5 ms·

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 whe

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.
  - manicdee 8y ago
    The persistent monitoring afforded by devices such as Apple Watch will directly lead to an increase in the detection rate of any condition that they are capable of detecting. These new detections will be conditions that had been previously undetected. Whether you class these as false positives (because the existing test suite doesn't detect them) or false negatives (because the existing test suite should have detected them) is perhaps a matter for debate. The practical outcome is more people living healthier lives because their persistent malaise has finally been identified. At first I was wondering how scheduling someone for a long-term ECG would cause damage, then I remembered that this feature will only become available in the USA soon. Given that the USA is a country where unexpected health care can destroy a person's life through either bankruptcy or the curse of being a woman/person of colour, yes I agree that detecting a previously undetectable condition could cause damage.
    - toast0 8y ago
      There has been a lot of recent research and recommendations for policy change around reducing the frequency of screenings for various things. Time and data will surely tell if this type of ECG screening is helpful or harmful on a population level. Certainly, some people will get a secondary ECG indicating intervention is required, and the intervention will improve their lives. Others may have a negative result from the intervention, and may never have found their way into this intervention without this screening. For some, this screening indicating a problem but a full screening indicating nothing will drive persistent anxiety. It is absolutely not the case that more medical intervention is an unqualified good, even ignoring the economic costs.
gist 8y ago
Exactly. And what's funny is that people seem to think that physicians make accurate judgements all the time and don't make mistakes. And that there are not a host of gray areas which are taken into consideration. Maybe a similar example is with a dog bite. If you say 'no it was my dog and they are not rabid' then doctor says 'ok no rabies shot needed'. If you say 'it's a wild dog (or friends dog)' and you don't know if it's rabid doctor thinks 'rabies shot needed'. Even if the actual chance of rabies (in your friends dog) is quite small (if the friend doesn't know if the dog has shots I mean). More info is not only not always helpful but comes with risks as well. If not we would monitor things more frequently than we do and the simple scale would lower the cost.
- manicdee 8y ago
  Would you say that, on the whole, physicians will make judgements that are approximately as accurate given new data about paroxysmal a-fib as they did before having this new data? Are they already condemning people to unnecessary treatment on the off-chance that treatment is helpful? Is there scope here for the AMA to refine procedures to suggest holding off on medication when a condition is only discovered by a persistent monitoring system such as Apple Watch? Even if the over-medication issue increases, are the live saved via early detection of equal value to the lives damaged by unnecessary medication? If there are more lives saved than damaged, is there a net benefit to society, or are we only interested in the lives lost through action and not at all concerned about the lives lost through inaction?
dan000892 8y ago
Something isn’t right when you’re considering lawsuit potential when making patient care decisions. I stand by my argument that a GP prescribing an anticoagulant based solely on an iWatch having detected a-fib is grossly negligent (just as—in keeping with my earlier comparison—he would be if he prescribed an anti-hypertensive to a patient who stated they had a BP of 180/120 at home one time). I’m not entirely sure why you docsplained that 12-leads cannot bend spacetime and that a Holter monitor would be likely be ordered to detect intermittent arrhythmias over a longer period of time, but thanks. Can I claim CE hours for this?
- citrablue 8y ago
  The argument against more monitoring is one of false positives. Suppose the Apple Watch has a 5% false positive rate, and detects problems with 1% of 100 million users.* That's 50k extra patients going to their doctors, thinking there might be something wrong with them. The next test may have a 1% false positive rate. That would put 500 extra patients on anti-coagulants. That may not materially change the public health calculation, or it may. But that's the calculus -- not that a GP would blindly prescribe, just that increasing the top of the funnel is not necessarily a good thing. (Plus, extra cost.) Positives and negative impact of additional testing must be measured for optimal decisions. * numbers to make the math easy
  - dan000892 8y ago
    As opposed to the “but I might get sued” argument, I find this argument totally reasonable. Thank you for stating it so clearly. I’m cautiously optimistic but recognize that we need more data because evidence-based medicine is all about testing hypotheses. The hypothesis here is that continuous 1-lead monitoring will provide a net benefit to the population employing it. Maybe it will and maybe it won’t; Either way I think it’s pretty cool that we’re about to amass a ton of relevant data from which we’ll be able to derive an answer.

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.
- manicdee 8y ago
  The persistent monitoring afforded by devices such as Apple Watch will directly lead to an increase in the detection rate of any condition that they are capable of detecting. These new detections will be conditions that had been previously undetected. Whether you class these as false positives (because the existing test suite doesn't detect them) or false negatives (because the existing test suite should have detected them) is perhaps a matter for debate. The practical outcome is more people living healthier lives because their persistent malaise has finally been identified. At first I was wondering how scheduling someone for a long-term ECG would cause damage, then I remembered that this feature will only become available in the USA soon. Given that the USA is a country where unexpected health care can destroy a person's life through either bankruptcy or the curse of being a woman/person of colour, yes I agree that detecting a previously undetectable condition could cause damage.
  - toast0 8y ago
    There has been a lot of recent research and recommendations for policy change around reducing the frequency of screenings for various things. Time and data will surely tell if this type of ECG screening is helpful or harmful on a population level. Certainly, some people will get a secondary ECG indicating intervention is required, and the intervention will improve their lives. Others may have a negative result from the intervention, and may never have found their way into this intervention without this screening. For some, this screening indicating a problem but a full screening indicating nothing will drive persistent anxiety. It is absolutely not the case that more medical intervention is an unqualified good, even ignoring the economic costs.

gist 8y ago

Exactly. And what's funny is that people seem to think that physicians make accurate judgements all the time and don't make mistakes. And that there are not a host of gray areas which are taken into consideration. Maybe a similar example is with a dog bite. If you say 'no it was my dog and they are not rabid' then doctor says 'ok no rabies shot needed'. If you say 'it's a wild dog (or friends dog)' and you don't know if it's rabid doctor thinks 'rabies shot needed'. Even if the actual chance of rabies (in your friends dog) is quite small (if the friend doesn't know if the dog has shots I mean). More info is not only not always helpful but comes with risks as well. If not we would monitor things more frequently than we do and the simple scale would lower the cost.

manicdee 8y ago
Would you say that, on the whole, physicians will make judgements that are approximately as accurate given new data about paroxysmal a-fib as they did before having this new data? Are they already condemning people to unnecessary treatment on the off-chance that treatment is helpful? Is there scope here for the AMA to refine procedures to suggest holding off on medication when a condition is only discovered by a persistent monitoring system such as Apple Watch? Even if the over-medication issue increases, are the live saved via early detection of equal value to the lives damaged by unnecessary medication? If there are more lives saved than damaged, is there a net benefit to society, or are we only interested in the lives lost through action and not at all concerned about the lives lost through inaction?

dan000892 8y ago

Something isn’t right when you’re considering lawsuit potential when making patient care decisions. I stand by my argument that a GP prescribing an anticoagulant based solely on an iWatch having detected a-fib is grossly negligent (just as—in keeping with my earlier comparison—he would be if he prescribed an anti-hypertensive to a patient who stated they had a BP of 180/120 at home one time). I’m not entirely sure why you docsplained that 12-leads cannot bend spacetime and that a Holter monitor would be likely be ordered to detect intermittent arrhythmias over a longer period of time, but thanks. Can I claim CE hours for this?

citrablue 8y ago
The argument against more monitoring is one of false positives. Suppose the Apple Watch has a 5% false positive rate, and detects problems with 1% of 100 million users.* That's 50k extra patients going to their doctors, thinking there might be something wrong with them. The next test may have a 1% false positive rate. That would put 500 extra patients on anti-coagulants. That may not materially change the public health calculation, or it may. But that's the calculus -- not that a GP would blindly prescribe, just that increasing the top of the funnel is not necessarily a good thing. (Plus, extra cost.) Positives and negative impact of additional testing must be measured for optimal decisions. * numbers to make the math easy
- dan000892 8y ago
  As opposed to the “but I might get sued” argument, I find this argument totally reasonable. Thank you for stating it so clearly. I’m cautiously optimistic but recognize that we need more data because evidence-based medicine is all about testing hypotheses. The hypothesis here is that continuous 1-lead monitoring will provide a net benefit to the population employing it. Maybe it will and maybe it won’t; Either way I think it’s pretty cool that we’re about to amass a ton of relevant data from which we’ll be able to derive an answer.