15 ms·

The argument you’re making has always bothered me because it’s hiding the ball. If finding something that otherwise carries no symptoms is best left untreated,

The argument you’re making has always bothered me because it’s hiding the ball. If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. If you know information is best not acted on in the abstract, then you also know you should not act on it in particular. So what you really mean but have left unspoken is one of two things. First, that doctors are untrustworthy people who make recommendations and decisions based on concerns other than their patient’s wellbeing, such as covering their asses from lawsuits or making more money. But rather than fix that, you would rather keep patients more ignorant and away from the doctor in the first place. Which actively harms people who do have honest doctors. That is, your approach of not testing hurts people with honest doctors to protect people with dishonest doctors. Or second, if you take dumb patients as the problem, you are willing to hurt people with good decision making ability (who would heed their good doctor’s advice to leave the possible ailment untreated) so you can protect people with bad decision making. Because many times, these tests will uncover things that obviously need treatment. They will save many lives. But because more stupid people will hurt themselves, then no one should have access to them. The political and moral assumptions built into these positions are immense and yet the medical field tucks those away and pretends that this is just a purely scientific truth, that someone running more harmless tests is actually inherently harmful. That is a lie! And a very nasty one at that.

ArtRichards 5y ago
If thats how you feel, I invite you to slapsgiving this year! Exactly 18:32 on the eve of Thanksgiving.
TaupeRanger 5y ago
Lots of problematic assumptions in your reply. >If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. Absolutely and demonstratively false. There is an entire field of health policy that destroys this harmful idea. First of all, just because something doesn't carry symptoms NOW doesn't mean it won't carry symptoms LATER, but doctors can't always predict this and aren't perfect decision making machines. Many times the patient will push them for further tests and treatment (or the doctors will advocate for it to ease the mind of the patient) which leads to potential harm from unnecessary treatments. And this is just ONE of the ways patients are harmed by unnecessary screening. There is also the psychological damage of having a condition you wouldn't have otherwise known about, and living with that knowledge (take aneurysms for example). Psychological stress has a real physical toll on the body. Then there's the COST associated with unnecessary screening and treatments, which (especially in the US) can run into the thousands quite easily for even simple interventions as a result of unnecessary screening. Even after that, a screening process can also find something that could be bad, but in some patients doesn't actually decrease their lifespan or quality of life. If we have no way of adjudicating between these cases or predicting which cases will end up bad if left untreated at the present moment, what do you think will happen? People will ask to be treated anyway, and iatrogenics will rear its ugly head. You cannot ASSUME that screening is automatically good. It must PROVE itself as such in a randomized clinical trial. This trial must show that people live longer and/or better as a result of this intervention. In many well documented cases, this turns out NOT to be the case, which entirely destroys your original rebuttal.
- throwawaynotmd 5y ago
  >Many times the patient will push them for further tests and treatment (or the doctors will advocate for it to ease the mind of the patient) which leads to potential harm from unnecessary treatments. >People will ask to be treated anyway, and iatrogenics will rear its ugly head. I just want to say that you are in agreement with my position here. Your point about psychological problems is interesting, but as long as people know what they’re signing up for, it’s okay. Some people aren’t prone to anxiety. Why should they pay the price because other people are? Part of my original point was that implicit in your argument is that people capable of handling it should be denied something because more people incapable of handling it can’t be stopped from hurting themselves. I think many people do not agree with that moral reasoning, so medical people hide it behind objective looking statistics. And as for cost, I don’t take any arguments from medical people about cost seriously. The reason why costs are so high is because doctors and the medical field as a whole run a massive protectionist racket to keep the supply of medical professionals low. How fresh of them to say that because they’ve limited the supply of medical resources to enrich themselves, patients must pay by having less access to care.
  - exdsq 5y ago
    Your point about a protectionist racket doesn't hold for countries in the EU which have the same rules around research data and patients
  - novok 5y ago
    I think once you become a doctor, you quickly realize that a large amount of the population do not have the temperament to deal with 'maybe' bad news. Many are not the 135 IQ %1 of the population with a low anxiety personality who accept that they will eventually grow old and die, which happens to coincide with many engineering types on HN.
    - pie420 5y ago
      Lol, i would argue that engineers, many of whose primary job function is to imagine worst case scenarios and engineer around those to prevent accidents, data loss, etc. Are the exact type of people that are prone to hypochondria. It's not about growing old and dying, it's about ignoring a stomach ache for a couple months and then being told you have terminal cancer, and then living with the regret of "if only I got it checked out earlier". In the engineering world, you are almost always rewarded for being extra safe and testing, fixing, and investigating anything that might seem a little off. If you do blood tests, MRIs, and cancer screens for every mole, cough, and stomach pain, you will go insane and develop hypochondria.
CWuestefeld 5y ago
if you take dumb patients as the problem, you are willing to hurt people with good decision making ability (who would heed their good doctor’s advice to leave the possible ailment untreated) so you can protect people with bad decision making. It seems like we've made this decision with covid-19. Dr. Fauci has been canonized, but we know that he's been intentional misleading the public through misinformation (starting from telling us that masks aren't effective in order to preserve the supply for medical providers, and later mis-stating herd immunity numbers to manipulate people into getting the behavior he wanted).
m3kw9 5y ago
“ If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision.” This is easy to say but hard to do, just need to imagine
bryan0 5y ago
> More information can never be harmful. This is an extremely naive viewpoint and in some situations quite dangerous.
- throwawaynotmd 5y ago
  I should say, if you know ex ante that certain results are not worth acting on, then when you actually get those results ex post, you should ignore them just the same. So actually running a test cannot formally be the problem.
  - TaupeRanger 5y ago
    That is not how medicine works, especially with cancer. Very often we simply don't know whether or not to "ignore" something. But the harms of knowing are not zero, and therefore screening can itself be a net negative. That's why a well powered RCT is required to say whether it benefits patients or not.
    - throwawaynotmd 5y ago
      We have a more detailed exchange going on elsewhere in this thread, with my latest comment, addressing your more detailed points, here: https://news.ycombinator.com/item?id=27630947 https://news.ycombinator.com/item?id=27630947
    - grahamburger 5y ago
      Isn't the only way to learn what things we can ignore and what things we can't ignore to do a lot more testing? Is there a better way to learn that? It seems like having a lot more data from tests is the kind of thing that would have some short term harm but massive long term benefits.
Fomite 5y ago
"More information can never be harmful." In my particular field of biomedical research, there has recently been a push for "Diagnostic Stewardship" because more information has demonstrably been harmful to patient well-being.
- throwawaynotmd 5y ago
  It’s not enough to say it’s harmful. How is it harmful? A blood test, for example, cannot be inherently harmful. (Okay, no more harmful than drawing blood). So it must be about what people then decide to do based on that test. That’s what my post is about.
  - Fomite 5y ago
    But vanishingly rarely are diagnostic tests given and then the results ignored. That's not how consumers of healthcare nor clinicians work.
  - vidarh 5y ago
    Do enough of them, and even basic blood tests cause harm. Infections happen. Rupturing veins happens. If your tests are for conditions that are rare enough, and where early detection does little enough to improve outcomes, even a tiny risk like that becomes a problem.
- captainmuon 5y ago
  I believe that's what the data says, but I have a really hard time reconciling it with common sense. More information is strictly better than less information, because you can always choose to ignore the extra information. I would say most medical decisions are made either due to statistics, or due to experience. What treatment has the highest chance of making the patient better, extending their life, or giving the best quality of life? You'd "just" have to adjust the tables for the new test. I mean in a contrived example, you could have the lab technician themself look up the numerical result (xyz > 100, abc < 10 whatever) in some table, and then there would be the rule to throw the result in the bin and report "don't treat" because this results in the best outcomes. I don't want to have all that extra diagnostic information, but I want my doctors to use it conditionally to improve my treatment if possible.
throwawaytcp 5y ago
If I can step in with a personal anecdote: I was diagnosed in my late 20s with papillary thyroid cancer. PTC is a very survivable cancer, with a near-100% survival rate (death usually only occurs in rare cases where the disease is diagnosed very late, the progession is atypical, or there are comorbidities at play). It is very easy to screen for and diagnose: a neck ultrasound identifies thyroid nodules, and if the nodules look suspicous they are biopsied in a 20 minute procedure performed under local anaesthetic. Treating papillary thyroid cancer is also relatively straightforward, as far as cancer goes: depending on the size of the lesion and the features, either half or all of the thyroid gland is removed surgically. In cases where the whole gland is removed (which is the majority), the patient is given a course or two of radioiodine therapy to nuke anything left over, and in many/most cases, it's a done deal. The vast majority of thyroid cancer survivors have to take thyroid replacement hormones (all patients who had the whole gland removed have to do this, and about half of patients who only had half the gland removed still need a small dose to keep up). I'm relatively lucky: the oral hormone seems to work just fine for me. I take a pill every morning and then go about my day. I will need to do this for the rest of my life, but hey, that's life. However, there's a substantial minority of patients who aren't so lucky: even with oral hormone replacement, they suffer from long-term sequelae including weight gain, low energy, brain fog, hair loss, and other hypothyroid symptoms. And there lies the crux of the issue: it turns out that even with increased diagnostic capability (thanks to the ubiquity of relatively cheap ultrasound exams in clinical practice), the number of people dying from thyroid cancer has stayed pretty much flat for decades (mostly due to more aggressive types than papillary, such as medullary or anaplastic). Yet, we take out a lot more thyroids now. The reason this happens is pretty simple: if you see something, you have to do something about it. So you're removing thyroid glands from people where the cancer might never have actually grown big enough to be a problem, and then subjecting those people to a lifetime of hormone replacement therapy. Something like 10% of all cadavers at autopsy have thyroid cancer: it's a cancer that very commonly develops, but only becomes a concern in a few patients. As of now, we don't have a good way to differentiate between "thyroid cancer that's a problem" and "thyroid cancer that'll be fine." The clinical guidelines have changed a bit in recent years: if the cancerous nodule is really small, they'll now do "watchful waiting" and monitor the nodule to see if it grows. But you're still subjecting a patient to potentially many years of worry and regular testing. And good luck getting life insurance if you have a microcarcinoma! Yeah, it's highly unlikely to kill you (especially when monitored), but try telling an insurer that. The medical profession is well aware of these concerns. That's why they avoid testing for thyroid cancer unless there are symptoms, such as thyroid hormone disturbances or a lump in the neck. If you were to make a thyroid ultrasound a regular test, you'd quickly overwhelm the system with cancer patients who probably never needed to be treated in the first place, and who may now have to get their thyroids removed and be dependent on pills for the rest of their lives.
deleted 5y ago
[deleted]
ganafagol 5y ago
> More information can never be harmful. That statement alone shows blatant ignorance of basic properties of the human psyche which makes reading the rest of your long reply rather pointless, as thought-through as it might have been from your perspective. Humans are not the perfectly rational machines you seem to make them out to be. You need to deal with people in the real world, not some dream utopia that does not exist.
dennis_jeeves 5y ago
>That is a lie! And a very nasty one at that. Nope. TaupeRanger's overall observations seem spot on.

ArtRichards 5y ago

If thats how you feel, I invite you to slapsgiving this year! Exactly 18:32 on the eve of Thanksgiving.

TaupeRanger 5y ago

Lots of problematic assumptions in your reply. >If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. Absolutely and demonstratively false. There is an entire field of health policy that destroys this harmful idea. First of all, just because something doesn't carry symptoms NOW doesn't mean it won't carry symptoms LATER, but doctors can't always predict this and aren't perfect decision making machines. Many times the patient will push them for further tests and treatment (or the doctors will advocate for it to ease the mind of the patient) which leads to potential harm from unnecessary treatments. And this is just ONE of the ways patients are harmed by unnecessary screening. There is also the psychological damage of having a condition you wouldn't have otherwise known about, and living with that knowledge (take aneurysms for example). Psychological stress has a real physical toll on the body. Then there's the COST associated with unnecessary screening and treatments, which (especially in the US) can run into the thousands quite easily for even simple interventions as a result of unnecessary screening. Even after that, a screening process can also find something that could be bad, but in some patients doesn't actually decrease their lifespan or quality of life. If we have no way of adjudicating between these cases or predicting which cases will end up bad if left untreated at the present moment, what do you think will happen? People will ask to be treated anyway, and iatrogenics will rear its ugly head. You cannot ASSUME that screening is automatically good. It must PROVE itself as such in a randomized clinical trial. This trial must show that people live longer and/or better as a result of this intervention. In many well documented cases, this turns out NOT to be the case, which entirely destroys your original rebuttal.

throwawaynotmd 5y ago
>Many times the patient will push them for further tests and treatment (or the doctors will advocate for it to ease the mind of the patient) which leads to potential harm from unnecessary treatments. >People will ask to be treated anyway, and iatrogenics will rear its ugly head. I just want to say that you are in agreement with my position here. Your point about psychological problems is interesting, but as long as people know what they’re signing up for, it’s okay. Some people aren’t prone to anxiety. Why should they pay the price because other people are? Part of my original point was that implicit in your argument is that people capable of handling it should be denied something because more people incapable of handling it can’t be stopped from hurting themselves. I think many people do not agree with that moral reasoning, so medical people hide it behind objective looking statistics. And as for cost, I don’t take any arguments from medical people about cost seriously. The reason why costs are so high is because doctors and the medical field as a whole run a massive protectionist racket to keep the supply of medical professionals low. How fresh of them to say that because they’ve limited the supply of medical resources to enrich themselves, patients must pay by having less access to care.
- exdsq 5y ago
  Your point about a protectionist racket doesn't hold for countries in the EU which have the same rules around research data and patients
- novok 5y ago
  I think once you become a doctor, you quickly realize that a large amount of the population do not have the temperament to deal with 'maybe' bad news. Many are not the 135 IQ %1 of the population with a low anxiety personality who accept that they will eventually grow old and die, which happens to coincide with many engineering types on HN.
  - pie420 5y ago
    Lol, i would argue that engineers, many of whose primary job function is to imagine worst case scenarios and engineer around those to prevent accidents, data loss, etc. Are the exact type of people that are prone to hypochondria. It's not about growing old and dying, it's about ignoring a stomach ache for a couple months and then being told you have terminal cancer, and then living with the regret of "if only I got it checked out earlier". In the engineering world, you are almost always rewarded for being extra safe and testing, fixing, and investigating anything that might seem a little off. If you do blood tests, MRIs, and cancer screens for every mole, cough, and stomach pain, you will go insane and develop hypochondria.

CWuestefeld 5y ago

if you take dumb patients as the problem, you are willing to hurt people with good decision making ability (who would heed their good doctor’s advice to leave the possible ailment untreated) so you can protect people with bad decision making. It seems like we've made this decision with covid-19. Dr. Fauci has been canonized, but we know that he's been intentional misleading the public through misinformation (starting from telling us that masks aren't effective in order to preserve the supply for medical providers, and later mis-stating herd immunity numbers to manipulate people into getting the behavior he wanted).

m3kw9 5y ago

“ If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision.” This is easy to say but hard to do, just need to imagine

bryan0 5y ago

> More information can never be harmful. This is an extremely naive viewpoint and in some situations quite dangerous.

throwawaynotmd 5y ago
I should say, if you know ex ante that certain results are not worth acting on, then when you actually get those results ex post, you should ignore them just the same. So actually running a test cannot formally be the problem.
- TaupeRanger 5y ago
  That is not how medicine works, especially with cancer. Very often we simply don't know whether or not to "ignore" something. But the harms of knowing are not zero, and therefore screening can itself be a net negative. That's why a well powered RCT is required to say whether it benefits patients or not.
  - throwawaynotmd 5y ago
    We have a more detailed exchange going on elsewhere in this thread, with my latest comment, addressing your more detailed points, here: https://news.ycombinator.com/item?id=27630947 https://news.ycombinator.com/item?id=27630947
  - grahamburger 5y ago
    Isn't the only way to learn what things we can ignore and what things we can't ignore to do a lot more testing? Is there a better way to learn that? It seems like having a lot more data from tests is the kind of thing that would have some short term harm but massive long term benefits.

Fomite 5y ago

"More information can never be harmful." In my particular field of biomedical research, there has recently been a push for "Diagnostic Stewardship" because more information has demonstrably been harmful to patient well-being.

throwawaynotmd 5y ago
It’s not enough to say it’s harmful. How is it harmful? A blood test, for example, cannot be inherently harmful. (Okay, no more harmful than drawing blood). So it must be about what people then decide to do based on that test. That’s what my post is about.
- Fomite 5y ago
  But vanishingly rarely are diagnostic tests given and then the results ignored. That's not how consumers of healthcare nor clinicians work.
- vidarh 5y ago
  Do enough of them, and even basic blood tests cause harm. Infections happen. Rupturing veins happens. If your tests are for conditions that are rare enough, and where early detection does little enough to improve outcomes, even a tiny risk like that becomes a problem.
captainmuon 5y ago
I believe that's what the data says, but I have a really hard time reconciling it with common sense. More information is strictly better than less information, because you can always choose to ignore the extra information. I would say most medical decisions are made either due to statistics, or due to experience. What treatment has the highest chance of making the patient better, extending their life, or giving the best quality of life? You'd "just" have to adjust the tables for the new test. I mean in a contrived example, you could have the lab technician themself look up the numerical result (xyz > 100, abc < 10 whatever) in some table, and then there would be the rule to throw the result in the bin and report "don't treat" because this results in the best outcomes. I don't want to have all that extra diagnostic information, but I want my doctors to use it conditionally to improve my treatment if possible.

throwawaytcp 5y ago

If I can step in with a personal anecdote: I was diagnosed in my late 20s with papillary thyroid cancer. PTC is a very survivable cancer, with a near-100% survival rate (death usually only occurs in rare cases where the disease is diagnosed very late, the progession is atypical, or there are comorbidities at play). It is very easy to screen for and diagnose: a neck ultrasound identifies thyroid nodules, and if the nodules look suspicous they are biopsied in a 20 minute procedure performed under local anaesthetic. Treating papillary thyroid cancer is also relatively straightforward, as far as cancer goes: depending on the size of the lesion and the features, either half or all of the thyroid gland is removed surgically. In cases where the whole gland is removed (which is the majority), the patient is given a course or two of radioiodine therapy to nuke anything left over, and in many/most cases, it's a done deal. The vast majority of thyroid cancer survivors have to take thyroid replacement hormones (all patients who had the whole gland removed have to do this, and about half of patients who only had half the gland removed still need a small dose to keep up). I'm relatively lucky: the oral hormone seems to work just fine for me. I take a pill every morning and then go about my day. I will need to do this for the rest of my life, but hey, that's life. However, there's a substantial minority of patients who aren't so lucky: even with oral hormone replacement, they suffer from long-term sequelae including weight gain, low energy, brain fog, hair loss, and other hypothyroid symptoms. And there lies the crux of the issue: it turns out that even with increased diagnostic capability (thanks to the ubiquity of relatively cheap ultrasound exams in clinical practice), the number of people dying from thyroid cancer has stayed pretty much flat for decades (mostly due to more aggressive types than papillary, such as medullary or anaplastic). Yet, we take out a lot more thyroids now. The reason this happens is pretty simple: if you see something, you have to do something about it. So you're removing thyroid glands from people where the cancer might never have actually grown big enough to be a problem, and then subjecting those people to a lifetime of hormone replacement therapy. Something like 10% of all cadavers at autopsy have thyroid cancer: it's a cancer that very commonly develops, but only becomes a concern in a few patients. As of now, we don't have a good way to differentiate between "thyroid cancer that's a problem" and "thyroid cancer that'll be fine." The clinical guidelines have changed a bit in recent years: if the cancerous nodule is really small, they'll now do "watchful waiting" and monitor the nodule to see if it grows. But you're still subjecting a patient to potentially many years of worry and regular testing. And good luck getting life insurance if you have a microcarcinoma! Yeah, it's highly unlikely to kill you (especially when monitored), but try telling an insurer that. The medical profession is well aware of these concerns. That's why they avoid testing for thyroid cancer unless there are symptoms, such as thyroid hormone disturbances or a lump in the neck. If you were to make a thyroid ultrasound a regular test, you'd quickly overwhelm the system with cancer patients who probably never needed to be treated in the first place, and who may now have to get their thyroids removed and be dependent on pills for the rest of their lives.

deleted 5y ago

[deleted]

ganafagol 5y ago

> More information can never be harmful. That statement alone shows blatant ignorance of basic properties of the human psyche which makes reading the rest of your long reply rather pointless, as thought-through as it might have been from your perspective. Humans are not the perfectly rational machines you seem to make them out to be. You need to deal with people in the real world, not some dream utopia that does not exist.

dennis_jeeves 5y ago

>That is a lie! And a very nasty one at that. Nope. TaupeRanger's overall observations seem spot on.