5 ms·

This is an incredible confusion, and I'm angry to see so many medical authorities and administrations taking the same stance: no, it's never too early to know.

This is an incredible confusion, and I'm angry to see so many medical authorities and administrations taking the same stance: no, it's never too early to know. The more the information the better everything. What could be too early is to act, supposing that by "act" is meant any predefined medical action. However why would it be any "too soon" for an awareness awakening by the sick individual that would bring a healthier lifestyle? Last thing I'd like to add, you just have to tell the individual about the trade-off and risks of the early act too, and this additional information will be enough to cancel any supposed danger of the early diagnostics information. When you think that giving some information is dangerous, then actually it's because you need to provide the targeted individual even more of what info you have.

foldr 6y ago
> it's never too early to know I don't see this. Suppose, hypothetically, that we could detect right now every illness or condition that you're ever likely to develop in the course of your life. Do you really want to read through that list? You're better off not worrying about it and enjoying your life.
- echelon 6y ago
  > You're better off not worrying about it and enjoying your life. I would rather have all of the information upfront so that I can make better informed decisions. We're all going to die. I'm not going to shy away from that by pretending it won't come.
  - foldr 6y ago
    There's no 'pretence' involved in not reading the list. I'm perfectly aware of my mortality. I just don't see any value in placing bets on what's going to kill me.
    - shard 6y ago
      Everyone is living with an invisible list made up by them in their minds. This is what drives people to exercise, eat healthy foods, get vaccinated, and wash their hands. This just clarifies the list, perhaps adding some items, perhaps changing the priorities.
  - deleted 6y ago
    [deleted]
- DavidSJ 6y ago
  I would absolutely read the list, in part because I simply value (self) knowledge. I notice that some people don't value knowledge for its own sake, and have trouble understanding those who make decisions solely for the sake of knowing, or solely to avoid dishonesty toward others, even at some narrow instrumental expense. But also, I would read the list of because of its instrumental value: * If I knew I were likely to die in ten years, I would live my life very differently than I do now. * If I knew I were at particular risk for certain illnesses, I would do what I can do minimize that risk.
  - foldr 6y ago
    I can't really see how not reading the list would require dishonesty towards others. It's probably a good idea to live your life as if you were going to die in 10 years anyway. The chance of this happening is non-negligible unless you are very young. Similarly, as far as minimising risk of illnesses goes, 99% of what you could do is what everyone should be doing anyway: eating healthily and exercising. Fundamentally, the paradox here is that the extra stress caused by reading the list is likely to be much worse for you than the consequences of not knowing what's on the list.
    - DavidSJ 6y ago
      Not reading the list doesn't require dishonesty toward others, but I was making a more general point: There are lots of people who are very ready to tell "white lies" to others for the sake of those others. As it happens, I think they are often the same people who wouldn't read the list. And these sorts of people don't really seem to understand the other sort: the sort who want to know the truth even if it's not instrumental. --- On the other topics: if I lived like I were going to die in ten years, then I'd have to abandon multiple projects of mine which I expect to take more than ten years to come to fruition. I don't think this would be appropriate unless I actually had a good reason to believe my premature death would come to pass.
      - foldr 6y ago
        I mean live as if there's a reasonable chance that you'll die in ten years. But even so, do you get no intrinsic satisfaction from the work involved? Is there no-one who could continue the projects if you died? If it's 'no' to both questions, then maybe you should stop doing them anyway.
- abalone 6y ago
  Nonsense. Catching cancer prior to stage 3 is HUGELY important. With prostate cancer it can be cut out or irradiated with a high cure rate at stage 2. Once it spreads though you are in a very different course.
  - foldr 6y ago
    I think you're talking about cancer screening rather than the hypothetical in my post. I was not suggesting that no-one should ever get screened for any illness. But it's a balance. Too much screening and testing can be just as harmful as too little - or perhaps even more so. Prostate cancer is actually a classic example of this (see e.g. https://www.health.harvard.edu/healthbeat/the-pros-and-cons-of-psa-screening#:~:text=Concerns%20about%20PSA%20screening&text=One%20study%20estimated%20overdetection%20to,such%20as%20incontinence%20and%20impotence. https://www.health.harvard.edu/healthbeat/the-pros-and-cons-...)
    - abalone 6y ago
      Your hypothetical includes every illness and thus, cancer. It is extremely helpful to detect cancer early. The prostate cancer field is rapidly evolving, and the “controversy” over PSA testing in the US over the last decade is looking like a big mistake. See for example https://jamanetwork.com/journals/jamasurgery/fullarticle/2680144 https://jamanetwork.com/journals/jamasurgery/fullarticle/268...
      - foldr 6y ago
        >Your hypothetical includes every illness and thus, cancer. I think there's a quantifier scope error here. I was saying "you don't want to see everything on the list", i.e. "it's not the case that for all x, you want to see x". You seem to be reading this as "For all x, you don't want to see x". Whatever the right answer is for specific cases (such as prostate cancer), I'm certainly not saying that all testing or screening is pointless. The paper you link to has a grand total of two citations listed on Google Scholar.
        6y ago
pintxo 6y ago
I pretty much agree with your points. But this is not what we see in reality today. I believe that part of today's problem is knowledge, interest and incentives. - About 40% of patients (in general) do not care enough about their health and delegate all decision making to the doctor. - I am simplifying here: If you ask a surgeon about the best therapy for your cancer, the answer will most likely be surgery. If the same patient would ask a radiologist, the answer will most likely be radiation. Which we might attribute to people more likely to believe in their own line of work. But in reality this might be more influenced by doctors being financially driven by their administrators to maximize patient throughput.
- l33tman 6y ago
  Fortunately these decisions are usually not done by the individual surgeon or radiologist but by a cross-disciplinary team during rounds and by input from wide long-term studies categorising the tumor type, treatment options and outcome.
  - pintxo 6y ago
    For metastasized cancers yes. But for primary cancers? Not such much. Patients need to step up and actively talk to multiple doctors if they want to get a complete picture.
l33tman 6y ago
It's just hard to take in that info.. Your average patient is not really capable, especially when delivered life-changing information and requiring THEM to decide what life-changing action to take. Most in that situation defers to what the physician recommends, which brings us back to the current situation. One root problem here is the lack of a firm connection between test result and long-term prognosis. You can have a supersensitive test, but if the prognosis varies wildly anyway and the possible procedure to do carries significant risk, the test has limited value. One general rule is that you should not order a test unless you're prepared to act on it, and the guidelines for when to act on the PSA levels are still debated. There are lots of other tests and pathologies and remedies that make sense to screen for (that can, like you say, make the patient go for a more healthy lifestyle etc).
- abalone 6y ago
  This is outdated. PSA is a very valuable test as it can flag you for new tests that can be performed short of a biopsy (4kscore, genetics, MRI, ultrasound). And biopsies are getting better at detection as well.
- henearkr 6y ago
  I think that your premise is that the knowledge that the doctor would have to pass to the patient in order for the latter to make enlightened choices would require squarely a long and tedious medical training. To which I would suggest that 1/ no, the knowledge to have for this particular test results, likely (and less likely) prognoses, and the associated possible medical acts and risks, is not equivalent to a full medical training, as it is a tiny bit of one specialty. But I acknowledge that it may require quite some time. 2/ there is no need to apply the same policy to every patient, and you can choose to only allow tests to the patients who went through the basics training evoked in 1/. In the end, if somebody wants to go through the process to get the knowledge to be able to deal with the information, why to deny it? Plus, that would make a nice incentive to get people to know better their own body.
  - l33tman 6y ago
    Well I agree fully that there are patients who are smart and could take in the info (for that matter, lots of doctors also end up as patients), and I'd hope their treating doctors give them any info they ask for and get them involved in the aspects. After all, in this specific case I'm pretty sure you can get a PSA taken by yourself even and then the cat's out of the bag. But in a broader sense, what I was thinking of was that when faced with a shocking piece of info ("you might die and there might be nothing we can do about it" etc.), most people don't stay very composed - there are several different reactions and phases and one is certainly "I want as much information as possible and I want to be involved in all decisions" but I'd argue it's not the most common reaction and even in that case, it's a crisis reaction and maybe not as logically driven (or productive at all) as it might seen at first. So then you'd first have to figure out how this specific patient would react before deciding to do the screening and if you just guess, you'd probable be criticized at some point, so you instead make sure you follow the national plans and recommendations.. Then the (sad) fact is that you usually have maybe 15 minutes allocated in primary care to say hello to a new patient, listen to the symptoms or concerns, examine, make a plan, inform the patient, say goodbye, dictate the journal. You can't spend hours educating the patient. I'd wish this was different (but then again that applies to any service interaction, even your car mechanic or whatever).

foldr 6y ago

> it's never too early to know I don't see this. Suppose, hypothetically, that we could detect right now every illness or condition that you're ever likely to develop in the course of your life. Do you really want to read through that list? You're better off not worrying about it and enjoying your life.

echelon 6y ago
> You're better off not worrying about it and enjoying your life. I would rather have all of the information upfront so that I can make better informed decisions. We're all going to die. I'm not going to shy away from that by pretending it won't come.
- foldr 6y ago
  There's no 'pretence' involved in not reading the list. I'm perfectly aware of my mortality. I just don't see any value in placing bets on what's going to kill me.
  - shard 6y ago
    Everyone is living with an invisible list made up by them in their minds. This is what drives people to exercise, eat healthy foods, get vaccinated, and wash their hands. This just clarifies the list, perhaps adding some items, perhaps changing the priorities.
- deleted 6y ago
  [deleted]
DavidSJ 6y ago
I would absolutely read the list, in part because I simply value (self) knowledge. I notice that some people don't value knowledge for its own sake, and have trouble understanding those who make decisions solely for the sake of knowing, or solely to avoid dishonesty toward others, even at some narrow instrumental expense. But also, I would read the list of because of its instrumental value: * If I knew I were likely to die in ten years, I would live my life very differently than I do now. * If I knew I were at particular risk for certain illnesses, I would do what I can do minimize that risk.
- foldr 6y ago
  I can't really see how not reading the list would require dishonesty towards others. It's probably a good idea to live your life as if you were going to die in 10 years anyway. The chance of this happening is non-negligible unless you are very young. Similarly, as far as minimising risk of illnesses goes, 99% of what you could do is what everyone should be doing anyway: eating healthily and exercising. Fundamentally, the paradox here is that the extra stress caused by reading the list is likely to be much worse for you than the consequences of not knowing what's on the list.
  - DavidSJ 6y ago
    Not reading the list doesn't require dishonesty toward others, but I was making a more general point: There are lots of people who are very ready to tell "white lies" to others for the sake of those others. As it happens, I think they are often the same people who wouldn't read the list. And these sorts of people don't really seem to understand the other sort: the sort who want to know the truth even if it's not instrumental. --- On the other topics: if I lived like I were going to die in ten years, then I'd have to abandon multiple projects of mine which I expect to take more than ten years to come to fruition. I don't think this would be appropriate unless I actually had a good reason to believe my premature death would come to pass.
    - foldr 6y ago
      I mean live as if there's a reasonable chance that you'll die in ten years. But even so, do you get no intrinsic satisfaction from the work involved? Is there no-one who could continue the projects if you died? If it's 'no' to both questions, then maybe you should stop doing them anyway.
abalone 6y ago
Nonsense. Catching cancer prior to stage 3 is HUGELY important. With prostate cancer it can be cut out or irradiated with a high cure rate at stage 2. Once it spreads though you are in a very different course.
- foldr 6y ago
  I think you're talking about cancer screening rather than the hypothetical in my post. I was not suggesting that no-one should ever get screened for any illness. But it's a balance. Too much screening and testing can be just as harmful as too little - or perhaps even more so. Prostate cancer is actually a classic example of this (see e.g. https://www.health.harvard.edu/healthbeat/the-pros-and-cons-of-psa-screening#:~:text=Concerns%20about%20PSA%20screening&text=One%20study%20estimated%20overdetection%20to,such%20as%20incontinence%20and%20impotence. https://www.health.harvard.edu/healthbeat/the-pros-and-cons-...)
  - abalone 6y ago
    Your hypothetical includes every illness and thus, cancer. It is extremely helpful to detect cancer early. The prostate cancer field is rapidly evolving, and the “controversy” over PSA testing in the US over the last decade is looking like a big mistake. See for example https://jamanetwork.com/journals/jamasurgery/fullarticle/2680144 https://jamanetwork.com/journals/jamasurgery/fullarticle/268...
    - foldr 6y ago
      >Your hypothetical includes every illness and thus, cancer. I think there's a quantifier scope error here. I was saying "you don't want to see everything on the list", i.e. "it's not the case that for all x, you want to see x". You seem to be reading this as "For all x, you don't want to see x". Whatever the right answer is for specific cases (such as prostate cancer), I'm certainly not saying that all testing or screening is pointless. The paper you link to has a grand total of two citations listed on Google Scholar.
      - 6y ago

pintxo 6y ago

I pretty much agree with your points. But this is not what we see in reality today. I believe that part of today's problem is knowledge, interest and incentives. - About 40% of patients (in general) do not care enough about their health and delegate all decision making to the doctor. - I am simplifying here: If you ask a surgeon about the best therapy for your cancer, the answer will most likely be surgery. If the same patient would ask a radiologist, the answer will most likely be radiation. Which we might attribute to people more likely to believe in their own line of work. But in reality this might be more influenced by doctors being financially driven by their administrators to maximize patient throughput.

l33tman 6y ago
Fortunately these decisions are usually not done by the individual surgeon or radiologist but by a cross-disciplinary team during rounds and by input from wide long-term studies categorising the tumor type, treatment options and outcome.
- pintxo 6y ago
  For metastasized cancers yes. But for primary cancers? Not such much. Patients need to step up and actively talk to multiple doctors if they want to get a complete picture.

l33tman 6y ago

It's just hard to take in that info.. Your average patient is not really capable, especially when delivered life-changing information and requiring THEM to decide what life-changing action to take. Most in that situation defers to what the physician recommends, which brings us back to the current situation. One root problem here is the lack of a firm connection between test result and long-term prognosis. You can have a supersensitive test, but if the prognosis varies wildly anyway and the possible procedure to do carries significant risk, the test has limited value. One general rule is that you should not order a test unless you're prepared to act on it, and the guidelines for when to act on the PSA levels are still debated. There are lots of other tests and pathologies and remedies that make sense to screen for (that can, like you say, make the patient go for a more healthy lifestyle etc).

abalone 6y ago
This is outdated. PSA is a very valuable test as it can flag you for new tests that can be performed short of a biopsy (4kscore, genetics, MRI, ultrasound). And biopsies are getting better at detection as well.
henearkr 6y ago
I think that your premise is that the knowledge that the doctor would have to pass to the patient in order for the latter to make enlightened choices would require squarely a long and tedious medical training. To which I would suggest that 1/ no, the knowledge to have for this particular test results, likely (and less likely) prognoses, and the associated possible medical acts and risks, is not equivalent to a full medical training, as it is a tiny bit of one specialty. But I acknowledge that it may require quite some time. 2/ there is no need to apply the same policy to every patient, and you can choose to only allow tests to the patients who went through the basics training evoked in 1/. In the end, if somebody wants to go through the process to get the knowledge to be able to deal with the information, why to deny it? Plus, that would make a nice incentive to get people to know better their own body.
- l33tman 6y ago
  Well I agree fully that there are patients who are smart and could take in the info (for that matter, lots of doctors also end up as patients), and I'd hope their treating doctors give them any info they ask for and get them involved in the aspects. After all, in this specific case I'm pretty sure you can get a PSA taken by yourself even and then the cat's out of the bag. But in a broader sense, what I was thinking of was that when faced with a shocking piece of info ("you might die and there might be nothing we can do about it" etc.), most people don't stay very composed - there are several different reactions and phases and one is certainly "I want as much information as possible and I want to be involved in all decisions" but I'd argue it's not the most common reaction and even in that case, it's a crisis reaction and maybe not as logically driven (or productive at all) as it might seen at first. So then you'd first have to figure out how this specific patient would react before deciding to do the screening and if you just guess, you'd probable be criticized at some point, so you instead make sure you follow the national plans and recommendations.. Then the (sad) fact is that you usually have maybe 15 minutes allocated in primary care to say hello to a new patient, listen to the symptoms or concerns, examine, make a plan, inform the patient, say goodbye, dictate the journal. You can't spend hours educating the patient. I'd wish this was different (but then again that applies to any service interaction, even your car mechanic or whatever).