Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find | Hacker News Reader

Surgery for Blocked Arteries Is Often Unwarranted, Researchers Find

nytimes.com

168 pointsra787 comments

Gina Kolata is a fine scientific writer, but I think that the presentation of the exclusions is a bit too brief and subtle.

The main controversy being addressed is whether revascularization in stable disease has benefit. Not heart attack patients. Not people with significant left main coronary artery disease. COURAGE and this trial address that question in different ways.

It is addressed in the article, but you kind of are left to draw your own conclusions:

> The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery, two situations in which opening arteries with stents can be lifesaving. Instead, the patients had narrowed arteries that were discovered with exercise stress tests.

This doesn't at all address the need for revasularization during a heart attack (about which there is universal agreement). It addresses whether revascularizing people not having a heart attack can be helpful.

The article in The Washington Post explains it better for the interested reader [1]. There is also this thread with a good discussion [2].

[1] https://www.washingtonpost.com/health/2019/11/16/embargoed-d...

[2] https://twitter.com/rwyeh/status/1194638074765967362?s=21

True, but that’s pretty much what I took from this article. People with vascular heart disease who have not had an acute coronary event still compromise a significant chunk of the patient population. Many of them still currently receive stents or cabg.

What brings a cardiology fellow at Mass General to Hacker News? I think it's great that you're here and sharing insight.

I've been on Hacker News longer than I've been at MGH ;)

Thanks for your kind words.

I remember an interesting anecdote (maybe from a Malcolm Gladwell book or freakonomics) that on days when there were big heart conferences, deaths from cardiac related causes dropped. The implication was that cardiac doctors are all at these conferences so they can't order invasive procedures which their patients may not need.

When all you have is a hammer, everything looks like a nail.

Edit: the original study https://www.ahajournals.org/doi/10.1161/JAHA.117.008230

That's lying with statistics. What matters isn't the daily death rate, but life expectancy. If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win.

That doesn’t always mean you should have the surgery any time soon.

Suppose that surgery can be put off for 10 years without any loss of effectiveness or short term risk of death. Now you’re going to wait even if it’s eventually a good idea. Some people that either have the surgery or waited are killed off by other issues, making the waiting group have a higher expected life expectancy overall.

That’s just one example where seemingly useful treatments are less useful than initially assumed.

Or 10 years later the surgery is seen as less or more effective, or a better version of it is developed.

"If a procedure has a 10% chance of killing you, and a 90% chance of extending your life by 30%, it's a net win."

I think it obviously depends on the specific probabilities and your current life expectancy, not to mention whether you are risk averse when it comes to the possiblity of immediate death.

For me, based on actuarial tables, I should expect to live for 36 years more. So the net expected gain with your example numbers is (0.9 * 10.8) - (0.1 * 36) = 6.1 years more. So that's a net benefit of ~17%, at a significant risk of dying right now. If it was normal to like that kind of deal, why would we buy insurance?

Also, there's something fishy about the problem statement in the first place, because a successful operation doesn't extend your life by 30%, unless nothing else was going to kill you before your originally anticipated lifespan.

Suppose you've just had a newborn. The doctor offers to perform surgery on your child which 10% of the time kills them, and 90% of the time extends their life expectancy 30%. Do you agree?

Absolutely.

I don't think so. All else equal, a 75 year old is more likely to drop dead tomorrow than a 25 year old (or healthy newborn) is, so the 10% death probability is less of a problem for them. Moreover, the years at the end of one's life are not quite the same as years of youth.

That's exactly why this is an _easier_ question for a newborn... the 30% is on their entire life and not their remaining years. Like, if the upside is living to 80 instead of 50, that's easier than it being the difference between living 5 months and 6 months.

Sure, but that 10% chance for a newborn represents basically their entire life while for a 50 year old it’s a life mostly already lived.

Obviously not. No sane person would believe such a promise.

Just imagine the scale and length of the clinical trials that would be required to test such a claim.

> That's lying with statistics

That’s Malcolm Gladwell’s bread and butter.

While true, I don’t think it’s as counterintuitive as presented as it doesn’t mean the procedures are unwarranted.

It’s only a useful study if deaths over the entire period also drop, and they don’t. It just moves deaths to the other dates, not reduce them.

For example. If a procedure has 20% chance of death and 80% chance of improving mortality, the more procedures done, the more deaths on the date of the procedures. But overall mortality is reduced.

So the conference just means fewer procedures that week, but not fewer procedures for the year. The procedures just get done before or after the conference with the same rate of death.

I love Gladwell’s stories, but he frequently tells pithy little vignettes that aren’t actually true. He brought up this factoid during his recent appearance on the Joe Rogan Experience.

What interest I had in trying to read Gladwell at some point, has now dissipated after reading this explanation. I wish if writers would be less hypebolic with their presentation of their matter.

As a concrete example of Gladwell's lack of depth, see Igon Value (misspelling of eigenvalue).

https://rationalwiki.org/wiki/Igon_Value_Problem

Wow, he really did that? They don't have adequate fact checkers either.

That might just be because didn't schedule risky operations on those days. It's hard to establish causation without a randomized trial.

I think that is pretty intuitive though - a day in surgery is almost always more risky than a day being sick without a surgery, because you are taking on some short term risk in exchange for reducing long term risk. That doesn't mean the surgeries are unnecessary, just that the risk is distributed differently.

Also mentioned in the book Range: Why Generalists Triumph in a Specialized World

Not to distract too much from the main takeaways, but I found this tangent very strange:

> The participants in Ischemia were not experiencing a heart attack, like Senator Bernie Sanders, nor did they have blockages of the left main coronary artery,

In context it sounds like the author is basically saying this study has nothing to do with a politician. Okay, so why bring it up?

Because Sen. Sanders had the exact surgery the article is talking about.

Ah, okay, that makes a lot more sense now.

Note that the article says bypass surgeries and stents are still considered life saving for heart attacks and main coronary blockages but likely unnecessary otherwise, since the outcomes for drug regimens and improved lifestyles are just as good for those other cases. Furthermore the doubt cast on drug/lifestyle regimens (they patients won’t stick to it) is also called out here as false since the drug regimen for stents can be more intensive.

My additional take away is that it is good for people to maintain healthy skepticism about our medical system, its incentives, and the accuracy of our current knowledge.

I think it's more the lifestyle choices than the medications that are the difficult things to stick with, regardless of surgery/non-surgery pathway. A few pills in the morning is nothing compared to the continuous discipline needed to stick to both an exercise regime and major diet changes.

I know TFA says for people without chest pain, but I’d be dead without angioplasty + stent.

http://archive.is/B6WME

ISCHEMIA: Invasive Strategy No Better Than Meds for CV Events

https://www.tctmd.com/news/ischemia-invasive-strategy-no-bet...

I haven't been able to find out what the medical alternative treatment consists of other than changing diet, losing weight, stop smoking, stop drinking, start exercising, taking statins, etc. These are, of course, all good and useful things, but I knew a man who had a quadruple bypass and refused to make any lifestyle changes. Maybe not having a bypass would have focused him on making those changes.

This is good news but my first thought was that it takes discipline to change a lifetime of bad habits. Are people really going to change their lives and adopt a new way of living and eating? I dought that it will happen. I suspect that surgery is still the best option for most people.

All surgery is risky, especially for old people. The stent thing seems a lot like the spinal fusion scam.

The stent procedure is so popular because it's a very simple procedure. The stent can be threaded through an arm vein and inflated near the blockage. Recovery is minimal.

Stenting costs an average of $25,000 per patient; bypass surgery costs an average of $45,000 in the United States. The nation could save more than $775 million a year by not giving stents to the 31,000 patients who get the devices even though they have no chest pain.

How much are the drugs? Probably not free. And they may have to be taken for the rest of the patient's life. That could add up.

I think that in general surgery is often unwarranted. surgery should be the absolute last resort.

I agree. Anything that's not emergent or immediately life saving you should think long and hard about. I had meniscus repair knee surgery in August. Now I have nerve damage that is causing pain in that lower leg. I probably would have been fine and recovered to moderate sports activity without it. My dad had knee replacement surgery at 76, and he never fully recovered from it. If it's at all elective, just say no as a default.

Friend of mine went to the doctor after tearing her meniscus. Doctor said she absolutely needed surgery and it won't heal without surgery. She said "thanks but no thanks."

It healed on its own.

They tried to sell me on meniscus surgery too. I saw a PT and he fixed my knees in two weeks with a hamstring stretch (I've since learned that about half the programmers I know have tight hamstrings. It hurts your knees and makes good posture impossible).

I’ve heard this referred to as programmers syndrome. The tight hamstrings also lead to frequent lower back pain as does the lack of movement. It takes as little as 15 minutes of sitting for your spinal discs to compress. Moving your legs restores the blood flow. Similarly sitting makes it difficult for your heart to pump blood from your feet. And if course there’s the unsightly posture as well. All of which is restored with regular stretches, yoga, etc. I’m no medical professional as I’m sure those who are can tell but these are the things I’ve learned over the years in my own experience. A lot is within our control but I also know a lot of people who have done everything possible from a dietary and exercise standpoint and still need a bypass relatively early in life. I have an in law who was a surgeon himself. He came home one day after work and his wife asks how’d it go today and he said oh not bad I ran a few tests recently and checked myself into the or for a stint. He didn’t bother to tell anyone before and might have not have said anything afterward either. We look at the medical profession largely through the lens of how our insurers and policy makers want us to view medicine. We also see anecdotal information that fools us into thinking one thing when it’s really another. Often times the most analytical minds can forget that it takes quite a bit of study and rigor to reach a valid conclusion. And at the same time we are seeing that the human body is not just one thing but billions of cells and bacteria that are as different from person to person as fingerprints are unique to the individual. What disturbs me most about these articles is that they very subtly shape the mindsets and opinions we hold to be skeptical of surgery in general and to be skeptical of surgeries late in life as luxuries of a bygone era unfit for today’s ideal lifestyle of personal discipline and pious austerity. As far as I’m concerned we haven’t yet scratched the surface of what’s possible to extend life to 100 or even 200 or beyond. And what a fantastic exploration that would be - equally as rewarding as becoming an interplanetary species. Sadly the current mindset seems to be reverting to an age where 45 was old and 55 was an ideal time to die and just think of the cost savings windfall we’d have if everyone were to agree.

Any chance you could link more info about that hamstring stretch?

Sure! Okay, so it’s not exactly a hamstring stretch, but it fixed the problem that kept me sedentary which in turn caused my hamstrings to get super tight. I’m sorry I don’t know the name of it so I’ll have to describe it (google failed me). Stand with one leg straight on a low stool or a stair step. Lean forward, pushing down very hard on your leg with both hands on your leg above the kneecap. I did this on each leg for a minute every hour or so.

The idea is to increase the range of motion in the leg. I gained a huge amount in just a few weeks, something like 15 degrees worth. From there I was able to walk and stand without pain (it felt so good that took up running just because I could!). When I’ve been sick or less active I can feel the tightness coming back and it only takes a few stretches to get back to normal again. The PT who helped me was trained in Mackenzie technique. I guess their idea is to give people focused stretches and exercises instead of the insane, unachievable workouts that PTs often prescribe.

The best hamstring stretch I've found is supine with a belt/strap.

https://youtu.be/Il1L75v6gq0

The reason I like it is because it's easy to do and precisely control no matter how inflexible you start out as.

There is evidence that meniscus surgery is no more effective than a placebo: https://www.nejm.org/doi/full/10.1056/NEJMoa1305189

"I want to go when I want. It is tasteless to prolong life artificially; I have done my share, it is time to go. I will do it elegantly" --Einstein

Alteplase is vastly inferior to stents according to current algorithms. Unless there's a novel approach the revascularition that has occured in the past month I didn't hear about, I'm skeptical that this isn't some type of p hacking. I can't read the article because it's behind a paywall.

That's not what the study it's about. If you can't be bothered or are not able to read the article, why would you feel compelled to comment?

The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to make it good at healthcare instead by the time I get old.

IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.

Google suggests it's about 10% (for the last 12 months)

A quick google and a few articles seemed to agree E.g.

"Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan"

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....

I’m checking out before I get there

You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)

I meant before I get there as in before the costs to keep me alive go eat the hell up

But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health.

Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.

Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.

That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives.

Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.

On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices).

Reward outcomes rather than fee-for-service?

This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.

If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries?

Less stress and less risk for the doctor.

No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.

Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath.

-For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup.

-Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour.

-Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour)

Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.

This assumes widespread bad faith, when I think the situation is much different.

The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.

Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful.

I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers.

I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.

I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.

I will be ending it soon

I had a life...I had a future

Yes, but now you have a cause.

Ever thought about attending law school? Or some other related course of action? You can stand up for the other people like you. You could be for them, what wasn't there for you.

I am not just playing emo and choosing not to go on because life is a drag. I have lost everything and everyone and live in severe pain and just existing takes all my energy. I have tried over and over again to work enough to have some sort of life but my body fails and that takes the mind with it. I was denied social assistance. Abandoned by family. Nothing has gone right since this was done to me. While I would love to help others again as I once did...I cannot manage myself and there is not sufficient help here. I want out of this country back to the only place I have ever really enjoyed living in Europe but I have not been able to realize that either. The last thing I have the energy for is something like law school. I'd need a lot more of Maslow's lower rungs secured before I could attempt something like that and I'd never be able to do it on a normal schedule. I am old and broken and on a thread. I have reached my mental coping limit after many years of pain and decline and abandonment.I need consistent help and stability in a healthy environment to survive. That has been denied and I have had nothing but the opposite. So there will be no survival.

I believe you, and I'm sorry. As a young father, it's hard to imagine how your family could abandon you. Yet of course they did, all the same. I offered purpose, as purpose is sustaining for some. But you are of course right- Maslow, after all, knew what he was talking about. I would help if I knew how. I hope you do not give up- there are people who care, even if finding them is difficult.

Im sorry you're going thru this. If I may ask, what was the procedure?

Orthopedic surgeries on lower limbs that was never needed...made even worse by another round of surgery meant to "fix" the first wrong one. The second was done incorrectly as well and was something different than I even consented to. This all created a lot of problems, new damage, and pain. Then the rest of the dominoes fell. Every system meant to protect and assist failed to do so. The doctors lied and their lawyers were more powerful. The disability system was adversarial and cherry picked the doctors lies whilst ignoring evidence I provided. The appeal went to the same judge who was hostile and denied me the first time. There was never any help throughout this. Nothing but failures and blame. After all if someone loses so often it must be them right? Then when you get depressed they retcon THAT as the cause of everything. That's what my family decided as they turned their backs. That I should have known and was somehow at fault. I would never trust an American doctor again, and hate this country and it's hatred for social systems, but I am trapped here now.

Physician here. Really sorry to hear about your situation.

I can't comment on what happened before but there may be ways out of your pain. Have you explored all options in terms of pain management.

Spinal cord stimulators? Baclofen pumps?

There are several options for treating 'neurogenic' pain including MR guided focused ultrasound (for which there is a clinical trial going on now at the University of Maryland). Where are you based?

I have tried multiple radiothermal sympathectomies in Europe to some effect, ruled out spinal cord stimulators years ago after talking to docs in Europe I trusted and patients who were unsatisfied with them (plus the cost is insane). Every procedure done in this country has made me worse or just cost me for nothing. I have no insurance. Fall in all the gaps for things. Honestly a low stress lifestyle with control of environment and temps etc is the best pain management I have ever had. Last time I was able to move to Europe and have a small flat in a place amenable to me and away from the assholes here I felt a lot better and managed without strong meds...meds which cause other problems, cost too much, and are increasingly difficult to access.

But my living situation now is very unstable and hostile and stress worsens pain and hopelessness. You can't solve that with pills and procedures. On top of that it's not as simple as "solving pain". I have lost all forms of security, have no family or social reliability, have obviously severe depression and anxiety because of all of this, keep taking more hits in all regards, and you can't just plug one hole while there are 7 others in the boat and an 8th about to blow etc. I will never have a full and good life, but a survivable one is possible just not accessible. I don't want to disclose my location online since I have been very candid about my situation as all I need is someone calling the authorities and causing me more loss of agency and massive medical debt. They won't help with what I really need but will 100% "help" by locking me up and feeling good about themselves.

I don't want more surgery or devices or procedures. I don't need more doctors. I have (actual not dramatized) PTSD about doctors and hospitals now. I don't trust them with the exception of two in Europe who actually helped me. Here the have never helped and have literally ruined my life. I need my basic needs secured and a peaceful and stable environment away from hostile people, in a place where I am not one emergency or major problem away from complete and permanent debt losing the tiny bit I have left.

I'm in no way bullshitting here, have you tried medical marijuana? I have spinal stenosis, and have resisted any non-conservative treatment because Western medicine is curiously bad at addressing this malady. Weed has helped tremendously, particularly with sleep where I had trouble finding comfortable positions.

Even if it were legal where I am...and it's not because of more American nonsense...I cannot afford it. I cannot afford MORE expense and am already sinking as it is. And again at this point pain control is like splinting the sprained ankle on a drowning person...they are still going under. If my basic life were not so terrible the pain would need less management. Even healing it entirely now wouldn't solve my problems since I am so far down in every way I'd just die pain free. It would take a long time of stability and security to stabilize and even then I am never getting back the quality of life I earned and deserve. But it's all pointless anyway because I am not even getting the splinted sprained ankle.

I don't mean to sound rude toward you and I know you mean well. Thank you for that. I have just crossed that line from despair into rage because I know I COULD live...but that I will not because it's not profitable for anyone for me to do so. That would enrage anyone but people deny this can happen to them while ignoring the actual solutions for those it does happen to. I have fought, begged, and raged about it for ages now and I will still be gone and it won't even register. I have learned I simply do not matter. Most people are terrible and most people are who make the rules of the game.

I don't know where you live but I hear a gram is like $5 in WA. Seems like it's at least worth a shot, and with nothing left to lose, why not move to one of the 11 states that have legalized recreational use.

(I admit I don't know if that price is for indica or sativa)

I don't know your whole story, and I haven't suffered as you, but at least some states in the country are trying [1]. I hope you've explored the possibility of relocating within the country.

[1] https://coloradosun.com/2019/10/07/colorado-public-health-in...

I cannot afford to live anywhere without help and even the poor quality help with mean and resentful family that I have where I am now is going away. I haven't just NOT tried to find alternatives. I've fought and failed for years. Things don't work, you are blamed, and people always betray you. I'm not wanting this end. I didn't choose this. I just will not survive homeless, or in constant stress, and am sick of being emotionally abused by shit people. My quality of life is already so poor I cannot suffer worse. I have reached my coping limit in all ways and there is no help. If I could afford to live on my own sustainably I'd leave this miserable country who's systems ruined my life. All a moot point anyway. There is no love, social support, family, anything. Who wants to live in a world where most people are so terrible anyway to allow this to happen to so many people as long as they get theirs. My cat is the only life I care about anymore and I cannot even ensure her future because I cannot ensure mine. I know how I sound. I am out of options and it enrages me. I know who I am and what I have done...it's everyone else who forgot.

Some thoughts:

- Do you have no way to travel/move? Do you have any money saved/access to money? Perhaps move to a friendlier state (as someone else suggested) or back to Europe as you mentioned?

- If you're completely stuck for funds, can you use crowdsourcing or go_fund_me? - I'm sure many people would want to help if they heard your story.

- If you're being poorly treated by family etc. can you not seek refuge with organizations such as the the salvation army?

- I don't really know much about dealing with homelessness but a quick search suggested: https://endhomelessness.org/how-to-get-help-experiencing-hom...

- Also try to do all the basics: get enough sleep, take in good nutrition, if you're able to exercise (even basic exercise) do it, try to find an environment with less stress (as above), try meditating if you haven't already.

- Hang in there, at least try the suggestions above. Let us know how you get on.

You have to hang on for her sake hestipod. Are they threatening to throw you out? Would they give you money? Is there anyone who can help? You are really worrying me. Please hang on for your cat's sake. It's her best hope. Hang on.

HN doesn't allow endless comment nesting to prevent arguing so this has reached a rate limit. This isn't me not hanging on anymore than telling someone drowning with weight around their neck and more added with time to just "float harder". I did my part...other people refused and more bad things keep happening blocking me from even doing more with less the once a decade even a slim chance comes along. People and systems have been fully capable of helping all along...the refused an continue to. I have always been here...always asking for help...always contactable in person, by phone, by email...I have always been clear about my needs from day one and nobody would help when they needs were much lower. People and systems in this country who can simply will not. It's everyone for themselves and all of those people thinking they deserve it and are the sole reason they succeed. Not a single system that I paid into and is meant to support people like me has done so. Not a single person who promised to stand by me like my former partner and family has done so. The ones who said "trust the doctors and dont worry we will always be here for you" when I was doubting more surgery. In all this time only one person has EVER offered a realistic potential plan for bespoke work that theoretically met all my needs, but my health declined more, the person I loved the most in this world ended their own life, and I could not get things in order enough to take that opportunity and it is now gone forever. My family who has seen what has happened to me have decided it has to be my fault since so much bad cannot happen to someone good. They blame me for their own failed 3rd and 4th marriages or any other miseries. They don't give a shit about me and I was only ever allowed to be here so they can lord it over the other family and have someone to punch down to and blame for their failings and that utility isn't even worth it for them anymore, because everything is about them and their egos and greed.

So what can I do? I can't squeeze blood from a stone. You can't plead with me to rescue myself from a riptide in a hurricane. You can't expect me to make desperate advice that never really works, or works one time out of 100,000,000 to somehow work THIS time. I don't have that power. I am sorry it worries you but even that's about your feelings...doesn't do anything practical for me but make me. I am sorry it upsets you but how someone else feeling bad about my betrayal and end isn't something I can do anything about. Should I pretend its all ok so nobody has to feel bad and die quietly Nobody REALLY cares...proof is in the pudding. People act in their own self interests nearly every time and my life doesn't further anyone's own self interests. I was a naive idiot to believe most others thought like I did...like the handful of rare souls I have met in life like my grandfather...altruistic and quietly helping. Doing the right thing and not blaming victims/ The distress anyone may feel momentarily reading this...like they do when they see any tragedy...will pass and they will go back to their Starbucks. 99% of people simply DO NOT CARE about others and the proof is there every minute of every day. They have far more important things to worry about like egos and profits. They will be far more angry about me in my last breaths criticizing them than they will be about my life collapsing entirely. I have seen it happen to people all my life...nothing changes.

When I needed a leg up to get back a sustainable life everyone who could help and every system ignored me and failed me. When it got worse and I could still manage partially but would need some help long term everyone who could help and every system ignored me and failed me. Now that it's in a state that will require long term support for me to even survive at all everyone who could and every system ignores me. I have done all I can...nobody does it alone but I am expected to as I hurtle toward the bottom. Gravity will win and I can't do a thing about it.

I'm going to try and reply (rate limit?). (And I won't keep harassing you with more posts). You are right it does affect my feelings to see someone hurting so much. Better that you criticize me - and live. You have had a long, tough run. I am also so sorry to hear about your loss.

Of course after enough trauma and hard knocks - and an impersonal system - you are worn out. I think that is why the poster above suggested basics like sleep and nutrition, if you can get them - not a global solution I know but it does help. (Small lever points).

Situations can change in really weird ways - that no one ever could have predicted - even when it has been tough for years, even when things seem really hopeless.

I'm not in the business of depressing you more, or taxing you emotionally. Your life does matter.

Why wouldn't you assume bad faith? In every interaction I've had with the healthcare system nobody has seemed to have good outcomes as the goal. It's never even discussed as a possible goal, much less implemented as a priority.

The doctors I know claim that they are good people and will treat anyone regardless of means, but they have also sent many patients into bankruptcy and suicide with five, six figure debts for minor procedures. That's not ethical. That is doing harm. It's either bad faith or sociopathy to ignore the fact that our life expectancy is going down every year, I'm not sure which.

About 2 decades back when I was naive, I would have agreed with you. I have since then looked critically at the healthcare system.

>This assumes widespread bad faith, when I think the situation is much different.

There is really widespread bad faith and there is widespread incompetence. A near complete lack of integrity. ( there are always the physician/practitioner who is the exception, but they are rare.)

>Doing nothing seems like giving up.

This point to the competence aspect. In many situations doing nothing is precisely what is needed. In many types of cancer this is what is to be done. (I cannot be certain but this seems to be the case). Aggressive early treatment appears to endanger the patient more than inaction. No treatment is also 'doing something' and not to be confused with 'we-do-not-care' type of inaction.

I think the American healthcare system has a particular issue as well - doctors are required to be salespeople. The skill sets needed to be a doctor and to be a salesperson seem immiscible in some ways.

I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.

They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade.

https://www.vox.com/science-and-health/2017/11/3/16599072/st...

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