The phrasing "expose patients to the risk of harming their health through the follow up" makes it sound like the follow-up is something that automatically and unavoidably just happens, as if no one has any agency in the matter. If that's true, due to some kind of regulations or rules or liability rulings, then that sounds like a problem.
To some extent this is resolved by backpropagating: if the test is just a two-value "positive"/"negative" thing, and you plan to take the same action (i.e. nothing) regardless of the result, then there's no point in taking the test. However, I expect there are also other tests where, say, the test has a "super positive" value (or value range) where you should take action, and a "technically positive" value where you shouldn't act (plus a "negative" value); and the test is worth taking because of the likelihood of "super positive", but that means you do sometimes end up with the "technically positive" result, and must solve the problem of knowing when not to act.
On an individual case you’re right. But in aggregate is where the nuance lies.
E.g. If 99 out of 100 cases are false positives, and those 99 people are harmed by taking action, but the one true positive was helped, which is the better policy to pursue? Blanket screening or none at all?
This gets more complicated when there are limited resources available, eg treating the 100 people means someone else misses out.
And then there are diseases like cancer, which pretty much every human will get, if they live long enough. So screening for some types of cancer can have negative health implications on some target populations.
If it is not worth taking the follow-up action, then it is not worth doing the screening either.
Concrete example. Younger women have firmer breasts. A chunk of relatively firm breast looks a lot like cancer. Therefore the younger a woman is, the higher the odds are of a false positive from a mammogram.
As a result a woman who is 30-40 SHOULD NOT get a mammogram UNLESS she has a variety of specific risk factors that increase the odds that a positive on the test is a true positive, and not a false positive.
There's a similar phenomenon when you look at fetal heart monitoring for otherwise healthy pregnant women going into labour. The two options are continuous monitoring, where the monitor is left in place for the entire hospital stay, and periodic monitoring, where a nurse installs it, takes a reading, and removes it about once an hour.
Common sense would dictate that negative outcomes are reduced with continuous monitoring, but it's actually the opposite, because the odds of the monitor detecting something in the intervening time and the intervention being correct are lower than the odds of the intervention causing some other unwanted side effect.
Also from my experience the "left in place" part is technically very challenging, because a woman in labor tends to move around quite a bit, whereas the nurse holding something against the patient for a moment is much more workable.
> the odds of the monitor detecting something in the intervening time and the intervention being correct are lower than the odds of the intervention causing some other unwanted side effect.
Huh. So that means, when the doctor decides to intervene based on what the continuous monitor comes up with, the interventions have negative expected value? Which means the doctors are making bad decisions about what interventions to make based on the data they have? I'll believe this is possible, but I want to ask to be sure.
I also would wonder about other explanations. You say "a nurse installs it, takes a reading, and removes it about once an hour"; presumably the nurse also glances at the patient and, if anything seems off, might ask the patient questions or take other appropriate actions. Could that be a significant effect? (In other words, to eliminate this potential difference, the better comparison for "continuous monitoring" would be for a nurse to come by once per hour and give the patient the same level of attention, perhaps going through the same motions that are involved in the monitor process.) Incidentally, as I read your comment, I expected it to conclude that the monitor itself or the process of repeatedly installing it and removing it was harmful (although that would point in the opposite direction).
It somewhat makes sense to me. Measuring all the time, you're susceptible to odd readings that are essentially false positives. If your device has a 1/1000 false positive rate, but you're usually only making one reading with it at a time, that's maybe acceptable. If you're making a million readings over a week because you're checking every second, than you're almost definitely going to have it show the same false positive enough that it looks real.
I just went and checked and I was slightly wrong about the methodology. The comparison was actually between continuous electronic monitoring and manual listening with a stethoscope. I would hope/expect that a nurse is coming to visually inspect a laboring woman at least once per hour regardless.
This [0] is one of the studies cited by the book where I learned about this phenomenon. Continous monitoring was found to have a higher incidence of c-section and forceps deliveries. The only condition where continuous monitoring came out ahead was in detecting seizures.
> Common sense would dictate that negative outcomes are reduced with continuous monitoring
This is also how people see constant glucose monitoring (CGM) and Type 2 diabetes. The idea is that knowing your glucose all the time would lead to better management, but that doesn't tend to be the case for populations of people.
The issue is that CGM gives information that the wearer can use to make a different choice in the future, but many Type 2 patients lack the mental framework/ability/experience to actually make those decisions.
CGMs are very useful tools (I wear one for Type 1) but they don't actually address the underlying issues for many.
Is everything else really equal here? I'd think "higher-risk" situations would be more likely to have a higher level of monitoring. In other words, was this randomised?
A lot of negative comments on this and there are no references provided, however some human traits are well-understood:
* people irrationally tend to add rather than remove complexity to solve problems
* experts' decision accuracy improves faster with more information than their personal evaluation of / comfort with those decisions
* people asked to evaluate the contents of a picture repeatedly while being shown increasingly faithful renderings who are shown worse (unusable) renderings of the picture to begin with are slower to reach an accurate evaluation overall
As a general observation on medical care, Team USA has been slow to adopt the practice of weighing absorbent materials during procedures including childbirth to measure blood / fluid loss and this has had measurable, negative outcomes for patients.
I think we have too much cultural habits, marketing suggestions, etc etc around the whole notion of "more is better". So more complexity, more gadgets, more yada yada without ever going back and checking the premises and accuracy of these things and their claims along the way. We get stuck in these "dwell points of the ideal" where we assume because something is deployed that it's in some ideal operating state and take a bunch of stuff for granted at that point.
Looking at this from the other direction is interesting. Suppose hospitals had a way to monitor fetal heart rate with no possible side effects (e.g. no possible placebo or psychological effects from wearing the monitor). And they discover that intervening based on the results leads to poor outcomes, and they do better if they completely ignore the data except for one sample taken every hour roughly on the hour.
One solution would be to say “great! Let’s sample once an hour!” But surely one could come up with much better filters and heuristics.
Of course, doing this in an ethical way might be complicated.
I work in software A/B testing. We have similar problems.
The better filter and heuristics is using an algorithm that’s fit for anytime valid testing. The issue here is a high false positive rate. If you come up with all your treatment guidelines in an environment where you check every few hours and change it to every second, you’ve increased your samples by 3,600. Something like heart rate isn’t independent, but that’s still a lot.
You need to use a different algorithm (or algo at all) and/or relax the thresholds. Just random numbers, but if 45bpm was an alert before maybe it needs to be 50bpm.
The primary function of fetal heart monitoring is for pseudoscientific use by ambulance-chasing lawyers to generate $1M-$40M (!!) malpractice payouts from ignorant juries for children born with cerebral palsy.
The saying goes: "The only thing that can prevent a birth injury is a expert witness".
It's an open secret that the readouts from the monitoring during labor don't really mean anything by themselves. They are mostly used to make sure something is going on and that the baby is doing okay. Theoretically you can calibrate the monitoring to have continuously comparable results but in practice there's no point. It's less about the values or the patterns and more about a general trend. But in terms of measuring the actual process, dilation trumps every other metric.
Also contractions stopping when you go to the hospital is a well-known thing literally caused by the change of scenery. This is why some midwives recommend taking the stairs: not because the elevator might get stuck but because the pelvic motion of going up stairs while very pregnant can (re-)induce the contractions. Also while being stuck in one place because of continuous monitoring can mess with labor (which is why midwives recommend pacing, squatting, etc rather than lying down), the periodic checks can also be counterproductive because they can "pause" the process.
It's good that we have modern pre-, post- and natal care available nowadays but a lot of the medicalization of the birthing process actually makes it more difficult to give birth and doctors (and lawyers tbh) tend to err on quantifiable metrics even when everything is fine and the measuring is counterproductive.
(this was written as a reply to hospitalhusband's reply which has since been deleted)
I find this sentiment almost offensive. Like it goes against everything I believe to say that less data is better. But the root of it is pretty clear "even basic blood tests can lead to unnecessary interventions or treatments". It's the belief that a test leads to interventions. But it doesn't have to of course. An intervention is a decision, and if an intervention is likely to be unnecessary, then they shouldn't intervene. "But the yadda-yadda-value is elevated", yeah well you said it yourself it's most likely nothing, so do nothing, just note it down for future reference.
Agreed 100%. It's absurd. The results get distilled as "more data leads to worse outcomes" and that's ridiculous -- it should be: "more data leads to bad decisions which lead to worse outcomes". We should ALWAYS strive to have more and better data. What needs to change is how we (and our doctors) respond to that data.
Whilst I agree in theory -- in practice, humans are prone to misreading data. We have to build our systems to accommodate human flaws, as engineering away human flaws is much, much harder, and potentially impossible.
If you ignore elevated values, why test in the first place?
Also, often the test itself is somewhat invasive. Sticking various apparatuses into our bodies comes with all kinds of risks, so it better be worthwhile to do it.
I'm not a doctor, but... Well the logical thing to do is 1. Ignore mildly elevated values in the absence of symptoms. 2. Take action on very elevated values. 3. Look for trends and anomalies in the data. "This guy has had a value in the low end on every previous check up, but now it's a bit elevated, what's up with that?"
Extreme values should be treated, and 'borderline' values should be ignored, but then they often aren't. People are scared when it comes to their health.
Also a blood test and urine sample aren't invasive and come with ~0 risk.
The issue is that depending on the situation, and on the patient in question, the intervention will shift from decision, to persuasion to mandatory.
For example, if you have a positive test for cancer, they will persuade you to follow it up. They will apply very emotionally manipulative techniques.
Another example, if the patient does not have the ability to decide for themselves, the doctor's opinion will hold a very heavy weight and can lead into a legal issue.
If you believe that science and medicine in 2023 is offering complete understanding and solutions to all or even many problems, then you will naturally feel like these two examples should be handled that way. However, the daily "revelations" of "new medical research" which contradict past results and understandings should be enough to cause doubt in that high level of confidence.
I have a personal example of this. My father died largely because of his annual physical. He hated doctors, became nervous around them and thus expressed hypertension in-office. He did not have material hypertension but did defer to his physician. Over the long term, despite my best efforts, this killed him.
His blood pressure medication regime was poorly managed and severely impacted his quality of life. He eventually suffered a syncopal episode while climbing stairs and died.
I was listening to Peter Attia on some podcast and he says to essentially throw out any BP reading that didn't occur after sitting down for five minutes. In his practice they have patients measure many times a day for multiple weeks just to get a baseline point to work from.
More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms.
Imho, a brilliant solution is direct primary care. For $80/mo, I have access to a dr that works for me, and not my insurance company. Absolute game changer in that he has a bias toward understanding and optimizing rather than gaming insurance metrics to be rated as a double-plus preferred provider or whatever.
Also gets my lab work done at a fraction of what my insurance deductible would be.
Combine it with a high deductible insurance plan to hedge against the truly catastrophic/expensive possibilities.
There are direct primary care providers all over. Google it. I can’t recommend direct primary care highly enough.
I honestly don’t know if ‘concierge medicine’ is a different thing, but from what it sounds like and my own experience with direct primary care they sound equivalent. Possibly different by cost or target demographic.
We have DPC, and it's amazing. We pay $250/month for a family of 4. Some places charge less, but then also charge you for each time you see the doctor. Ours is all inclusive except for any in office incidentals - like lab work.
It's truly amazing. Our doctor knows us all well, can get responses to email or text within just a few minutes, generally same day appointments, or next day if she's really busy. Most things we don't even need to go in for - I did a recent international trip, and she just ordered me all of the needed travel medications without having to stop in.
I don't know how to get around this problem but wife and I paid $1,500 for a year's worth of concierge care only to have the physician close up shop after 4 months. I suppose if we paid month-by-month that would have helped.
Dr. Attia also shared his personal experience similar to @sklargh's grandfather where he suffered a head injury after fainting while standing up from bed. High blood pressure can kill you over years, but excessive low blood pressure can kill you tomorrow.
In America we also (mis)use blood pressure machines. I'd better quality or used correctly, they're usually ok. However, I've had nurses just crank the thing up to 200. No shit it's going to be high - it cut off my circulation for 90 seconds while it climbs all the way up and then all the way down. I can feel my pulse increase in force trying to get blood to my numb arm. Let's be lazy and let the machine do everything for us.
"More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms."
I largely agree, although from a slightly different angle. Many newer doctors just read from their Epic WebMd equivalent and record your answers. I assume it's so they don't get sued.
Yah, I purchased one of the automatic monitoring machines at home after having a couple slightly elevated readings at dentist/etc offices.
And what I learned is that I can swing my blood pressure from slightly low to slightly elevated simply by how I sit, how relaxed I am, and untold other variables that result in being able to consciously swing it 20+ mmHg, and other times it can swing that much (or more) just between multiple consecutive readings where I don't move/etc between them.
I've also had Nurses swap the Cuff size and drop that much, or just do two in a row in the Dr's office and get massively different results.
So, for me, I don't know how to determine an actual bp if the noise is greater than the signal. Taking the average over multiple times a day, for a few weeks is probably reasonable. But then, I'm pretty sure the amount of exercise and what I eat day to day could swing it one way or the other depending on the time of the year (aka I sweat a lot more during the summer and drop weight, etc).
I was laid off in November, coincidentally on the same day I had a doctors exam. I didn't want to reschedule it so I went. My BP was suddenly 150-160. They were somewhat concerned (I'm young and almost an underweight BMI) until I explained I just got laid off about 4 hours ago. Fun stuff. Weird memory.
I did this for the doctor, and my pressure readings were much better at home, which should be no surprise. They asked me to bring in the machine to check it against their own measurements. It takes three readings a minute apart, and then does its calculations to produce the numbers. After the first cycle, the assistant wanted nothing to do with it, and started fiddling with the machine in annoyance to get it to do whatever she wanted. There was not even a discussion about it. There must have been many other sides of beef in the office that she had to hurry to poke and prod as fast as possible. And what do you know, I think that visit produced the highest blood pressure they had seen in me yet. I think that was the same visit I had to point out that their fridge with blood samples in it wasn't closed fully. The doctor made it a point to stop and ask me if something was bothering me that visit because my frustration at how bad US general practice had become was obvious.
> I was listening to Peter Attia on some podcast and he says to essentially throw out any BP reading that didn't occur after sitting down for five minutes.
Or just assume that your systolic will be about 3 points higher if you weren't sitting for five minutes, or whatever the normal correction is for you. You shouldn't accept a diagnosis of high blood pressure from your doctor if (as is most likely) they aren't measuring it correctly, but the deviation from the "correct" measurement also isn't random.
This is commonly known as "white coat syndrome". Some patients get nervous in medical offices, and some healthcare providers don't follow the recommended measurement protocol of allowing the patient to sit quietly for 5 minutes first. So this leads to some false positive hypertension diagnoses and iatrogenic harm.
Hypertension is common, dangerous, and generally under diagnosed. So primary care doctors have been trained to look for it and treat it aggressively. Overall the healthcare system is probably doing too little about hypertension rather than too much.
My doctor calls this doctor’s office hypertension. If the reading is high, he always makes a point to circle around and do it again at the end of the appointment. For me, there’s usually a 10-20 (units, I forget which ones) difference. I do not have hypertension
On the better handled side of this, my doctor pointed out that issue at my physical and instead of putting me on blood pressure meds he told me to get a blood pressure cuff and gave me a paper to fill out with daily readings before jumping to any conclusions.
It seems very many people have this problem - skim through the hundreds of comments on this page [0].
I remember when I first panicked about having my BP taken: I had an irrational thought that the cuff would completely cut off my circulation and kill me. (I since discovered I have OCD.) So of course my BP shot up. And a second time, I was running like crazy to get to the appointment, and very stressed from a new job I'd just started and had just finished for the day, so again the BP was crazy high.
Since then, I always panic about taking my BP, even at home, though it's worse in the office. To my previous worries, I've added fears about heart attack/stroke from high BP, irony of ironies but a common one.
My solution is to buy a machine with a memory, take several readings per day over a period of at least a week (2-3 weeks is better), and cover up the screen on the monitor with a piece of card when taking the readings. At the end of the 2 weeks, remove the card, discard the first two days' readings, and take the average of the remaining readings. When I do this, my BP is almost normal (low 120s over low 80s).
I don't waste my time trying to relax, since it tends to make things worse, although I do make sure I've been still for a couple of mins. I have a supportive doctor who understands statistics, which helps.
(Standard disclaimer: this isn't medical advice. IANAD. Real hypertension is dangerous.)
Do not listen to these so called experts, they are the first ones that will tell you, if you have had early diagnostics things could have been very much different.
The future with the ozempic type drugs is interesting; now a doctor will tell you to lose weight and can give you a pill that makes it more difficult for your body to absorb extra sugar and carbs and you can lose weight, even if you are diabetic already
Something has to be happening in the environment that's making people fatter. The only process that is statistically successful on a population level in getting people to lose significant amount of weight is a hormone regulating drug, and it has to be kept up for the rest of the life of the fat person or they'll gain it all back. Even the extreme surgical intervention of cutting the stomach seems somewhat temporary. WTF is happening?
I call bullshit on this. I had a very rare heart condition that was discovered during one of my yearly check ups. Chasing the root cause led us to even more scarier findings.
How many examples of bad outcomes would it take to retract your "bullshit" assessment?
Ideally, somebody would take all the good that came from the checkups, and compare that to the amount of bad effects where poor interventions were chosen, and weigh them out. Such a study would be quite useful...
I’m pretty sure bad outcomes out number good ones. Were there bad outcomes because of an incompetent provider or a test with high false positives? I’m pretty sure it’s the former.
As always, population-level recommendations don’t result in perfect individual recommendations. Your condition was very rare, and the test is not perfect. Thus if it were done routinely, many people would be flagged as a false positive and treated unnecessarily to catch your one case.
Sure, if we are dropping anecdotes, my kids were over diagnosed/incorrectly diagnosed. It ended up costing me slightly under 1 thousand dollars before other doctors said 'no big deal'.
The weirdest part about these, both of the diagnosis seemed like there was no possible solution, so even with the confirmatory tests, it wasn't like anything was going to change.
However they were insistent of getting multiple specialists on it.
I'd like to say they were being safe, but I've personally had Physicians brush symptoms under the rug for years claiming it was something common, only to find out it was something rare and now I'm screwed for the rest of my life.
Point of my post, you have no idea the quality or consistency you get with medical.
With kids it's problematic. A doctor will see thousands of kids with acute nothing burgers and then one day a kid with emergent type 1 diabetes will come in. Another bad thing is rate conditions are rare and there are a f'ckton of them.
What bothers me is at least in the US we've forced doctors to adopt an MBA driven pop mass manufacturing system. Like they're some schmuck in a chicken factory.
The test and interventions may be harmful and should be addressed if so, but if your checkup is harmful, your doctor needs to take it easy with that knee-cap mallet
You would think doctors would be able to collect data and then come up with statistical tables of “hey you may have xyz. The risk to look into this further has these possible complications with these success/failure rates. The risk of no intervention has these other set of outcomes with these likelihoods”
All you get at a doctor is someone typically saying “eh you’re young don’t worry about it” until it’s too late. It would be nice if the medical world was more data driven but it’s more handy wavy “ehhh I went to med school and I think you are ok”
Your expectations are unreasonable. Most doctors are practitioners, not researchers. They are applying existing care protocols rather than collecting data and coming up with statical tables. Good doctors will follow evidence-based medicine practices where applicable, but individual cases often diverge from the standards.
There is a huge amount of medical research going on but the field is so complex that progress is necessarily slow. Carrying out long-term studies in humans is extraordinarily expensive because researchers need large study populations to extract a useful signal from the noise caused by confounding factors. You could make a case that doctors should intervene earlier to prevent chronic conditions while patients are still young rather than waiting for more serious signs and symptoms to develop. But on the other hand, the available drugs often have significant side effects that impact quality of life or cause other harmful side effects. So it's not an easy call and there are still many unknowns.
With all due respect, I think it’s unreasonable to call my expectations unreasonable.
That mindset is the mindset of an old company - “we just do things around here like that because that’s the way they’ve always been done.” The field should move forward with technology we shouldn’t settle for something because that’s the way it is.
Your expectations are unreasonable. This is not a problem that technology can solve. Large scale, long term human trials will always be expensive no matter how much technology we throw at the problem.
If you have a suggestion for improvement then be specific. Vague complaints aren't helpful.
OK? Where can I buy a high-fidelity simulation? You might as well say that the solution to high energy costs is just to build fusion reactors. Great idea in principle but we don't actually know how to do it yet.
Simulations are already used in the early-stage drug development process and they're useful to reduce the number of substances that move on to animal trials. If you build a better one then you can make a fortune. But we are at least decades away from being able to accurately simulate the complex interactions in a human body. And I doubt that simulations will ever be useful for writing something like a clinical practice guideline for prescribing statins; that type of knowledge can only be gained by conducting human trials to see what works in the real world. Engineers accustomed to working with machines and electronics generally don't understand how messy biological research can get.
I think the issue is that it becomes hard to estimate risk factors on an individual level with enough resolution to come up with such a table. Its easy to conclude that on average, walking a lot every day leads to better health outcomes, but probably hard to say whether you walking a lot would lead to better outcomes for you specifically. All this stuff has variance. On average, overweight people die sooner, but there are still overweight people who are long lived, and its hard to say whether you share those same latent variables that are actually influencing this result.
As an analogy to business, sometimes the best thing is to do nothing. Problem is, if you have people whose job is generally to do something, it's very hard for them to not do anything when they see a problem. Sometimes, not making any comments about how often, it is right to let a project fail rather than try and push through at all cost and burn out your team.
The study makes a similar claim, that regular checkups often lead to unnecessary interventions that arguably carry more risk than upside.
Most primaries are useless. Having someone who works in healthcare in your family is of incredible value, and the general advice is to always see a specialist.
We could likely do away with primary doctors in the US. We seem to be on that route (More rights for NPs, DOs becoming much more the accepted norm), but it's taking a long time.
For someone who doesn't know, it's impossible. But being a patient advocate has a moral hazard that insurance companies (who provide them now) aren't equipped to deal with.
Which is why the GP is so useful IMO. Maybe they could be replaced with a nurse though. The administrative assistant matches their referral with someone in my network. You need that medical profession somewhere in the chain, otherwise people browsing insurance websites for in network providers just aren't qualified to decide if they need to see an orthopedist or a podiatrist or a physical trainer for example.
I observed that happening around me for a long time, this research only confirms it, however, I think that the problem is stated in a wrong way. IMO the issue here is not that checkups are bad on their own, but rather that used medical checks and resulting therapies are done in some sort of "standard" way, rarely taking into account patient's history or having more detailed look on what causes the particular problem.
This is, of course, done in order to scale checkups on economic scale, otherwise, almost no person could afford it.
This can be observed in some cases when some young, fit solider dies on basic exercise from heart failure caused by heart anomaly that is not being screened during standard medical examination prior to being enlisted.
This is just clickbait and people comment the title without reading the article.
It doesn't say "don't do checkups"
> “The conclusions do not imply that physicians should stop clinically motivated testing and preventive activities,”
The article is saying that some tests give false positives, some tests even if positive don't point to illness without symptoms, but people get treated for illness.
I believe you should do checkups, but ask for second opinion before treatment in case that you feel ok and your family history doesn't point to risk factors. And that is also mentioned:
> However, Krogsbøll warned about the importance of distinguishing between people who do not feel sick and those with symptoms or a personal or family history of risk factors
Exactly. There's no set definition for "annual physical exam." This article notes you shouldn't be regularly checking for uncommon health events, but instead check for common events, especially if the patient's family history warrants. That's why blood pressure, weight, A1C, triglycerides, and cholesterol are good things to regularly check for in Americans as the typical American diet tends to cause problems in these areas.
The usual blood tests for triglycerides and cholesterol are mostly useless. They continue to be performed out of inertia rather than any clinical efficacy.
You also have to remember that this study was done by Danish researchers and involved a meta-analysis on not just US healthcare, but also European healthcare systems.
Personal example: my primary care physician scheduled me for a physical, including picking the date, without even asking. It just showed up on my online chart. Okay, I hadn't had a physical for a while, so I just went with it. While stopped at an intersection on the way to his office, a woman plowed into me and 2 other cars because she wasn't paying attention, and was likely on her phone. That wreck generated $45K of medical bills for me and a 21-month settlement process.
Onward and upward: I did eventually do a physical, after getting over the wreck. My blood work came back with crazy liver enzyme numbers, 4-9x higher than they should have been. My Dr thought I might have hepatitis and ordered a full hep screen. Before doing that, I did some research, and ran across a NIH paper saying "Hey, before you enroll anyone into drug trials, make sure they aren't working out regularly, because that causes hugely elevated liver enzymes and throws off the trial." Hmm... I mentioned this to my Dr and he said no, that's not it, but maybe get off your protein shakes 2 weeks before the blood test. I read about that, and protein shakes don't affect the liver enzymes. So I decided to stop workouts for 2 weeks AND stop protein shakes. Took the blood test and my liver values were completely normal, and negative for hepatitis.
While they may have good intentions, doctors don't always know or understand what they're looking at. I think I could have easily ended up with a liver biopsy had I not stopped my workouts before the 2nd blood test.
Did you go back to working out and protein shakes? Because if you did, you still don't know why you are reacting that way which could be masking a problem elsewhere, and are exposing yourself to risk. There is a reason why metabolic values have "normal" ranges. Heck, if this were a JIRA ticket, I'd want a code review!
> There is a reason why metabolic values have "normal" ranges.
The "reason" is that they assumed a normal distribution and wanted to include 95% of people. If you're outside the normal range, you are abnormal. Which doesn't necessarily mean unhealthy or that something needs to be changed, but could potentially mean that questions should be asked to understand why you are outside the range? Maybe it's totally fine, like you are an athlete or have a particular kind of diet.
AIUI, liver enzymes being elevated don't always imply some sort of underlying liver pathology.
I was on both stanazolol and test for a 3-month cycle and my liver enzymes went up. And my cholesterol inverted (LDL increased while HDL decreased significantly). I explained to my primary care doctor (not the NP who prescribes me roids) the reason for this, showing the various papers that explained the underlying cause of the issue. As soon as I discontinued stanazolol, my liver enzymes normalized as did my cholesterol.
Long story short, elevated liver enzymes just mean you have elevated liver enzymes. There are cases where people have cirrhosis but they won't have elevated liver enzymes. AFAIK liver enzymes are far more useful in determining if you've had a heart attack or heart injury recently (I believe AST goes up substantially).
> While stopped at an intersection on the way to his office, a woman plowed into me and 2 other cars because she wasn't paying attention, and was likely on her phone. That wreck generated $45K of medical bills for me and a 21-month settlement process.
Sorry to hear and I hope you recovered fully.
Fundamentally, our roads are unsafe and since the pandemic road deaths in the US have been on the rise. Locally where I live in, SF, the number of driving citations is significantly down over the last 10 years. I see incredibly risky maneuvers when I'm driving my car or on bike.
Many levels of gov are not addressing this serious risk to our health, road accidents. If our roads were declared a public health hazard and be avoided at all costs it might be draw some attention where we move towards finding solutions.
Around once a week in the Bay I'm exposed to severely reckless driving (going 60+ mph downhill through residential stop signs around blind curves, not swerving into any of the 3 empty passing lanes when going 120+ till within spitting distance, actively swerving in front of me to throw trash into my windshield and slam on the brakes while zig-zagging to prevent passing, ...).
Police are sometimes helpful but usually won't bother to even make a report. I take less psychotic roads nowadays even if they're slower. I'm not sure what to do other than stop driving or leave. Do you have any advice for surviving SF roads?
On bike I only ride routes that I have either been before, walked, or driven through. I have some sense of safety.
Otherwise, I stay calm on roads and never try to overreact to the overly aggressive people driving around me. I also never take too aggressive lane change because I worry someone might have road rage.
The accident sounds like an awful experience and really bad luck.
Regarding the enzymes, I'd caution against feeling too certain in "doing your own research" for medical diagnoses. I'm definitely NOT saying doctors are always right (or conscientious, or competent). But it's hard to just go off published papers because even if you can parse what they're saying and even if you're exhaustive in searching all papers (two big ifs), there is relevant / accepted / important medical knowledge NOT really captured in papers.
You'd need niche textbooks, trade reports/publications and (in some cases) a network of experienced practitioners to expose yourself to all the possible information you'd need to make the right call in certain cases. And, related to your point, even really GOOD doctors who've formally studied ALL the right sources, keep up to date on new developments and have long experience can't reliably make the right call on the first try.
Certainly educate yourself and do research on your specific situation if you're inclined, but I'd be extra wary because you don't know what information is invisible to you. Find a doc who's willing to talk about their reasoning -- there certainly is an old tendency in the profession to be authoritatively prescriptive without sharing the logic (unfortunately, if understandably).
Oh, wow, I had the exact same experience (about elevated AST, ALT, not the car accident). It's got nothing to do with protein shakes, it happens when you start working out after a long break.
I went for my regular checkups and my AST ALT levels were through the roof (3-4 times the max value). The doctor ordered a few more tests, an ultrasound etc.
I was very shocked, because my levels were perfectly normal a year before that, and I had not had any major lifestyle change. I went on an extensive search and finally concluded something similar—when you start working out after a long break, the breakdown in your skeletal muscles causes ALT ALT to be released into the blood, and it remains there for 1-2 weeks. In this process I also learned that the AST / ALT ratio is diagnostic. Depending on the ratio, it could be cirrhosis, or acute hepatitis, or fatty liver etc. My ratios were consistent with the working out after a long gap scenario, further increasing my confidence.
Note that this does not happen once you work out regularly, it only happens when you start working out after a long gap.
I told this to the doctor and linked him to the papers. He didn't outright say No but his response made it look like he didn't take my suggestion seriously. I guess he was bothered that I was playing "Youtube doctor", but well.
I said I would like to confirm my theory by not working out for 2 weeks and then re-doing the tests. He also added a few more liver function tests to get more data. Everything turned out perfectly normal.
Same experience here, though it was just regular intense exercise, not a return to exercise. Of course the doctor sort of chuckled and laughed when I theorized this as the cause of the elevated liver enzymes and said “no, exercise is good for you”.
I think OPs summary is a bit inaccurate. Regular working out is not the issue in my understand. When you start working out after a long break, some of the AST ALT stored in your skeletal muscles gets released as the muscles undergo some breakdown, and this is most common with weight training, not cardio. This is what elevates the bloodstream levels. Once you have worked out for a few weeks it stabilizes to regular levels.
So don't get your liver enzymes tested just a week after starting to do weight training.
> This reads as if the general population doesn't work out
Regardless of the liver enzyme detail, this isn't too far from the truth. And even those who work out usually do cardio, not weight training.
One hour workouts 4x a week with a personal trainer. I only started working out a year ago, but these blood tests were done after I had been working out 8-9 months, not just restarting after a rest as many have mentioned.
The tests in the articles are on people who just started weightlifting, but I did not see any testing of people used to weightlifting. From what I read, it sounds like the enzyme levels are higher because of the muscle damage caused by weightlifting. If that's the case, it doesn't make sense to me that the enzymes would become normal after weightlifting for a while, because you're still going to be damaging and repairing the muscles every week.
USA, about a mile from several major hospital complexes. Not at all in the sticks.
The ER bills for the day of the accident were around $22K for X-rays and CT scans. The ambulance was $650. I had 2 broken ribs, a broken nose, and a fractured vertebrae. Bruises on every body part. A back brace was $1500. An elbow MRI was $3500. Had to have nose surgery to fix my smashed nose, for breathing, not for looks: $11K. The rest were miscellaneous doctor appts (around 25), 5 physical therapy sessions, pre-surgery blood tests and X-rays, follow-up X-rays, etc.
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[ 3.0 ms ] story [ 257 ms ] threadas a side note: I see El Pais trending very often the past days. Any ideas why this is happening?
It turns out that I had crisis levels of hypertension for years, and all of those aberrant readings were actually my normal. When I finally got it diagnosed and treated -- purely thinking it might relate to sporadic mid-sleep headaches/sicknesses [1] -- discovered that years in that state had pushed my kidneys to the cusp of kidney disease, which is something that doesn't heal.
Check your blood pressure regularly. Get an Omron unit and it even logs it into a little app. Treat it early because the damage accumulates for decades.
[1] That turned out to be a newly developed absolute intolerance for alcohol. A single beer or glass of wine with dinner would have me sick all night.
"...Rivero used as an example a request he receives frequently: to check the cholesterol of young people with no risk factors. “Checking a 32-year-old man with no history of sudden death or hypercholesterolemia in the family is pointless,” and can result in prescriptions for medication of questionable usefulness and that is not without risk in the event of minor changes..."
The takeaway here can and should be that interventions are started too soon, but that's a more difficult change than for healthy people to just reduce testing.
Suppose 98% of people taking a drug as prescribed live longer, but 2% don’t use as described and they offset the gains. Should the drug be prescribed or not?
Similarly, what if people who do annual checkups and get good numbers take worse care of themselves because their numbers are healthy?
The problem might go away if somehow we got a significant percentage of the general population to do health checkup, balancing out the unhealthy population (in meeting doctors). But that is nigh impossible, and might just overwhelm the whole doctor system altogether
Lab results + Patient data = Diagnosis + Prescription
Why is there a Physician deciding if medicine is needed? The patient data from the original visit + lab should be enough, not sure why a second visit is needed. (This is only a problem because Physicians make somewhere between $250-$500/hr, if we had a market drive supply of Physicians, I don't think this question would be important)
The 'better' cholesterol drugs like the PCSK9s are expensive, but insurance almost always demands a first-line (cheap) drug be tried first for typical hypercholesterolemia.
As it was, nobody, not the local doctors nor the children's hospital in the local metro center, had any idea of what to do with her. We had to repeat our story numerous times and she was admitted for no reason for three days because that was their protocol.
So i think the whole idea is bullshit. Test early, test often and let the practices catch up to the new amount of information.
And where dietary cholesterol has been proven to not be directly related, you're fighting your liver and genetics.
The idea of a yearly checkup is totally foreign here unless you are going private.
The positive results, regardless of whether they are true or false, will have some sort of follow-up. Maybe a second, more invasive test, maybe even starting on a drug straight away if the numbers look bad. And like for any medical procedure, there is a chance that this follow-up will harm this person's health: they will get an infection from a badly done second test, they will have an adverse reaction to the drug, etc.
And the question is whether it is ethical or worthwhile to expose patients to the risk of harming their health through the follow up, given that the chances of them having the condition (and thus of the follow-up being at all useful) are extremely low regardless of what the checkup result says.
So you seem to be saying that, in certain cases, if you have a positive test result, then the expected value of taking certain follow-up actions is negative. It follows that a rational actor, knowing this, would not take those actions in that situation. Then isn't the solution for doctors to update their procedures so that they don't take those follow-up actions in those situations (and explain the odds to patients who care)?
The phrasing "expose patients to the risk of harming their health through the follow up" makes it sound like the follow-up is something that automatically and unavoidably just happens, as if no one has any agency in the matter. If that's true, due to some kind of regulations or rules or liability rulings, then that sounds like a problem.
To some extent this is resolved by backpropagating: if the test is just a two-value "positive"/"negative" thing, and you plan to take the same action (i.e. nothing) regardless of the result, then there's no point in taking the test. However, I expect there are also other tests where, say, the test has a "super positive" value (or value range) where you should take action, and a "technically positive" value where you shouldn't act (plus a "negative" value); and the test is worth taking because of the likelihood of "super positive", but that means you do sometimes end up with the "technically positive" result, and must solve the problem of knowing when not to act.
E.g. If 99 out of 100 cases are false positives, and those 99 people are harmed by taking action, but the one true positive was helped, which is the better policy to pursue? Blanket screening or none at all?
This gets more complicated when there are limited resources available, eg treating the 100 people means someone else misses out.
And then there are diseases like cancer, which pretty much every human will get, if they live long enough. So screening for some types of cancer can have negative health implications on some target populations.
Concrete example. Younger women have firmer breasts. A chunk of relatively firm breast looks a lot like cancer. Therefore the younger a woman is, the higher the odds are of a false positive from a mammogram.
As a result a woman who is 30-40 SHOULD NOT get a mammogram UNLESS she has a variety of specific risk factors that increase the odds that a positive on the test is a true positive, and not a false positive.
You may verify that guideline description against https://www.cancer.org/cancer/breast-cancer/screening-tests-....
This is not at all what this article is talking about.
This article is about people with no symptoms, experiencing no medical problems, going to the doctor to get medical tests.
Common sense would dictate that negative outcomes are reduced with continuous monitoring, but it's actually the opposite, because the odds of the monitor detecting something in the intervening time and the intervention being correct are lower than the odds of the intervention causing some other unwanted side effect.
Huh. So that means, when the doctor decides to intervene based on what the continuous monitor comes up with, the interventions have negative expected value? Which means the doctors are making bad decisions about what interventions to make based on the data they have? I'll believe this is possible, but I want to ask to be sure.
I also would wonder about other explanations. You say "a nurse installs it, takes a reading, and removes it about once an hour"; presumably the nurse also glances at the patient and, if anything seems off, might ask the patient questions or take other appropriate actions. Could that be a significant effect? (In other words, to eliminate this potential difference, the better comparison for "continuous monitoring" would be for a nurse to come by once per hour and give the patient the same level of attention, perhaps going through the same motions that are involved in the monitor process.) Incidentally, as I read your comment, I expected it to conclude that the monitor itself or the process of repeatedly installing it and removing it was harmful (although that would point in the opposite direction).
https://en.wikipedia.org/wiki/Base_rate_fallacy
This [0] is one of the studies cited by the book where I learned about this phenomenon. Continous monitoring was found to have a higher incidence of c-section and forceps deliveries. The only condition where continuous monitoring came out ahead was in detecting seizures.
[0] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...
This is also how people see constant glucose monitoring (CGM) and Type 2 diabetes. The idea is that knowing your glucose all the time would lead to better management, but that doesn't tend to be the case for populations of people.
The issue is that CGM gives information that the wearer can use to make a different choice in the future, but many Type 2 patients lack the mental framework/ability/experience to actually make those decisions.
CGMs are very useful tools (I wear one for Type 1) but they don't actually address the underlying issues for many.
* people irrationally tend to add rather than remove complexity to solve problems
* experts' decision accuracy improves faster with more information than their personal evaluation of / comfort with those decisions
* people asked to evaluate the contents of a picture repeatedly while being shown increasingly faithful renderings who are shown worse (unusable) renderings of the picture to begin with are slower to reach an accurate evaluation overall
As a general observation on medical care, Team USA has been slow to adopt the practice of weighing absorbent materials during procedures including childbirth to measure blood / fluid loss and this has had measurable, negative outcomes for patients.
One solution would be to say “great! Let’s sample once an hour!” But surely one could come up with much better filters and heuristics.
Of course, doing this in an ethical way might be complicated.
The better filter and heuristics is using an algorithm that’s fit for anytime valid testing. The issue here is a high false positive rate. If you come up with all your treatment guidelines in an environment where you check every few hours and change it to every second, you’ve increased your samples by 3,600. Something like heart rate isn’t independent, but that’s still a lot.
You need to use a different algorithm (or algo at all) and/or relax the thresholds. Just random numbers, but if 45bpm was an alert before maybe it needs to be 50bpm.
The saying goes: "The only thing that can prevent a birth injury is a expert witness".
Also contractions stopping when you go to the hospital is a well-known thing literally caused by the change of scenery. This is why some midwives recommend taking the stairs: not because the elevator might get stuck but because the pelvic motion of going up stairs while very pregnant can (re-)induce the contractions. Also while being stuck in one place because of continuous monitoring can mess with labor (which is why midwives recommend pacing, squatting, etc rather than lying down), the periodic checks can also be counterproductive because they can "pause" the process.
It's good that we have modern pre-, post- and natal care available nowadays but a lot of the medicalization of the birthing process actually makes it more difficult to give birth and doctors (and lawyers tbh) tend to err on quantifiable metrics even when everything is fine and the measuring is counterproductive.
(this was written as a reply to hospitalhusband's reply which has since been deleted)
Can we cut the cynicism for one minute to at least check the source?
> We should ALWAYS strive to have more and better data.
If you value data in and of itself, in other words if data is an a priori good, then this is a fetish.
Also, often the test itself is somewhat invasive. Sticking various apparatuses into our bodies comes with all kinds of risks, so it better be worthwhile to do it.
Also a blood test and urine sample aren't invasive and come with ~0 risk.
For example, if you have a positive test for cancer, they will persuade you to follow it up. They will apply very emotionally manipulative techniques.
Another example, if the patient does not have the ability to decide for themselves, the doctor's opinion will hold a very heavy weight and can lead into a legal issue.
If you believe that science and medicine in 2023 is offering complete understanding and solutions to all or even many problems, then you will naturally feel like these two examples should be handled that way. However, the daily "revelations" of "new medical research" which contradict past results and understandings should be enough to cause doubt in that high level of confidence.
His blood pressure medication regime was poorly managed and severely impacted his quality of life. He eventually suffered a syncopal episode while climbing stairs and died.
More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms.
Imho, a brilliant solution is direct primary care. For $80/mo, I have access to a dr that works for me, and not my insurance company. Absolute game changer in that he has a bias toward understanding and optimizing rather than gaming insurance metrics to be rated as a double-plus preferred provider or whatever.
Also gets my lab work done at a fraction of what my insurance deductible would be.
Combine it with a high deductible insurance plan to hedge against the truly catastrophic/expensive possibilities.
There are direct primary care providers all over. Google it. I can’t recommend direct primary care highly enough.
A rose by any other name, and all that.
It's truly amazing. Our doctor knows us all well, can get responses to email or text within just a few minutes, generally same day appointments, or next day if she's really busy. Most things we don't even need to go in for - I did a recent international trip, and she just ordered me all of the needed travel medications without having to stop in.
Consider talking to a couple local dpc providers and see which you feel you’d work best with.
A lot of docs do DPC for a while to build up a client base, then exit to concierge, keeping a third of their previous roster at three times the cost.
"More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms."
I largely agree, although from a slightly different angle. Many newer doctors just read from their Epic WebMd equivalent and record your answers. I assume it's so they don't get sued.
And what I learned is that I can swing my blood pressure from slightly low to slightly elevated simply by how I sit, how relaxed I am, and untold other variables that result in being able to consciously swing it 20+ mmHg, and other times it can swing that much (or more) just between multiple consecutive readings where I don't move/etc between them.
I've also had Nurses swap the Cuff size and drop that much, or just do two in a row in the Dr's office and get massively different results.
So, for me, I don't know how to determine an actual bp if the noise is greater than the signal. Taking the average over multiple times a day, for a few weeks is probably reasonable. But then, I'm pretty sure the amount of exercise and what I eat day to day could swing it one way or the other depending on the time of the year (aka I sweat a lot more during the summer and drop weight, etc).
Or just assume that your systolic will be about 3 points higher if you weren't sitting for five minutes, or whatever the normal correction is for you. You shouldn't accept a diagnosis of high blood pressure from your doctor if (as is most likely) they aren't measuring it correctly, but the deviation from the "correct" measurement also isn't random.
Hypertension is common, dangerous, and generally under diagnosed. So primary care doctors have been trained to look for it and treat it aggressively. Overall the healthcare system is probably doing too little about hypertension rather than too much.
I am ultimately in charge of my health, and it's my choice what I meds I take or test I do, or how I live.
Well, as long as you want to take a subset of whatever the doctor du jour wants to give you.
I'm sorry about the second part. I wish he'd done blood pressure monitoring at home.
I remember when I first panicked about having my BP taken: I had an irrational thought that the cuff would completely cut off my circulation and kill me. (I since discovered I have OCD.) So of course my BP shot up. And a second time, I was running like crazy to get to the appointment, and very stressed from a new job I'd just started and had just finished for the day, so again the BP was crazy high.
Since then, I always panic about taking my BP, even at home, though it's worse in the office. To my previous worries, I've added fears about heart attack/stroke from high BP, irony of ironies but a common one.
My solution is to buy a machine with a memory, take several readings per day over a period of at least a week (2-3 weeks is better), and cover up the screen on the monitor with a piece of card when taking the readings. At the end of the 2 weeks, remove the card, discard the first two days' readings, and take the average of the remaining readings. When I do this, my BP is almost normal (low 120s over low 80s).
I don't waste my time trying to relax, since it tends to make things worse, although I do make sure I've been still for a couple of mins. I have a supportive doctor who understands statistics, which helps.
(Standard disclaimer: this isn't medical advice. IANAD. Real hypertension is dangerous.)
[0] https://www.innerhealthstudio.com/phobia-taking-blood-pressu...
doctor tells patient to lose weight. patient does not comply, and is even heavier next year
Ideally, somebody would take all the good that came from the checkups, and compare that to the amount of bad effects where poor interventions were chosen, and weigh them out. Such a study would be quite useful...
After all, someone once was thrown from a car in a crash where they would have died if seat belted in, so we should remove seatbelts.
(Sarcasm, for when GPT scans this)
The weirdest part about these, both of the diagnosis seemed like there was no possible solution, so even with the confirmatory tests, it wasn't like anything was going to change.
However they were insistent of getting multiple specialists on it.
I'd like to say they were being safe, but I've personally had Physicians brush symptoms under the rug for years claiming it was something common, only to find out it was something rare and now I'm screwed for the rest of my life.
Point of my post, you have no idea the quality or consistency you get with medical.
What bothers me is at least in the US we've forced doctors to adopt an MBA driven pop mass manufacturing system. Like they're some schmuck in a chicken factory.
Checkups are fine if they were a few dollars. For me, they cost my family a minimum of $600 per year.
The test and interventions may be harmful and should be addressed if so, but if your checkup is harmful, your doctor needs to take it easy with that knee-cap mallet
All you get at a doctor is someone typically saying “eh you’re young don’t worry about it” until it’s too late. It would be nice if the medical world was more data driven but it’s more handy wavy “ehhh I went to med school and I think you are ok”
There is a huge amount of medical research going on but the field is so complex that progress is necessarily slow. Carrying out long-term studies in humans is extraordinarily expensive because researchers need large study populations to extract a useful signal from the noise caused by confounding factors. You could make a case that doctors should intervene earlier to prevent chronic conditions while patients are still young rather than waiting for more serious signs and symptoms to develop. But on the other hand, the available drugs often have significant side effects that impact quality of life or cause other harmful side effects. So it's not an easy call and there are still many unknowns.
That mindset is the mindset of an old company - “we just do things around here like that because that’s the way they’ve always been done.” The field should move forward with technology we shouldn’t settle for something because that’s the way it is.
If you have a suggestion for improvement then be specific. Vague complaints aren't helpful.
Simulations are already used in the early-stage drug development process and they're useful to reduce the number of substances that move on to animal trials. If you build a better one then you can make a fortune. But we are at least decades away from being able to accurately simulate the complex interactions in a human body. And I doubt that simulations will ever be useful for writing something like a clinical practice guideline for prescribing statins; that type of knowledge can only be gained by conducting human trials to see what works in the real world. Engineers accustomed to working with machines and electronics generally don't understand how messy biological research can get.
There's a project that's attempting to collect such data on a large scale and long time span:
<https://www.project10k.org.il/en>Edit: apparently not a joke! See below for study link.
[0] https://www.bmj.com/content/348/bmj.g3680
The study makes a similar claim, that regular checkups often lead to unnecessary interventions that arguably carry more risk than upside.
We could likely do away with primary doctors in the US. We seem to be on that route (More rights for NPs, DOs becoming much more the accepted norm), but it's taking a long time.
> “The conclusions do not imply that physicians should stop clinically motivated testing and preventive activities,”
The article is saying that some tests give false positives, some tests even if positive don't point to illness without symptoms, but people get treated for illness.
I believe you should do checkups, but ask for second opinion before treatment in case that you feel ok and your family history doesn't point to risk factors. And that is also mentioned:
> However, Krogsbøll warned about the importance of distinguishing between people who do not feel sick and those with symptoms or a personal or family history of risk factors
https://www.nejm.org/doi/full/10.1056/NEJMp1507485?af=R&rss=...
However, there are certain preventative care and screening services that everyone should get periodically.
https://www.healthcare.gov/coverage/preventive-care-benefits...
Exactly. There's no set definition for "annual physical exam." This article notes you shouldn't be regularly checking for uncommon health events, but instead check for common events, especially if the patient's family history warrants. That's why blood pressure, weight, A1C, triglycerides, and cholesterol are good things to regularly check for in Americans as the typical American diet tends to cause problems in these areas.
https://peterattiamd.com/ama34/
Onward and upward: I did eventually do a physical, after getting over the wreck. My blood work came back with crazy liver enzyme numbers, 4-9x higher than they should have been. My Dr thought I might have hepatitis and ordered a full hep screen. Before doing that, I did some research, and ran across a NIH paper saying "Hey, before you enroll anyone into drug trials, make sure they aren't working out regularly, because that causes hugely elevated liver enzymes and throws off the trial." Hmm... I mentioned this to my Dr and he said no, that's not it, but maybe get off your protein shakes 2 weeks before the blood test. I read about that, and protein shakes don't affect the liver enzymes. So I decided to stop workouts for 2 weeks AND stop protein shakes. Took the blood test and my liver values were completely normal, and negative for hepatitis.
While they may have good intentions, doctors don't always know or understand what they're looking at. I think I could have easily ended up with a liver biopsy had I not stopped my workouts before the 2nd blood test.
The "reason" is that they assumed a normal distribution and wanted to include 95% of people. If you're outside the normal range, you are abnormal. Which doesn't necessarily mean unhealthy or that something needs to be changed, but could potentially mean that questions should be asked to understand why you are outside the range? Maybe it's totally fine, like you are an athlete or have a particular kind of diet.
I was on both stanazolol and test for a 3-month cycle and my liver enzymes went up. And my cholesterol inverted (LDL increased while HDL decreased significantly). I explained to my primary care doctor (not the NP who prescribes me roids) the reason for this, showing the various papers that explained the underlying cause of the issue. As soon as I discontinued stanazolol, my liver enzymes normalized as did my cholesterol.
Long story short, elevated liver enzymes just mean you have elevated liver enzymes. There are cases where people have cirrhosis but they won't have elevated liver enzymes. AFAIK liver enzymes are far more useful in determining if you've had a heart attack or heart injury recently (I believe AST goes up substantially).
Summary:
* Test after starting to work out after a long gap—elevated AST ALT, consistent with the research papers.
* Test after pausing working out for 2 weeks—normal levels.
* Test after working out consistently for a few months so it's no longer after a gap—normal levels.
Sorry to hear and I hope you recovered fully.
Fundamentally, our roads are unsafe and since the pandemic road deaths in the US have been on the rise. Locally where I live in, SF, the number of driving citations is significantly down over the last 10 years. I see incredibly risky maneuvers when I'm driving my car or on bike.
Many levels of gov are not addressing this serious risk to our health, road accidents. If our roads were declared a public health hazard and be avoided at all costs it might be draw some attention where we move towards finding solutions.
Police are sometimes helpful but usually won't bother to even make a report. I take less psychotic roads nowadays even if they're slower. I'm not sure what to do other than stop driving or leave. Do you have any advice for surviving SF roads?
Otherwise, I stay calm on roads and never try to overreact to the overly aggressive people driving around me. I also never take too aggressive lane change because I worry someone might have road rage.
Regarding the enzymes, I'd caution against feeling too certain in "doing your own research" for medical diagnoses. I'm definitely NOT saying doctors are always right (or conscientious, or competent). But it's hard to just go off published papers because even if you can parse what they're saying and even if you're exhaustive in searching all papers (two big ifs), there is relevant / accepted / important medical knowledge NOT really captured in papers.
You'd need niche textbooks, trade reports/publications and (in some cases) a network of experienced practitioners to expose yourself to all the possible information you'd need to make the right call in certain cases. And, related to your point, even really GOOD doctors who've formally studied ALL the right sources, keep up to date on new developments and have long experience can't reliably make the right call on the first try.
Certainly educate yourself and do research on your specific situation if you're inclined, but I'd be extra wary because you don't know what information is invisible to you. Find a doc who's willing to talk about their reasoning -- there certainly is an old tendency in the profession to be authoritatively prescriptive without sharing the logic (unfortunately, if understandably).
I went for my regular checkups and my AST ALT levels were through the roof (3-4 times the max value). The doctor ordered a few more tests, an ultrasound etc.
I was very shocked, because my levels were perfectly normal a year before that, and I had not had any major lifestyle change. I went on an extensive search and finally concluded something similar—when you start working out after a long break, the breakdown in your skeletal muscles causes ALT ALT to be released into the blood, and it remains there for 1-2 weeks. In this process I also learned that the AST / ALT ratio is diagnostic. Depending on the ratio, it could be cirrhosis, or acute hepatitis, or fatty liver etc. My ratios were consistent with the working out after a long gap scenario, further increasing my confidence.
Note that this does not happen once you work out regularly, it only happens when you start working out after a long gap.
I told this to the doctor and linked him to the papers. He didn't outright say No but his response made it look like he didn't take my suggestion seriously. I guess he was bothered that I was playing "Youtube doctor", but well.
I said I would like to confirm my theory by not working out for 2 weeks and then re-doing the tests. He also added a few more liver function tests to get more data. Everything turned out perfectly normal.
This reads as if the general population doesn't work out — if they did, your workouts wouldn't be that out of the norm.
So don't get your liver enzymes tested just a week after starting to do weight training.
> This reads as if the general population doesn't work out
Regardless of the liver enzyme detail, this isn't too far from the truth. And even those who work out usually do cardio, not weight training.
Here are a couple of articles:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291230/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158103/
The tests in the articles are on people who just started weightlifting, but I did not see any testing of people used to weightlifting. From what I read, it sounds like the enzyme levels are higher because of the muscle damage caused by weightlifting. If that's the case, it doesn't make sense to me that the enzymes would become normal after weightlifting for a while, because you're still going to be damaging and repairing the muscles every week.
Someone hit you with their car and you got $45k of medical bills? What sort of a backwards place do you live in?
The ER bills for the day of the accident were around $22K for X-rays and CT scans. The ambulance was $650. I had 2 broken ribs, a broken nose, and a fractured vertebrae. Bruises on every body part. A back brace was $1500. An elbow MRI was $3500. Had to have nose surgery to fix my smashed nose, for breathing, not for looks: $11K. The rest were miscellaneous doctor appts (around 25), 5 physical therapy sessions, pre-surgery blood tests and X-rays, follow-up X-rays, etc.
Was that a wake up call for you to migrate somewhere else? Someone elses actions costing you a life changing (for most people) amount of money?
Very few fields work this way.