7 ms·

“Since all medical interventions come with risks, many people will suffer harm from unnecessary tests and procedures.” I agree with this statement generally, b

“Since all medical interventions come with risks, many people will suffer harm from unnecessary tests and procedures.” I agree with this statement generally, but in this specific case it seems tenuous. If the iWatch’s 1-lead EKG detected a-fib, the next course of action would be a more reliable diagnostic, specifically a proper 12-lead EKG interpreted by a qualified medical professional, perhaps followed by a Holter monitor to record 5 or more leads over a 48+ hour period. A 12-lead involves attaching ten electrode stickers to a patient which are then wired up to a backpack-sized monitor which passively reads the difference in electrical activity between specific electrodes. It’s a simple non-invasive procedure that’s performed a hundred thousand times a day in the US. In fact, it’s so simple and low-risk that I as a lowly EMT am allowed to perform it. (To drive this point home, the state of California does not allow me to prick a patient’s finger to get the drop of blood required to ascertain blood sugar. I need a paramedic to do that for me.) It’s absurd for this doctor to suggest an asymptomatic young person could be prescribed anticoagulants for a-fib “diagnosed” by an iWatch. I can understand doctors expressing opposition to “self-diagnostic medicine” but to make these arguments about a 1-lead makes as much sense as arguing that people shouldn’t be able to buy and operate a blood pressure machine without a prescription.

ghufran_syed 8y ago
Not so “absurd” - you may be missing some context. A 12-lead ecg can diagnose whether you have a-fib at the time of the ecg. The question for the doctor is whether you may have “paroxysmal” ie intermittent a-fib. So what if the Apple Watch said ‘a-fib’, but the 12-lead is negative. Most doctors are probably going to end up ordering a holter- monitor, to monitor the patient’s rhythm over 24-72 hours. Some proportion of those patients may have very short runs of a-fib, and would likely have remained blissfully ignorant (and well) without the Apple Watch. Instead, they may well end up anti-coagulated, because if that patient is not anticoagulated and gets a stroke later ( which may or may not be due to a-fib), the doctor is going to get sued. Whereas if the doc starts the patient on anticoagulants, and tells the patient that, “ there’s a risk of bleeding, but...”, that is much less likely to end up in a lawsuit.
- heartIssuesGal 8y ago
  FUD
  - ghufran_syed 8y ago
    Feel free to counter my statement with actual arguments, I’m assuming (principle of charity here) that you do have some. Decisions are really easy to make when you have no responsibility - whereas having one of your patients die from brain bleeds on anticoagulation (as well as having patients stroke out when anticoagulation might have prevented it) tends to give you a healthy appreciation for the harms on both sides of a decision that you make about people’s lives
- dpkonofa 8y ago
  What? That "context" seems absurd considering that the alternative is that the person has 0 warning and 0 indication of either kind of a-fib. Even if the person doesn't have paroxysmal a-fib but the Apple Watch detects an irregularity, I think it would be grossly irresponsible for a doctor to prescribe anticoags without confirming some kind of condition.
- toxik 8y ago
  Wait, so the argument against having more data is that sometimes that data is misinterpreted or misunderstood? That does not seem like a good argument.
  - eli 8y ago
    The cost to a false positive in terms of stress alone should not be underestimated.
  - ufo 8y ago
    If you are not going to act on the information, then the extra expense of the exam is wasted. If you are going to act on the information, then you must weight the benefit of early detection against the damage caused by unnecessary exams and treatment when there are false positives. False positives are specially problematic when screening a large number of healthy people.
heartIssuesGal 8y ago
Even if "tests" (omg no!) are ordered, they're not going to jump directly to invasive procedures like biopsies or catherization (have had both!$. They're going to do exactly what you've described as a "lowly emt" - thank you for posting this. Screw this "doctor" and their FUD.
Someone 8y ago
”the next course of action would be a more reliable diagnostic, specifically a proper 12-lead EKG interpreted by a qualified medical professional, perhaps followed by…” I think you’re missing the argument made (fairly poorly, IMO) in this article: that preventive medicine often isn’t worth the money for society. For relatively rare diseases, false positives typically outnumber true positives by a wide margin. If that’s the case for this Apple Watch, that means many users will needlessly be stressed thinking “I’ve a heart problem”, something that will cause some loss of QALY’s (https://en.wikipedia.org/wiki/Quality-adjusted_life_year https://en.wikipedia.org/wiki/Quality-adjusted_life_year) and will trigger tests that will take resources that may better be spent elsewhere. That’s for society, though. Richer I ndividuals may not care about the extra costs, and people doing lots of checkups may be less stressed about false positives.
dreamcompiler 8y ago
In rural New Mexico, EMTs can do finger sticks and King airways and epi injections and certain other interventions that normally require a medic because our transport times are long. But yeah, we also do ECGs all the time. What worries me is that a 1-lead ECG is not worth much. If a 12-lead is only 90% accurate, a 1-lead is bound to be much worse.
monkeydreams 8y ago
I don't know how it works in the US, but in the Australian public system you cannot organise a medical intervention without the right results from the proper tests. The Apple Watch in this scenario becomes a symptom for the doctor to assess in order to plan for diagnostic tests, not a diagnostic test in and of itself.

ghufran_syed 8y ago

Not so “absurd” - you may be missing some context. A 12-lead ecg can diagnose whether you have a-fib at the time of the ecg. The question for the doctor is whether you may have “paroxysmal” ie intermittent a-fib. So what if the Apple Watch said ‘a-fib’, but the 12-lead is negative. Most doctors are probably going to end up ordering a holter- monitor, to monitor the patient’s rhythm over 24-72 hours. Some proportion of those patients may have very short runs of a-fib, and would likely have remained blissfully ignorant (and well) without the Apple Watch. Instead, they may well end up anti-coagulated, because if that patient is not anticoagulated and gets a stroke later ( which may or may not be due to a-fib), the doctor is going to get sued. Whereas if the doc starts the patient on anticoagulants, and tells the patient that, “ there’s a risk of bleeding, but...”, that is much less likely to end up in a lawsuit.

heartIssuesGal 8y ago
FUD
- ghufran_syed 8y ago
  Feel free to counter my statement with actual arguments, I’m assuming (principle of charity here) that you do have some. Decisions are really easy to make when you have no responsibility - whereas having one of your patients die from brain bleeds on anticoagulation (as well as having patients stroke out when anticoagulation might have prevented it) tends to give you a healthy appreciation for the harms on both sides of a decision that you make about people’s lives
dpkonofa 8y ago
What? That "context" seems absurd considering that the alternative is that the person has 0 warning and 0 indication of either kind of a-fib. Even if the person doesn't have paroxysmal a-fib but the Apple Watch detects an irregularity, I think it would be grossly irresponsible for a doctor to prescribe anticoags without confirming some kind of condition.
toxik 8y ago
Wait, so the argument against having more data is that sometimes that data is misinterpreted or misunderstood? That does not seem like a good argument.
- eli 8y ago
  The cost to a false positive in terms of stress alone should not be underestimated.
- ufo 8y ago
  If you are not going to act on the information, then the extra expense of the exam is wasted. If you are going to act on the information, then you must weight the benefit of early detection against the damage caused by unnecessary exams and treatment when there are false positives. False positives are specially problematic when screening a large number of healthy people.

heartIssuesGal 8y ago

Even if "tests" (omg no!) are ordered, they're not going to jump directly to invasive procedures like biopsies or catherization (have had both!$. They're going to do exactly what you've described as a "lowly emt" - thank you for posting this. Screw this "doctor" and their FUD.

Someone 8y ago

”the next course of action would be a more reliable diagnostic, specifically a proper 12-lead EKG interpreted by a qualified medical professional, perhaps followed by…” I think you’re missing the argument made (fairly poorly, IMO) in this article: that preventive medicine often isn’t worth the money for society. For relatively rare diseases, false positives typically outnumber true positives by a wide margin. If that’s the case for this Apple Watch, that means many users will needlessly be stressed thinking “I’ve a heart problem”, something that will cause some loss of QALY’s (https://en.wikipedia.org/wiki/Quality-adjusted_life_year https://en.wikipedia.org/wiki/Quality-adjusted_life_year) and will trigger tests that will take resources that may better be spent elsewhere. That’s for society, though. Richer I ndividuals may not care about the extra costs, and people doing lots of checkups may be less stressed about false positives.

dreamcompiler 8y ago

In rural New Mexico, EMTs can do finger sticks and King airways and epi injections and certain other interventions that normally require a medic because our transport times are long. But yeah, we also do ECGs all the time. What worries me is that a 1-lead ECG is not worth much. If a 12-lead is only 90% accurate, a 1-lead is bound to be much worse.

monkeydreams 8y ago

I don't know how it works in the US, but in the Australian public system you cannot organise a medical intervention without the right results from the proper tests. The Apple Watch in this scenario becomes a symptom for the doctor to assess in order to plan for diagnostic tests, not a diagnostic test in and of itself.