4 ms·

I have never understood this rationale to not do more comprehensive diagnostics. Sure, it costs more up front. But wouldn’t catching problems earlier save mor

I have never understood this rationale to not do more comprehensive diagnostics. Sure, it costs more up front. But wouldn’t catching problems earlier save more money and suffering in the end?

kayodelycaon 4y ago
Because none of this happens in a vacuum. The tests aren’t perfect and open to interpretation, but that’s the least of the problems here. Sometimes no action is the correct action, but no one is going to do that. How many laws have been passed because “something needs to be done” even though nothing in the law needed fixing? Many people, I’d say most, are not happy with inaction. Knowing something may be seriously wrong can have an enormous emotional cost for some people. Dismissing this as irrational is like saying humans are irrational. (Spoiler: they are)
- jjoonathan 4y ago
  Exactly, and the human "bias towards action" is amplified by legal mandate. A doctor can't recommend inaction if a pack of lawyers is lurking in the bushes waiting to pounce if the situation worsens.
- dwelch 4y ago
  Agreed. I think the article and parent comment seem to be from the perspective of someone who has never had to, say, read or interpret a chest CT. Or had to tell someone that they have an indeterminate module that may be cancer but may be nothing. The article also seems to imply that their is one entity or person who controls all aspects of diagnosis (hence the meme at the top), from taking a history and doing a physical exam to perfectly understanding the intricacies of all additional diagnostic testing. Of course, your primary care doctor may not understand exactly what percentage of people in a low (or high) risk cohort with this lung nodule with certain specific imaging features turn out to have cancer. Hopefully the radiologist does—but they didn’t talk with the patient to assess their risk tolerance and data-collection preferences before saying “consider further evaluation with tissue sampling” in that report. At the end of the day, respecting patient autonomy matters. It sounds like whoever wrote this article would lean towards asking their doctor to collect as much information as possible. Others wouldn’t. In a perfect world, the patient will be well informed by their doctor, be well-counseled on the risks and benefits of a test / intervention, and will be capable of understanding things like statistics well enough to come to an informed decision that works for them. In reality, that often does not happen for a number of reasons.
petercooper 4y ago
I get a full MRI imaging every two years so I spent a lot of time researching the ethics around it just to be prepared, and there are two things I could bring up. First, false positives. There can be things that looks like problems but aren't, or that are problems but with complicated risk profiles around their management or resolution (especially true of aneurysms). For heavily studied situations where imaging is low risk and hugely effective with low false positive risk, most countries do have screening programs, such as regular cervical smears or mammograms for women of certain ages, as well as aortic aneurysm screening for men over 65 (in the UK, at least). Second, psychology. A surprising (to me) number of people do not want to know about their medical status until a problem actually occurs. But then once they do know, many folks can be prone to undue worry or hastily made emotionally driven decisions that run contrary to data. I'm going to totally make up these figures but as a demonstration of the idea, imagine that brain aneurysm scans tend to find aneurysms of concern in 5% of people and that of these 5%, 4% are likely to die within 5-10 years due to that aneurysm. Scan the entire country and you now have millions of people potentially terrified of an aneurysm that won't kill them. If an aneurysm is found and you are offered an operation with a 5% chance of mortality, are you taking it? The research I saw when I was looking into it is that, yes, most people want to get rid of the "problem", despite a higher risk of short term mortality rather than sitting it out. This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.
- SemanticStrengh 4y ago
  > Although cardiovascular disease is widely recognized as the leading cause of death, a lesser known fact is that aortic aneurysm is the 15th leading cause of death over the age of 65 years in the USA. I was not aware of this. non-surgical interventions: https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_CJ-13-1252/_article/-char/ja/ https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_C... > This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too. Great points. Is it legal for a doctor to hide informations to its patient? such as the fact he has a seemingly "minor" aneurysm ? > I get a full MRI imaging every two years You might wanna study radio-protectors such as NAC. I had read it is also a contrastive agent but it's unclear to me what it help to see and what it might inadvertently hide (if anything)
incongruity 4y ago
A number of reasons come to mind: 1. Not doing anything in the face of “evidence” is ripe for malpractice lawsuits, rightly or wrongly 2. Not doing anything in the face of “evidence” can drive anxiety for patients and many clinicians want to be seen as having some answer or path forward, however: 3. Not all diagnostics are risk or pain free 4. Not all diagnostics are precise enough to make treatment decisions clear, correct, and authoritative - so more diagnostics will lead to more false positives which, when paired with the previous points lead to trouble for the clinician and possibly the patient.
ufo 4y ago
That is one of those things that sound intuitively true, but isn't necessarily the case in practice. One example that I am more familiar with: thyroid nodules. Recently, the medical guidelines have increased the size threshold for a biopsy, where you poke a needle in it to find out whether it is cancer or not. We could assume that diagnosing these cancers when they are smaller would always better, but that is not the case... On one end, it turns out when the nodule really is cancer, it is just as safe to wait to do the biopsy only after it has grown over the size threshold. And on the other end, the biopsies are not 100% accurate. A good percentage of the time, it can't say conclusively whether it is cancer or not. When that happens the only way to know for sure is to surgically remove the thyroid, which might result in the patient being put on lifelong hormone medication. One might think that in a perfect world we would act rationally over this uncertain information and not remove the thyroid when all it has is a small nodule with uncertain diagnosis. However, human intuition doesn't work well with percentages. When a patient is told they have a chance of having cancer, no matter how small, they will want to pursue every avenue to investigate and resolve the matter, even when the cost benefit is not worth it. When they looked into the statistics of how many people were getting thyroid surgery we could see that as imaging technology improved, more and more people had thyroid surgery, with no reduction in the number of deaths from thyroid cancer.
CogitoCogito 4y ago
> Sure, it costs more up front. But wouldn’t catching problems earlier save more money and suffering in the end? No? That's even shown clearly in the anecdotes of the original blog post.

I have never understood this rationale to not do more comprehensive diagnostics. Sure, it costs more up front. But wouldn’t catching problems earlier save more money and suffering in the end?

kayodelycaon 4y ago

Because none of this happens in a vacuum. The tests aren’t perfect and open to interpretation, but that’s the least of the problems here. Sometimes no action is the correct action, but no one is going to do that. How many laws have been passed because “something needs to be done” even though nothing in the law needed fixing? Many people, I’d say most, are not happy with inaction. Knowing something may be seriously wrong can have an enormous emotional cost for some people. Dismissing this as irrational is like saying humans are irrational. (Spoiler: they are)

jjoonathan 4y ago
Exactly, and the human "bias towards action" is amplified by legal mandate. A doctor can't recommend inaction if a pack of lawyers is lurking in the bushes waiting to pounce if the situation worsens.
dwelch 4y ago
Agreed. I think the article and parent comment seem to be from the perspective of someone who has never had to, say, read or interpret a chest CT. Or had to tell someone that they have an indeterminate module that may be cancer but may be nothing. The article also seems to imply that their is one entity or person who controls all aspects of diagnosis (hence the meme at the top), from taking a history and doing a physical exam to perfectly understanding the intricacies of all additional diagnostic testing. Of course, your primary care doctor may not understand exactly what percentage of people in a low (or high) risk cohort with this lung nodule with certain specific imaging features turn out to have cancer. Hopefully the radiologist does—but they didn’t talk with the patient to assess their risk tolerance and data-collection preferences before saying “consider further evaluation with tissue sampling” in that report. At the end of the day, respecting patient autonomy matters. It sounds like whoever wrote this article would lean towards asking their doctor to collect as much information as possible. Others wouldn’t. In a perfect world, the patient will be well informed by their doctor, be well-counseled on the risks and benefits of a test / intervention, and will be capable of understanding things like statistics well enough to come to an informed decision that works for them. In reality, that often does not happen for a number of reasons.

petercooper 4y ago

I get a full MRI imaging every two years so I spent a lot of time researching the ethics around it just to be prepared, and there are two things I could bring up. First, false positives. There can be things that looks like problems but aren't, or that are problems but with complicated risk profiles around their management or resolution (especially true of aneurysms). For heavily studied situations where imaging is low risk and hugely effective with low false positive risk, most countries do have screening programs, such as regular cervical smears or mammograms for women of certain ages, as well as aortic aneurysm screening for men over 65 (in the UK, at least). Second, psychology. A surprising (to me) number of people do not want to know about their medical status until a problem actually occurs. But then once they do know, many folks can be prone to undue worry or hastily made emotionally driven decisions that run contrary to data. I'm going to totally make up these figures but as a demonstration of the idea, imagine that brain aneurysm scans tend to find aneurysms of concern in 5% of people and that of these 5%, 4% are likely to die within 5-10 years due to that aneurysm. Scan the entire country and you now have millions of people potentially terrified of an aneurysm that won't kill them. If an aneurysm is found and you are offered an operation with a 5% chance of mortality, are you taking it? The research I saw when I was looking into it is that, yes, most people want to get rid of the "problem", despite a higher risk of short term mortality rather than sitting it out. This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too.

SemanticStrengh 4y ago
> Although cardiovascular disease is widely recognized as the leading cause of death, a lesser known fact is that aortic aneurysm is the 15th leading cause of death over the age of 65 years in the USA. I was not aware of this. non-surgical interventions: https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_CJ-13-1252/_article/-char/ja/ https://www.jstage.jst.go.jp/article/circj/advpub/0/advpub_C... > This is just one of the reasons doctors grimace when people want to get such scans without cause, but there are many others beyond the scope of this reply too. Great points. Is it legal for a doctor to hide informations to its patient? such as the fact he has a seemingly "minor" aneurysm ? > I get a full MRI imaging every two years You might wanna study radio-protectors such as NAC. I had read it is also a contrastive agent but it's unclear to me what it help to see and what it might inadvertently hide (if anything)

incongruity 4y ago

A number of reasons come to mind: 1. Not doing anything in the face of “evidence” is ripe for malpractice lawsuits, rightly or wrongly 2. Not doing anything in the face of “evidence” can drive anxiety for patients and many clinicians want to be seen as having some answer or path forward, however: 3. Not all diagnostics are risk or pain free 4. Not all diagnostics are precise enough to make treatment decisions clear, correct, and authoritative - so more diagnostics will lead to more false positives which, when paired with the previous points lead to trouble for the clinician and possibly the patient.

ufo 4y ago

That is one of those things that sound intuitively true, but isn't necessarily the case in practice. One example that I am more familiar with: thyroid nodules. Recently, the medical guidelines have increased the size threshold for a biopsy, where you poke a needle in it to find out whether it is cancer or not. We could assume that diagnosing these cancers when they are smaller would always better, but that is not the case... On one end, it turns out when the nodule really is cancer, it is just as safe to wait to do the biopsy only after it has grown over the size threshold. And on the other end, the biopsies are not 100% accurate. A good percentage of the time, it can't say conclusively whether it is cancer or not. When that happens the only way to know for sure is to surgically remove the thyroid, which might result in the patient being put on lifelong hormone medication. One might think that in a perfect world we would act rationally over this uncertain information and not remove the thyroid when all it has is a small nodule with uncertain diagnosis. However, human intuition doesn't work well with percentages. When a patient is told they have a chance of having cancer, no matter how small, they will want to pursue every avenue to investigate and resolve the matter, even when the cost benefit is not worth it. When they looked into the statistics of how many people were getting thyroid surgery we could see that as imaging technology improved, more and more people had thyroid surgery, with no reduction in the number of deaths from thyroid cancer.

CogitoCogito 4y ago

> Sure, it costs more up front. But wouldn’t catching problems earlier save more money and suffering in the end? No? That's even shown clearly in the anecdotes of the original blog post.