Half the posts in this thread bring back the old SlashDot adage: The plural of anecdote is not data.
I am not sure what the point this article is trying to make is. I do not feel more informed for having read it.
It seems a populist appeal to the idea that the medical institution has no idea what it is doing. Is it good, is it bad? It doesn't matter. The end result is damaged institutional trust.
How many people would read this article and go "yeah doctors have no idea what they are doing," then go to their alternative medicine to spend $100 on a dubious "medicine"? How many people here are actually equipped to have a meaningful understanding of the information presented? Why did the author not present the institutional position or data supporting yearly checkups and why it's misleading?
As long as billionaires are able to influence people to fight about anything other than wealth disparity, they win. We are not experts, we should leave decision making to people who know what they don't know rather than to people who don't know what they don't know (us).
The point I got from the article is to bias against medical interventions. That doesn't mean never consider them, but they really need to have a serious reason to occur.
It doesn't have to that doctors are bad at their jobs, but rather that they're humans, and humans are hardwired to try to make other humans happy, and patients like being actively given treatment as opposed to "have you considered sleeping well, eating well, and just letting your body do its thing?"
The sources that the article has, an article in the BMJ[0] and Cochrane[1], are actually targeted at primary care physicians (after all, random laypeople don't read medical journals!), to basically tell them to chill, and tell their patients to just let themselves be.
> The point I got from the article is to bias against medical interventions.
I will always regret not asking what the difference in outcome was from a surgery on a ligament in my ankle. I feel like the surgeon saw a thing they could fix and said they should do so. I don't think they had an internal monologue of does it matter and I never checked.
Not a major mistake, but not one i would make again
I think this is unnecessarily conspiratorial. Medical tests often have much more uncertainty than most expect, and many interventions are net negative on average.
This particular research was new to me but I have seen a number of studies of cancer screenings and treatment showing the same or even worse effects. The recommended standards for some cancer screenings have been updated in recent years to be more restrained since it was shown they were having a negative effect in certain cases.
Many tests have fairly high false positive rates. This leads to a lot of unnecessary treatment with negative health consequences. There are also a number of scenarios where treatment reduces the mortality rate from one specific issue, but increases mortality overall because of the associated harm of treatment.
This isn't some homeopothy plug -- that stuff is nonsense. But I would suggest being somewhat skeptical of boilerplate medical advice.
> I think this is unnecessarily conspiratorial. Medical tests often have much more uncertainty than most expect, and many interventions are net negative on average.
If a crucial test is giving false positives, rather than dismissing the test altogether, it would be more beneficial to adjust the response protocols, invest in improving the test's accuracy, or focus on better informing patients about the potential risks and benefits. Discarding a test entirely could lead to missed opportunities for early detection and intervention, which can be crucial for certain conditions. There has to be some balance between skepticism and the potential value of medical tests and screenings.
This article gives people things to consider and does not dare give specific advice. Everybody is different. Some people are in touch with their bodies and can detect if something is going wrong, and others are not. Institutions and pharmaceutical companies can adversely affect our health if they are able to influence doctors to advise us wrongly in a for profit health care industry. If you look at the health of the US population with a declining life expectancy, rising obesity, immunological diseases, and cancer, some self learning seems like a good thing rather than to leave your health up to institutions, companies, and doctors.
> Everybody is different. Some people are in touch with their bodies and can detect if something is going wrong, and others are not.
Piggybacking off the parent, this is a major issue that medicine doesn't seem to have figured out how to deal with. Some people are so in touch with themselves they can tell they are getting sick before they have any measurable symptoms. Other people go months or years without knowing something is seriously wrong. Because modern medicine is about systematizing decisions (everything is a code), the patient's own internal sensations are given little weight compared to the measurements of an external instrument. The result is that if the particular set of tests which were ordered show nothing abormal then it can be hard or impossible to get treatment.
> Some people are so in touch with themselves they can tell they are getting sick before they have any measurable symptoms. Other people go months or years without knowing something is seriously wrong.
And many people derive imagined diagnoses from their anxieties, then come up with confident narratives based on "researching" online. Most of us are terrible at self-diagnosis, doubly at determining the causality to wherever they've arrived. There's a reason the double blind standard was a critical innovation.
>Some people are in touch with their bodies and can detect if something is going wrong
and how does one come to know this?
> If you look at the health of the US population with a declining life expectancy, rising obesity, immunological diseases, and cancer, some self learning seems like a good thing rather than to leave your health up to institutions, companies, and doctors
Could you show your work? Some steps are clearly missing between the premise and the conclusion
>Could you show your work? Some steps are clearly missing between the premise and the conclusion
Life expectancy is dropping in the US according to official studies you can easily find. It is now lower than China. Obesity, immunological diseases, and cancer have also been rising over the decades. I am not going to pin anything to specific causes as that will spur a debate too long for my attention. IMO the system is generally failing us. Without your health, you have nothing. It is too important for me to completely trust to others especially with how our system is currently incentivized.
This is an issue that is by nature difficult to study in a rigorous, controlled manner. I can tell you that it is a real phenomenon but probably can't prove it in a way you would consider satisfactory. We see the highest levels of this internal body awareness among people who have spent many years using their bodies at peak performance levels. They do their normal daily training and something feels a little "off" before any obvious signs or symptoms appear. But if you only associate with sedentary office workers then you might be skeptical. A lot of people feel like crap so often that to them it begins to feel normal.
I don't think the solution is just leaving our complex decisions over to others. I think the solution is that we all need to be better informed. A doctor doesn't decide to do something for us unless we're incapacitated. The doctor informs us of our options and risks and we get to make the decisions ourselves.
In the same vein (vain pun would have been better), we need more opportunities to decide for ourselves than we currently do, not fewer. Why should any other major decision a country makes be any different? We hand over the decision making over too often when we should be turning those situations into more opportunities to let democracy to rule. Inform the public and let them decide. Allowing others to decide for us has been a shit show.
No. The government should provide consequences for those who violate trust promoting the idea that I can trust someone else who is from the same society I am.
Here is a game that shows what happens at a societal level when doctors lie or mechanics over charge: https://ncase.me/trust/
In the game of prisoners dilemma, society itself must ensure that defection is a losing strategy. This idea has a name: rule of law.
The government is us. Not some aliens. We should be democratically deciding what is correct and what is a violation and what the consequences for violating trust are. We should not hand that decision over to a few elected representatives. This should be a collective democratic process.
* legalize abortion? yes or no
* go to war? yes or no
* arm teachers? yes or no
* corporate news outlet allowed to sell ad time to corporations they report on? yes or no
* nondemocratically run businesseses allowed to function as a news outlet? yes or no
How do "we" decide something? It sounds like you are advocating for mob rule but calling it democracy. Help me understand how that is not what you are saying.
What is the "collective democratic process" you are advocating for? How does a law get made and how does a law get enforced?
Democracy is mob rule. Direct democracy. The fear of "too much democracy" is only a fear for people who are afraid that others might not want the same things they do. One person, one vote is mob rule. What that requires is a well informed, well educated population. Instead we have an ignorant, uninformed population that leaves all of the important decisions to a hand full of representatives that tend to run things the way their wealthy donors want.
But I don't think that's changing. This is key to young person vs old person thinking. Young people believe we can actually change to a well informed population. They end up getting old realizing that wasn't actually possible, become rich (because we're talking about the smart ones here) and then end up donating to representatives for getting things to run the way they believed it should be. See what I did there?
> What that requires is a well informed, well educated population.
Isn't this very uncommon, in addition to the need to be at least somewhat compassionate (e.g. in regards to issues that might not affect individuals personally, but that affect minorities, or simply those who are different)? A certain social cooling might be needed in many societies, less extremism, less identity politics, less hate.
This post is an amalgam of barely formed thoughts followed by..."but fight a class war". It's nonsense from beginning to end.
Why is critical data "populist"? Why is undamaged institutional trust your goal? Are institutions inherently trustworthy, or is it that they aren't but should be presented as such? Why are you concerned with the literacy of the audience rather than the content of the article? In your mind, why is is every author's duty to present two arguments (which is not a research mandate, the article being a research summary presented in popular article format).
Anointing "experts" is not how science works.
Again, the article being equivalent to a research abstract and research being the basis for science.
We removed science from the unquestionable "expertise" of the Church many centuries ago. At which point we placed in the hands of research and its critique.
> Half the posts in this thread bring back the old SlashDot adage: The plural of anecdote is not data.
I find the application of this logic to be entirely one-sided. Positive anecdotes are data, negative anecdotes are wives tales.
Simplifying medical information into data points is a dangerous practice which by now should be revealing itself as entirely fraudulent. Anecdotes provide context which doctors and science love to dismiss. I'll take a handful of anecdotes and appreciate all the context they provide, meanwhile the context-free "science" will go back and forth never getting anywhere nearer to better health outcomes.
How do you think rare vaccine side effects have been discovered and recorded? By collecting thousands of "anecdotes" from individuals reporting anomalous symptoms.
How do you think illicit drug harm is measured? They can't exactly pump people full of cocaine and ketamine in a lab to study overdose effects - you collect anecdotes (individual cases), catalog them, aggregate and adjust for sample bias.
Anecdotes are individual, cherry-picked testimonies. When you collect enough of them you get a statistically significant data point. It may be biased based on how your data was collected but the same can be said for many scientific studies that turned out to be flawed in their data collection. As long as you are aware of what the possible bias is, you have data.
My best friend is diagnosed with a disease nobody has a cure, his wife, Krohns disease, his son on the spectrum. They visit the doctor every 3 months (each) since 2015. And each time they go it's more decay and more confusion.
I'm not anti science but there are echos from nntaleb Antifragile in this.
Institutional corruption will not be solved by losing trust in the institutions. When the institution dies because nobody trusts it you don't all of a sudden get good health care.
So if you believe that our medical institutions are corrupted, anger at the institution itself is misdirected. The corruptive force is billionaires and the measurement for the level of corruption is wealth disparity.
> Institutional corruption will not be solved by losing trust in the institutions. When the institution dies because nobody trusts it you don't all of a sudden get good health care.
That's a fair point. "Burn it down" is not a good solution. The system, even while corrupted, still results in vastly improved outcomes relative to what people could expect 100-150 years ago.
> So if you believe that our medical institutions are corrupted, anger at the institution itself is misdirected. The corruptive force is billionaires and the measurement for the level of corruption is wealth disparity.
I'm not going to say greed has nothing to do with it, but this is just such a reductive take that I don't think really even begins to address the multitude of perverse incentives going on with our healthcare system.
Money gets to vote on candidates before people do. Before any general election there is a primary, and to win the primary you do fundraising. People with money give politicians money with the implicit understanding that making anti-donor decisions will result in withdrawal of future money or (thanks to citizens united) unlimited contributions to their opponent.
Money literally votes on political candidates before any person does. That is why we have a "democracy" more responsive to money than to the will of the average voter.
Even if you look at it as a black box, Princeton did a study and asked if the legislation our politicians pass correlate most with the average citizen, interest groups, or the desires of rich people, the correlation was highest with rich people: https://scholar.princeton.edu/sites/default/files/mgilens/fi...
Multivariate analysis indicates that economic elites and organized
groups representing business interests have substantial independent
impacts on U.S. government policy, while average citizens and
mass-based interest groups have little or no independent influence.
As wealth concentrates, it is able to purchase and corrupt further institutions. Bezos bought WaPo, Musk bought Twitter, I'm sure there are more examples. Do you think that is a form of power that is able to manipulate public opinion or government policy? Do you think ownership of a media outlet could help a person concentrate their wealth or fight being taxed?
Even from a mathematical approach. If Billionaires are able to earn 5% year over year interest at minimal risk, while large swathes of people will never make enough to have a savings, what do you think the long term consequences of that will be? If inequality is increasing and never decreasing, what do you think the long term effects will be? What types of things cause inequality to decrease, are we doing those things?
How much wealth has to concentrate before you are comfortable labeling it oligarchy?
Here is Yale history professor and expert in European history Timothy Snyder talking about oligarchy, the rule of the wealthy few. "What is oligarchy?": https://www.youtube.com/watch?v=biZVrh821RA
In this video he explores what oligarchy is and what effect oligarchy (the state of extreme wealth inequality -- too many billionaires) has on social programs like healthcare, namely that there won't be social programs/investment in institutions.
I agree we live in a relatively oligarchic society - that is an inescapable outcome for democracies.
We would probably disagree as to the causes and alternatives to this oligarchic structure, but I don't want to go down that rabbit hole at the moment.
What I am saying is that when you look at the problems with the medical profession, there is more at play here than the self-interest of billionaires. You talk at high levels about the impact of inequality on overall government policy, but not everything that goes wrong with an industry is a result of government policy, let alone policies favored by the wealthy. Medical research is fraught with issues of reproducibility. Government regulations artificially restrict the supply of healthcare. Technological advancement means that many people can now live sedentary lives, and it's adversely affecting health outcomes.
What the politics of inevitability does is that it teaches you to narrate in such
a way that the facts which seem to trouble the story of progress are disregarded.
So in the politics of inevitability, if there is huge wealth inequality as a
result of unbridled capitalism, we teach ourselves to say that that’s kind of a
necessary cost of this overall progress. We learn this dialectical way of
thinking by which what seems to be bad is actually good.
And, of course, that applies to foreign affairs as well. When we look at
countries that are not making the quote-unquote “transition” to democracy the way
we expect, you know, we find excuses. We imagine that the general trend is going
to our direction in some deep way. And then we fail to notice, what has been the
case for the last 15 years or so, that the world is actually moving in a very
pronounced and easily observable way away from democracy.
But the way that things are breaking now in the U.S. is that our politics of
inevitability, which we’ve held to in the last 25 years, basically this idea that
“since communism ended in 1989 there are no alternatives,” basically this idea
that “technology must lead to enlightenment,” this idea that “the market must lead
to democracy.” Those ideas have now come back to clobber us. Neither of them ever
had any foundation. Both of them are highly persuasive to a lot of people and
that’s lead to some consequences, which are very dangerous for the rule of law and
indeed for democracy. Believing that, for example, more market means more
democracy means that you don’t regulate things that you really need to regulate,
like offshore wealth or anonymous transactions or shell companies. And that
creates a world, a gray zone of capitalism where, for example, a Donald Trump can
begin close relationships with Russian oligarchs. If you believe that technology
automatically leads to progress, then you don’t watch very carefully as certain
kinds of social platforms lead people into a politics of “us and them” and destroy
a sense of common factuality. The story that you’re telling yourself the whole
time about how “the market or tech have to lead toward enlightenment and
democracy” dulls your mind to what’s actually happening until you reach the point
that we’ve reached now.
> but not everything that goes wrong with an industry is a result of government policy,
It is not positive government policy that is the problem but government failure to act because the government operates on behalf of money (oligarchy), not on behalf of us (democracy).
If not the government, where do you think a solution comes from?
> Here is a relatively quick video of him pretty directly critiquing what you just stated...
None of that big wall of text seems to directly address anything I actually said.
> It is not positive government policy that is the problem but government failure to act because the government operates on behalf of money (oligarchy), not on behalf of us (democracy).
The only thing worse than pedantry is wrong pedantry. Your attempt at correcting me here is wrong because The absence of the kinds of policies you would like to see is still policy.
In other words, not everything that goes wrong with an industry is the result of the government not doing what you wish it would do.
And to be more specific, even those things that go wrong because of government policy are not necessarily caused by oligarchic influence.
So when the US FDA is shilling for obesity drugs, says that being obese isn’t a lifestyle problem but is purely genetic. Medical schools are lowering/removing certain standards for admission under the guise of ‘equity’ - thats all just some billionaires faults? Sorry, I don’t buy it. The medical and pharmaceutical industries have been rotting for decades in the US and protecting them, “because it would be better for our healthcare system” is exactly the mentality that gets you into this mess to begin with. State the problem, state it clearly. Don’t shift blame around to invisible boogeymen.
>So when the US FDA is shilling for obesity drugs, says that being obese isn’t a lifestyle problem but is purely genetic
The FDA has never claimed obesity is purely genetic and it's own guidelines state multiple factors for obesity and stringent guidelines for the approval of drugs that target specific genetic disorders.
>Medical schools are lowering/removing certain standards for admission under the guise of ‘equity’
This doesn't seem true at all, and seems like an extension of the "woke" boogeyman we see in undergrad.
The problem with this kind of thinking is it's hard to assign anysort of motivation for these actions without sounding cartoonish. The FDA wants to say obesity is a purely genetic for what reason? Who is enriched when the FDA says this? Does the FDA get some kickback every time there's a new obese person?
>State the problem, state it clearly. Don’t shift blame around to invisible boogeymen.
The for-profit medical system has created a two-tier treatment system that is incentivized to protect profits over providing adequate care. This includes both providing poor treatment to those who cannot pay as well as providing ineffective treatment to wealthier americans in order to sell more expensive, patented drugs. Any political action to change this system is effectively stonewalled due to "invisible boogeymen" who all happen to have the same political interests in keeping current profitable system and are able to easily buy politicians to prevent any radical change from going through. The incentive is clear - to protect profit margins.
Help us out here. Let's say hypothetically we confiscate all wealth above $1B. How exactly would that improve average healthcare outcomes? Please take us through the causal chain step by step.
If an institution is a net negative and it dies then we are better off immediately. Even if it’s not a net-negative and it dies we might be better off in the long term because something better replaces it.
> So if you believe that our medical institutions are corrupted, anger at the institution itself is misdirected. The corruptive force is billionaires and the measurement for the level of corruption is wealth disparity.
Don't you mean not enough billionaires? It seems like they are the only ones that can circumvent the political roadblocks to deliver things like cost plus drugs. There aren't that many of them nor are they involved in a lot of the industries plagued with these issues.
Most issue are from regulator capture from honestly not even that rich of people.
I would just stop there. For over 10,000 years we've had two systems: one where a small group of very rich people control society and admit it, and one where they don't. The former was arguably better, at least it was honest.
I have watched most of Dr. Fung's videos but had not seen this one. Hopefully he also points out that the FDA is funded by the very people they are testing and often allow the people they are testing to perform the tests.
> It seems a populist appeal to the idea that the medical institution has no idea what it is doing.
Isn’t at least the section about false positives an indication that doctors know what they’re doing, and know what they cannot do?
> Why did the author not present the institutional position or data supporting yearly checkups and why it's misleading?
Because it’s not a scientific article? The article mentions the arguments and has links to a paper in the BMJ (paywalled, unfortunately)
> We are not experts, we should leave decision making to people who know what they don't know rather than to people who don't know what they don't know (us).
So, why do you want this article to show data supporting its claims?
"yeah doctors have no idea what they are doing" isn't really that far off the mark for a lot of things.
The health of the average person in the west (And globally) is in decline. Obesity, diabetes, heart disease and cancer are all massively massively increased from where they were 100 years ago.
If the standard advice given isn't working for people (And it most obviously is not) then looking for alternatives really is the only thing people feel they can do.
In todays age being average in health is a poor decision.
>The health of the average person in the west (And globally) is in decline. Obesity, diabetes, heart disease and cancer are all massively massively increased from where they were 100 years ago.
In the US, life expectancy has increased by 30 years since 1900. People weren't dying of cancer and heart disease as frequently because 24% of them had already died by the age of five.
Possibly dumb question: can an early 30 something trust that number to apply to them?
I'd imagine the calculation is more sophisticated than I can imagine, but can it take into account things that haven't necessarily had their full impact yet? Like potential world war, deep recession/depression, massive unrest, things like microplastics, forever chemicals, dropping testosterone, the after effects of covid itself as well as everything around it.
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.
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”.
> 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.
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).
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).
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.
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.
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.
> 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).
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.
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.
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)
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.
> 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?
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 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".
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.
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.
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.
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 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.
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 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.
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.
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 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.
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.
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
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.)
Since this thread is chock full of anecdotes, here's mine that is the exact opposite.
I was completely healthy into my late 20's. I started a new job at 30. I got health insurance and figured for my 30th I'd get a checkup ... my first exam since I was 18 under my parent's plan. My blood pressure was high, so they did some tests which uncovered portal hypertension, and found I may eventually need a liver transplant. Zero history of it in the family. Good thing I had a checkup because I thought I was the model of health.
Again, since these are all anecdotes, I'm sharing. Yes be alert and ask questions but don't just blow it off. Maybe not yearly, but at least twice a decade maybe?
Cholesterol and blood pressure can reach out of normal levels fairly suddenly. They need to be treated as soon as this evidence appears. All sorts of conditions can be spotted by a capable practitioner. Contrary to the tone of the article, most doctors are not over-treating; they will watch something that’s on the borderline. I fear that this article will give justification to the many people who are “too busy” or just don’t like going to the doctor.
Oh and by the way. I know of no better analogy, as you grow older and things start failing, than that the body is like an old car. You’ll see, mark my words.
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.
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.
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.
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.
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.
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.
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”
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.
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.
MY FIRST PSA. It all started about a year earlier when my family doctor of 20 years retired. In the fall of 1994, my new doctor gave me a physical exam to establish a new baseline. The physical involved an assortment of blood tests, all of which were in the normal range, with one exception. The test called PSA came back with a result of 5. The acceptable range, according to the lab computer, was 0 to 4.
I didn't know what this test was. In fact, I don't think I'd ever had one before. My doctor's comment was, "It's slightly elevated. It's probably nothing to worry about, but I think you should see a urologist."
Yeah, this is the classic "regulations are written in blood" logic. If the cost is invisible and the benefit is visible we do not price as we would if it were made apparent.
Presumably our internal model clamps some kinds of things to zero and other things to infinity.
When thinking about it, I would prefer to take a test and detect cancer even if the test gives me a near equal risk of cancer. It's strange to my rational self, so I must struggle to reconcile it.
If anything, the article you referenced is a perfect example of someone doing their own research and diagnostics. Most people do not get this level of care, nor have the intellect to work the diagnostics the way he did.
The risk/value proposition is likely much different for people just deferring to doctors, especially for those doctors that are on the lower end of the performance spectrum.
There seems to be some solid data that mammograms, colonoscopies, and treating prostate cancer (with many caveats on that last one) is actually mostly not beneficial in reducing overall mortality.
The reasons are likely complex and nuanced, but do your research carefully if your doctor is trying to talk you into one of those. You probably will only benefit their next car payment, not your health.
For a mammogram, it doesn’t increase survival over a manual exam.
For colonoscopies, you have one in 1400 chances of saving a life and one in 1000 chances of perforating a bowel and dying here and now instead of in 30 years. There’s another exam with lower risks and most of the benefits.
For prostate cancer, if you have the aggressive kind, intervention has almost no effect. You’re dead either way.
If you have the slow growing kind, you’ll likely die of something else. The risks of treatment are mostly balanced against the benefit. But treatment will nuke your quality of life.
I don’t have time too dig up sources right now, so don’t take my word for it. Look for the studies, they’re quite approachable.
>one in 1000 chances of perforating a bowel and dying here and now
that sounded impossible and googling a bit I think it's off by a couple of orders of magnitude: closer to 1 in 10000 chances of perforation, which has a single digit % of death
He doesn’t give any numbers there. I may well be completely out to lunch, but that source doesn’t modify my opinion.
Here's the results of the first large randomized clinical trial - the gold standard in medicine. The study involved over 80,000 participants in Nordic countries.
"colonoscopy reduced cancer incidence but not death"
Doesn't reasoning like this fall under the ecological fallacy? You can't use statistics to predict the outcome for the individual.
If I get a colonoscopy tomorrow there is not a 1/1000 chance I'll die of a perforated bowel. Except perhaps by pure coincidence. My odds will be different. Maybe 1/10. Maybe 1/10,000.
A government can use statistics like these to direct spending, but as an individual you need to take your own personal history into account, and your trust in your medical professionals, and roll the dice.
Your should assume your odds are 1 in 1000, without reason to believe otherwise. Your actual odds are obviously going to be different, but that is unknown to you and shouldn’t affect your reasoning about the risks.
> After analyzing 17 clinical trials involving 230,000 people and comparing adults from the general public who got checked to others who did not, they found that general checkups had “little or no effect” on total mortality or cancer, cardiovascular, heart disease and stroke mortality.
So general checkups have a little or no effect on total mortality, but the studies themselves don't say anything about additional risks, they are more of an "opinion". And to add to it, “little or no effect” on total mortality or cancer, cardiovascular, heart disease and stroke mortality could mean a lot of things. Does it mean people die anyway, but get to live longer? Did the studies take into account effects of regular testing from a young age? The listed diseases are also closely related to hereditary problems, but is the finding the same for other health issues that may not have a genetic component to them?
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.
The physician who acknowledges the imperfections of a diagnostic test will ask, "In view of this test result, how uncertain should I be about this patient?" Fortunately, there is a method for answering this question: the theory of probability. [1] is a primer for applying probability theory to the interpretation of test results and deciding when to do a test rather than treat or do nothing.
Physicians often must start treatment when still uncertain about whether the patient has the disease. If treatment is started, there is a risk of causing harm to a person who does not have the disease, as well as the prospect of benefiting the person who does. If treatment is withheld, a person who is diseased will be denied a chance at a rapid, effective cure.
The method for solving this problem analytically is called the threshold model of medical decisionmaking (Pauker and Kassirer 1975, 1980; Doubilet 1983). The threshold model is an example of expected-value decisionmaking that is applied to a particular type of decision.
The key idea is the treatment threshold probability, which is the probability of disease at which one is indifferent between treating and not treating. The basic principle of the threshold model is the following dictum: Do a test only if the probability of disease could change enough to cross the treatment threshold probability.
[1] Sox H, Stern S, Owens D, et al.; Institute of Medicine (US) Council on Health Care Technology. Assessment of Diagnostic Technology in Health Care: Rationale, Methods, Problems, and Directions: Monograph of the Council on Health Care Technology. Washington (DC): National Academies Press (US); 1989. 2, The Use of Diagnostic Tests: A Probabilistic Approach. https://www.ncbi.nlm.nih.gov/books/NBK235178/
Medicine is still clearly medieval in this respect, and would be considered insane in any other field:
"Gosh I hope my SQL database still has enough storage, but I better not check because adding a disk to the RAID array might cause a failure on rebuild." It's not a factually incorrect statement, but the problem isn't with the checking.
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 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.
Nassim Taleb wrote at length about his beliefs about "iatrogenic" harm, which is that caused by the doctor themselves. His ideas about it are mercifully summarized in the FS blog: https://fs.blog/iatrogenics/ and how it expands as a pattern to be aware of.
Searched immediately for Taleb as he is the most notable example of calling this out.
The second being a classic Munger idea of misaligned incentives. Doctors hardly get to practice medicine anymore and is why old variations of common sayings like “Never trust a doctor who only knows medicine, a lawyer who only knows law, or a pharmaceutical company that only knows profits” still circulate. Except the punchline has become reality for a number of professions.
Here's a small quiz regarding the false positives mentioned in the article.
If 3 in 1000 people in the general population are HIV positive, and a HIV test has a 1% false positive rate, (assuming no false negatives for simplicity) how likely is it, that if you run routine tests on a random group of people, for an individual to be healty despite the test coming out positive?
Despite the fact that false positives only occur 1% of the time, the answer is about 70% that they are healthy. This question has actually been put in front of practicing physicians, an overwhelming amount could not answer this question correctly, many were off by a magnitude.
Worth keeping that in mind when your doctor uncriticially tries to prescribe you something for a relatively rare disease because a measurement was positive.
> _Worth keeping that in mind when your doctor uncriticially tries to prescribe you something for a relatively rare disease because a measurement was positive._
yes and yet this is slightly overgeneralizing
what you have to keep in mind specifically is that these two things, prevalence in to he population and false positives (and negatives!) do _exist_ and that you should inform yourself about them and factor that into your decision making
a PCR COVID test for example is something you don't argue with. and the quick tests on the other hand came in widely different qualities.
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.
In my observation and experience with watching the medical profession do what it does with many family members, it is an art form of personal preservation to avoid being caught in the teeth of the medical industry. Nothing in that sentiment implies undue trust in alternative medicine.
That being said, there are minor things that people can do to avoid and solve problems. Which might otherwise get over-treated should one submit to a doctor. Go to bed early, become skilled with vitamin C usage for vascular health preservation, find a way to be active every day, avoid PUFA, get your iron checked for overdose (they enrich everything with it), etc.
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..."
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.
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 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.
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 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.
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
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?
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)
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.
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.
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?
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.
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.
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.
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.
This article is really aimed at the more dubious tests (e.g. cholesterol) than doing yearly checkups per se.
I'd agree with the idea that some tests aren't as good as others, and we lump critical checkups (let's say cardiography) with more shakier ones, like waist circumference or cholesterol. Finding issue with the later falls a lot more into pop science than actual hard evidence based physical intervention.
Removing the pop science from the periodical checkups would definitely be a good idea, stopping yearly checkups altogether is throwing the baby with the bath water.
> Too much cholesterol puts you at risk for heart disease and stroke, two leading causes of death in the United States.
For instance if you have high cholesterol but clinically no artery or cardiac issues, lowering your cholesterol will essentially do nothing for you. Some doctors will follow the manuals and still have you lower your levels "just in case" (they'll want to lower a potential risk), but we're the entering the fuzzy part that has no consensus.
PS: what values are high is also actively debated, and ethnicity and other factors will affect what is "normal". That's another aspect where it's a lot more touchy/feely than a "your arteries are clogged" diagnostic.
In my humble opinion, this fails the deductive reasoning test, and therefore the analysis is missing key explanatory factors (some of which the authors seem to allude to).
Of course checkups carry the risk of false positives. And I have trouble believing that: early detection/intervention isn’t going to lead to better health outcomes, regular screenings won’t lead to early detection, and that adherence to a treatment regime (e.g. high cholesterol = improve diet, increase exercise, maybe take medication) won’t improve outcomes.
Primary sources for this article appear to primarily be a 2014 cochrane review and 2008 article; the journalism looks to be mostly just asking a family doc a few questions - low quality.
"Thus, for statistical reasons, the more patients there are in a population, the more reliable a positive result will be. Conversely, a positive is more likely to be false in the case of rare diseases."
This description of Baye's theorem is wrong. It should say that the higher the prevalence of the disease in the population, the more reliable a positive result will be.
3blue1brown has a good yt video on the topic which I recommend:)
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.
As usual, the medical industrial complex (which includes insurance companies) is asleep at the wheel of innovation, and blaming patients for their inadequacies in disease detection.
The obvious result of an aggressively for-profit healthcare system: aggressively squeezing profit out of everything it can and let then let the doctors take all the heat for it.
Not just for-profit, but aggressively separating the payor and costs (government, insurance) from the treatment and patient, thereby reducing accountability in the system
Everyone I know who had cancer (and that is a large and increasingly growing list...) found out about it because they went in to the doctor for a non-routine appointment because they felt pain, or felt a lump, or had a weird reaction to a vaccine, or whatever else. Even early stage cancer can produce symptoms, and luckily most of those people survived.
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.
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?
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
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.
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.
I am not sure what the point this article is trying to make is. I do not feel more informed for having read it.
It seems a populist appeal to the idea that the medical institution has no idea what it is doing. Is it good, is it bad? It doesn't matter. The end result is damaged institutional trust.
How many people would read this article and go "yeah doctors have no idea what they are doing," then go to their alternative medicine to spend $100 on a dubious "medicine"? How many people here are actually equipped to have a meaningful understanding of the information presented? Why did the author not present the institutional position or data supporting yearly checkups and why it's misleading?
As long as billionaires are able to influence people to fight about anything other than wealth disparity, they win. We are not experts, we should leave decision making to people who know what they don't know rather than to people who don't know what they don't know (us).