The madness of reduced medical diagnostics
dynomight.net
dynomight.net
Knew a fellow who was told he had a "weak blood vessel in his brain", had probably had it forever, but now he's retired they can "go in and fix it" and so he goes in for a surgery to remove a threat he was unaware of and that had not hurt him yet.
He got out after a week, never really recovered, and died within 2 months. Apparently there was another aneurysm they failed to see or fix; because it couldn't have been a direct result of his procedure.
Well there are solutions that have negligible risk of damage and potent likeliness of protection/improvement, e.g. for narrowed arteries the vasodilator tadalafil in low dose should be a net improvement. Then you might want to combine it with a pro-angiogenic drug such as VEGF or better BPC-137.
Also even if someone seems asymptomatic it doesn't mean he is, narrowed arteries very likely to increase his aging rate and chances of death and are likely to create a nocitropic effect by creating a mini brain ischemia.
https://en.m.wikipedia.org/wiki/Cerebral_arteriovenous_malfo...
He explained it to me as "they said i had a time bomb that hadn't gone off yet in my skull" but he wasn't convinced until they scared his wife too. My impression was that the seriousness of the condition was debatable, that was the feeling i got from him. What he might've been told by his doctors i dunno.
I imagine someone will be jumping on the occasion to point out that not all car dealers are crooks, but the rising number of anecdotes is concerning.
The phrase “safe and effective” has a legal meaning and only applies to (1) drugs and vaccines, (2) high risk medical devices, and (3) novel medium risk medical devices.
The phrase “safe and effective” notably does not apply to the practice of medicine, which is not regulated by FDA. When it comes to medical practice, you are usually speaking in the language of (CMS) quality / value - “quality adjusted life years” - and then clinical endpoints - blood pressure below X.
I know this is being pedantic, but as someone who has had an up close view of FDA regulatory policy / process from both sides of the table, it literally hurts my head to see some of the inaccurate and misguided stuff that gets bandied about on the interwebs.
Be careful about reducing the testing just because it drives over treatment because under treatment is quite deadly, cheaper maybe but also has a serious impact of life expectancy and disease burden. Life expectancy is dropping in the UK and disease burden is one of the highest in the western world and growing. The grass isn't greener on the low test and treatment side, health care is still increasingly expensive and the results are worse.
You’re willing to trade off a few extra deaths if you can save a certain amount of money. Hell NICE in the UK put a very firm GBP figure on the value of a life-year.
It works great at a population level since you maximize outcomes and keep costs low.
But that isn’t that comforting when you’re the poor bloke who dies from lung cancer that could have been detected early but NICE said the 50GBP test isn’t cost-effective.
Or even make a certain amount of money: https://www.openthebooks.com/substack-investigation-faucis-r...
From my own experience it's typically done a few ways: 1) the government decides what treatment will be paid for and which ones won't [this works pretty well since patients don't know what they're missing], 2) the government simply caps a budget and pushes treatment decision down - doctors and hospital are forced to make trade-offs. Countries that do #2 often have long wait times for elective procedures - that's the cost control mechanism.
The US does neither one of these very well (but does them to some extent, but it's unevenly applied), so costs are very high (in addition to other factors). But if one wants universal care and a manageable healthcare budget, you need to say "no" to some things that would otherwise still benefit the patient.
It would be awesome if in cases like this, the doctor would suggest the patient to pay this 50GBP out of their own pocket.
[0] - https://ourworldindata.org/grapher/life-expectancy-vs-health...
There are a million factors that go into life expectancy other than just the healthcare system.
But you’ll get sued if the scan suggests something but you don’t follow up and do the biopsy, and it turns out to be cancer. The author doesn’t seem to realize this is all happening against the background of potential litigation.
But any patient likely 1. doesn't care about ensemble performance 2. will get stressed out at the mildest indication of concern 3. induce a concave payoff for a trigger-shy doctor (no credit for correctly not intervening, and massive discredit for incorrectly not intervening).
If a doctor receives a test result that shows a suspicious mass, then neglects to order a biopsy to investigate further, there are 2 rough outcomes.
1. It was nothing 2. It was cancer
If it turns out to be (2), the doctor and the practice/hospital/whatever gets sued for malpractice.
On a more ranty note, why does everyone think they are better at other people's jobs than those people are? Where is the basic trust in the other? You think a doctor in the United States after ~15 years of school doesn't know that most biopsies turn out to be more harmful that useful? Come on. Restore some basic trust in other's competence.
I don't think any actor in that chain is malicious, it's just an example of poorly aligned incentives. Screening companies, doctors and patients all believe they are making the most optimal choice.
Physicians can fire patients, although they seldom do so because of declining a medical procedure. Professional ethics and state laws generally require the physician to first hand off the patient to another physician first; they can't just drop someone with zero notice.
There is generally no mandated checklist, at least not from a legal standpoint. Some healthcare provider organizations do require their employees to follow certain written standards of care. Medical societies also publish evidence-based care guidelines. Compliance is voluntary but gross deviations could be factor in liability cases or in actions by state medical boards.
Insurance reimbursement is an entirely separate issue. Every insurance plan has a different network of providers and different rules about which services are covered under various circumstances.
> Why are we taking as given that a net-negative decision to do a biopsy will be made
The author should stop wearily pretending that anxiety isn’t a common result of a positive test, and recognize that the average person is not comforted by a Bayesian analysis when their health could be at risk.
If continuing to a biopsy is as common as the author says (I don’t have any data on it), that suggests anxiety IS a common response and we can’t simply wish it weren’t the case. Mental health is health.
Anxiety is one of the worst outcomes of over-diagnostics.
Because then suddenly, I’ll become hyper aware of every potentially significant symptom and have to resist the urge to constantly google and check if there’s a chance it might indicate something. Is that pimple a pimple? Hey, I don’t remember my neck feeling this lumpy. Boy, I sure do seem to have sinus issues a lot. Are these joint aches normal? Etc, etc, etc.
As a kid, I felt absolutely invulnerable to worrying about my health. The first time I experienced true health anxiety is when my doctor pointed out a mole on my back and said “do you want to check this mole for cancer?” to which I replied, “oh, I guess so?”… only he didn’t. Because he checked with insurance, and insurance came back negative on it.
I am still in my 20s. I’m not in the best health, but my everyday life is pretty uninhibited by health issues. I don’t wake up with coldsweats. So yeah, it could happen to me, but frankly it’s worth being skeptical at my age.
But when the doctor pointed out that mole, they shattered the mental barrier I had between myself and cancer patients. I knew mentally that of course it could happen to me, but I had absolutely no idea that the signs of it could literally be hiding on my back, and I would be none the wiser. I googled and I learned a whole lot, and my intuitions were very wrong. In fact, I had many symptoms that can indicate various cancers. I heard stories about pimples that were not pimples, back pain that was not back pain, etc. people living normal lives who just went in for a checkup and suddenly faced certain death.
I’ve mostly snapped out of the hypochondria mindset, but still today I wonder about some symptoms in a way I never would’ve before. My life is altered by this one thing a doctor said off hand.
And for what it’s worth, I’m not saying he should not have done that. Insurance should’ve covered the biopsy just in case. I’ve outright noticed that sometimes, doctors will slightly edit your responses to things to get insurance to OK a diagnostic, and I think it’s in some part because they know that if you don’t get that peace of mind it could be damaging. Being hyper aware of your heart beat or super concerned about sleep apnea is not as bad as suffering from actual disease, but it’s certainly it’s own kind of hell.
It’s weird to me because much like cancer patients, I viewed myself as separate from hypochondriacs and immune to it as a whole. A lesson learned the hard way, and now I feel a twinge every time I see a new headline about cancer or hypochondria.
Because to me this sounds more like "your insurance won't pay for it because it is not an indicated study by ACR criteria."
I hear that spending hours on the phone trying to justify a test to an insurance company is no fun, and I bet the task is not made any easier if you don't actually believe that the study will help the patient.
Meningiomas by chance?
Has the monitoring improved your health? I'm not sure whether I would be more or less troubled if I had symptoms with an unclear cause vs a possible cause but unclear management plan. I suppose this will be highly variable.
More and more, the general public has come to see medicine as the Genius Bar service department for the human body. Everything that can be fixed, should be fixed. Let's get this thing back to like-new condition as we can, right?
But in reality, medicine is still much closer to the older model of simply seeking to reduce human suffering. You will die of something one day and most likely you will have 8 other things wrong with you when it happens. Curing all cancer in all humans would only at about 2 years of average increased lifespan because of all the other causes of death that are creeping up right behind it in the background.
So there is a tension here of what medicine should conceptually be doing. If, in the effort to "fix everything" (which is impossible), you actually introduce more suffering (by treating a diagnostic finding that may never have resulted in symptomatic disease), then many would say that's a failure of medicine.
If you can afford to be outside the insurance system in the US you can get excellent care. That can include having tests done that aren’t covered by insurance and avoiding tests that an insurance company would normally require just for CYA reasons, but aren’t worth the risk.
But the incentives of the insurance-driven care are not aligned with optimal patient outcome.
I had an experience with a doctor who was supposedly so prestigious that she didn’t accept insurance. I ended up going to two appointments where she did nothing but push for redoing some tests in her expensive laboratory at a cost of $5000. She couldn’t explain why her lab was different and eventually admitted that they used the exact same equipment as my previous (insurance-covered) test.
When I declined and tried to leave she offered me the “discount” of $1000 off for new patients. It was really just one big push to funnel people through her expensive lab combined with a fancy office and nice bedside manner.
Don’t assume that just because someone is outside of the insurance system they’re going to provide superior care.
Just because they don’t take insurance doesn’t mean they don’t have their own ethical sketchiness. However, just because there are bad non-insurance docs out there doesnt mean there aren’t excellent, ethical ones of the type OP described.
My wife gets to visit them a lot due to a skin cancer episode, and her former practice was swallowed up by some private equity dermatology group. I learned about their operations via a case study published one of their vendors - a commission/incentive management software platform. Up to 70% of provider pay is about pushing magic goop for your face.
It seems like there's a problem right up front: prestige.
My main doctor doesn't accept insurance though she will give you a form with the diagnosis codes marked if you want to submit it yourself. She simply doesn't want to deal with the paperwork. There's none of the fancy "concierge" and "membership" bullshit, much less "prestige". She just has an ordinary doctor's office, and doesn't own a lab or anything.
But in exchange for filing the insurance form if I remember to: the longest I've had to wait to see her when I was sick was a couple of hours, I can bring my dog with me to my visits, and she and I pass scientific papers back and forth when determining treatment. But the main advantages of "no insurance" are that we have lots of time for a visit (if needed) and nobody looking over her shoulder for prior auth or such. It's a much more collaborative model.
Unfortunately I don't think this model scales, but my exposure to the more formula-driven mass medical system has been discouraging.
Now, consider the GP who has healthy 50yo, does a PSA anyway and it's positive. The GP could still decide not to act. But the patient is not so likely not to do anything. Or even understand the odds. At that point, if the patient dies, the GP is likely to get sued because he should have acted. Even if over all of his patients, not acting was more efficient. If the GP decides to act, however, regardless of whether the patient survives, he won't be blamed for it. So doctors have a nasty incentive to act.
- Physicians want to avoid getting sued - Physicians want to get paid , just like everyone else. - The payor in the system is not the patient, but a faraway entity removed from the situation on the ground.
In such instances, all 3 factors influence a decision. If a decision to perform procedure X is close to 50/50 (test/no test)
Do you think "no test" will win ?
Now put that in the macro context of millions of patient visits. now, since we are talking diagnostic testing, you may need to be tested at a hospital. So now, you are voluntarily exposing yourself to a hub of tired doctors/bureaucracy/germs.
That starts looking like madness , for sure
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)
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.
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.
I was not aware of this. non-surgical interventions: 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)
Doesn't seem to be a clear indication that it actually helps for that, but it's used for quite a lot of other things, like treating paracetamol overdose.
bruh radiations induce oxidative stress and free radicals which is the major cause of damage, which the antioxidant GSH (NAC) prevents/reduce
Now I have real money for the first time, I'm sure that makes access easier, but I'm not sure how to search and assess for quality medical care. It seems like search engines are not the way and it's mostly word-of-mouth. I guess I'll go around my office asking coworkers if their pcp is any good / has an opening...
I just want to go into a lab where I can have the imaging / diagnostics run, no question, have the ability to look at the charts myself and send them to whatever doctor -- rather than convincing a doctor to do imaging tests in the first place.
Are you in the US? How are you able to request MRI scans without an immediate cause?
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.
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.
No? That's even shown clearly in the anecdotes of the original blog post.
Isn't this already the case? Tests that are considered worth doing regularly even without extra symptoms are done regularly. E.g. mammograms and colonoscopies/stool tests.
(I'm ignoring your focus on "yearly" since really you care about "regularly" given that yearly is totally arbitrary and timing that makes sense is clearly dependent on the tests in question.)
In my opinion, the only justifiable factors are probably along the lines of:
- invasiveness (e.g. if it's non-invasive or minimal cost)
- benefit to the patient if detected
- cost relative to other screenings/actions that can be done for the patient
Everything else seems strictly suboptimal.
Your entire argument here seems to require patients to be rational agents. They aren't.
Yes, my argument does rely on patients being rational agents.
> They aren't.
That may be true, but it's certainly paternalistic (in the formal, definitional sense) to act as if they are not rational agents and withhold information/reduce autonomy. This is a case of pure paternalism (again, in the formal philosophical sense).
Different ethical systems, of course, make different judgements on whether this behavior is moral. It's also up for debate whether this is a desirable feature of the medical system.
Call it whatever you want. Idealizing patients as rational agents instead of considering how they are in reality results in worse outcomes. If your goal is to actually help people, you should base your arguments on how things are in reality instead of some idealized dream world.
That's a fair position (you seem to be a utilitarian), and probably quite defensible. But, one could argue that patient choice is an important feature for our medical systems to have. I certainly want to be able to refuse medications that my doctor recommends (e.g. opioids) or seek alternate advice/second opinions. My cost-benefit analysis equation is probably not the same as my doctor.
To be clear, I'm not talking about an "idealized dream world", as you put it -- I'm talking about patient autonomy in the real world, even if it means allowing patients to make what seems like a suboptimal decision.
You can do this.
> I'm talking about patient autonomy in the real world, even if it means allowing patients to make what seems like a suboptimal decision.
Patients are allowed to have these tests done against the recommendations of doctors (of course the costs might not be covered by insurance).
So I'm not really sure what you're arguing anymore...
Does the position seem clear now? I apologize if this line of reasoning was not clear earlier.
The reality that patients are irrational agents _is_ a justifiable reason.
> Therefore, the only justifiable factors that should be considered when screening patients that preserve patient autonomy...
Your position is clear. I disagree. I think given real constraints (economic, legal, psychology of patients/doctors/etc.) focusing on overall quality of outcomes makes most sense. You can disagree if you want, but don't pretend it's not justifiable.
edit: Besides all the tests are available to you. You can pay them if you'd like. Given they are low-cost (at least those you're focusing on here) it really isn't a burden on you to get the tests done yourself.
I'll note that I never "pretended that it's not justifiable". I did explicitly say earlier:
> That's a fair position (you seem to be a utilitarian), and probably quite defensible.
I'm disengaging, for now, since it seems like we understand each other's position, and we had a productive, lively discussion.
I listen to my supremely well educated plastic surgeon wife regularly discussing and giving guidance to office staff around patients in their private practice. Their general approach is to get patient statistics, and that is all, without the aggregated vital signs. I asked her once, "Why don't you get the patient vital signs too?"
Her response was unexpected, "If we get patient vital signs, we immediately become liable for patient overall health. Our malpractice insurance is specific to the practice of medicine for plastic surgeons, and plastic surgeons only. Our front office staff are normally front office only, or aspiring doctors on a break between their undergrad and entry to medschool. Our practice uses no Nurse Practicioners, Physician's Assistants, or nurses. We're not set up, or staffed appropriately to deliver general medical care."
Conclusion 1: Medical care is characterized by liability control; there are logistics/staffing aspects to medicine around specific types of care.
Medical Diagnosis we think of as scans, remote tests. You get a CAT scan, you get an MRI, or X-ray, bam, 15 seconds, 5 minutes, or an hour later (after waiting in a hospital for hours) you're done and some radiologist or other specialist is interpreting the results and you have a diagnosis. That is true in some cases, but not others. If you get a positive mammogram, or a suspicious lump what is the next step? Welp, that is regularly one of two things - a needle biopsy, or an investigational biopsy. Needle implies small, thin, fairly painless. Not this needle - instead imagine a needle designed for tissue harvesting, like a horse sized needle. This big giant thing needs to go into your breast to suck up enough of the suspicious lump for a pathologist to examine it. Alternatively, you could have an investigational biopsy where a surgeon takes a small amount of tissue from inside your breast with a scalpel. Investigational biopsies via scalpel can be a big scam too, where a car accident occurs, a cut tendon in the hand, and the surgeon decides to open up the arm past the wrist to visualize all the soft tissue up the arm. Lucrative billing enhancements.. But, when it comes to breasts, we know that certain life changes predispose towards a positive mammogram for a limited time window. Stopping breast feeding being the foremost change that can cause suspicious lumps.
Conclusion 2: Diagnostic tests can be quite painful, and, at the wrong time, quite unneeded. Some of them are damaging. Good medicine is about as much when to intervene, and when to test, just as much as it is about when not to intervene and when not to test.
Literacy is a skill.
See above.
I'm not sure if the author has ever had a biopsy, but most people will seek out care if they get some concerning result, like a nodule on the lungs that's "probably benign because of your priors."
Maybe you could opt in to "I am fully rational and will only make decisions using bayesian statistics with accurate priors."
Maybe you could hide test results or generate false results based on probabilities as not to steer someone into an unnecessary procedure. (Yes this it tongue in cheek)
Those who really really want to do that next test because they want the information are free to do that. But it seems like the exact mentality that will make you more prone to a botched biopsy. If you keep following the trail of more information you will get to a test that may not be best for your health outcome. That may be the initial x-ray.
It seems that if you have not-fully-rational human beings and an obligation to truthfully inform them of the results of medical tests, then maybe not doing the test to begin with has significantly better health outcomes. Can you not chain bayesian probabilities?
If the research literature says that patients who get scans showing lumps in their lungs have X% chance of having lung cancer, there is an implicit conditioning there in the patient having complained to the doctor of some kind of symptom that prompted the scan. X% isn't the probability of having cancer given lump on scan, it's the probability of having cancer given a lump on a scan in patients have breathing trouble. If you test too much you run the risk of there not being data about what the baseline is! Studies for a lung cancer treatment usually take 1000 random people and give them all lung x-rays and then wait to see how many get cancer later and survive the experimental treatment, instead they usually find 1000 people already diagnosed with lung cancer that had it diagnosed by traditional means (e.g. scans prompted by breathing problems). The same reasoning applies to deciding whether to do a biopsy -- most biopsies are going to be prompted by scans from a relevant patient complaint, so statistics computed to determine the risk/benefit tradeoff are implicitly conditioned on that. You need a separate study to determine the risk/benefit for incidental discovery.
We are not.
One person's natural lump is another's cancer.
One person's low heart rate is another's natural genetic gift.
Modern medicine , particularly compensation, wants to put everything in neat black/white boxes.
Which is why tests are more dangerous than they seem. You are not average, and you shouldn't compare yourself to any perceived average because the human body is not average.
You should compare yourself to you, and that's all the doctor should use.
Of course no one would stand for such an intrusive system. But over time it would improve diagnosis.
How exactly would you follow? Stress testing, angiography, cardiac MR, CCTA??
If such a correlation were found, more intervention would indicated, if not, then not.
It’s a pretty slow process, but outcome is what really matters, and even if slow it would be faster than doing nothing.
A test has a specific sensitivity and a rate of false positives. So for screening (CT in this case) you would want a high sensitivity and low cost, while the false positives would not be your priority. The positives should go through a confirming test (biopsy in this case) with a high specificity. Here cost and sensitivity are usually secondary.
Now insurers look at the screening tests rate of false positives. If they deem it too high, they don't want doctors to do those tests on a population with a low probability of having the condition you are screening for (low base rate). If the patient belongs to a subgroup shown to have a high enough base rate of a condition, then it makes sense to do the screening.
Then you have different patients, some want to get one MRI each year, some only want to run diagnostic after they experience symptoms. I believe most doctors respect that individual risk tolerance within the given framework.
Now the thresholds obviously should be revised regularly as cost, test properties and even base rates of diseases change, but I don't see a systemic defect here, my blind spot?
> But because that patient was low-risk, the harms of that biopsy will outweigh the benefits.
> Thus, you shouldn’t do the CT scan.
> What? If the harms of the biopsy outweigh the benefits, don’t do the damn biopsy!
I'm not sure what the point of doing the CT scan if we're not going to act on its result.
Sure, you gain the confidence that everything's gucci if it turns negative. Is that really worth the stress of the test going positive and the not doing the biopsy? Seems dubious to me.
* Most illneses are easier to treat and have better long term outcomes in terms of morbidity, when they are detected early / in a asymptomatic stage.
* We could collectively use the data collected from scanning "healthy" people, and adjust our bayesian priors so that we can more accurately adjust our diagnostic measures. E.g. common virus infections can give you brain lesions visible in MRI scans. However since MRIs are expensive we rarely scan healthy people so every lesion in an MRI is an immediate supicion of MS or other neurodegnerative diseases. We simply don't have good baselines for this.
The latter would allow us to look at all the indicators more holistically to make a well balanced judgement if more invasive diagnostics are warranted.
Is it better to know? To not know? To know when it's the moment? BTW I'm in Italy so it wouldn't even be that expensive to do every couple years.
This machine will tell me how I feel better than I can do it myself. This secondhand abstraction is more reliable than my firsthand observation
It’s just a full-body MRI. Costs a couple thousand dollars. Would put it in the category of neat curiosity and possibly useful as a baseline or if you have surprise cancer or something. But totally unnecessary and to be avoided if you’re prone to medical anxiety.
Why such scaling with the size? Pure greed? The guy has mostly to push a button..
2) one should have a legal right to command a MRI scan without paid analysis.
MRIs are expensive machinery that take highly-trained and well-paid technicians to maintain and operate. The imaging process takes an hour alone; start to finish, it's a two-hour process that is far from just pushing a button.
> one should have a legal right to command a MRI scan without paid analysis
I don't think there is a law, in America, prohibiting MRIs without expert analysis. But one, that's useless. And two, the people who don't think it's useless are the ones most likely to misinterpret the data and cause problems for the MRI provider.
> Result: How much does an MRI scan cost in India? The average cost of MRI scan in India is usually between Rs. 1500 to Rs. 25000.
> Query: Rs. 25000 in US dollars
> Result: 25,000 Indian Rupee equals 321.02 United States Dollar
...so ok, there's a chance the first answer is wrong and/or there's some factor I'm missing, but assuming it isn't one must again ask the question: Why does an MRI cost $5k?
For the record, asking specifically about a full body scan did not change the price:
> Query: cost of an full body MRI in India
> Result: [...] And the full-body scan cost you between INR 18000 to INR 25000 in India.
Where did $5k come from? I said a "couple thousand dollars," though looking at my e-mail it was $1,500. A 4 to 5x cost differential from India to New York City seems explicable.
> A 4 to 5x cost differential from India to New York City seems explicable.
Then please explain it, because you seemed to be saying that this expense was inherent to the machine and had little to do with cost of related labor. If that was the case, one wouldn't expect an MRI in India to cost 1/5th as much.
I also doubt it would be any less expensive here in south central Wisconsin than it is in New York City.
The machines are expensive. They also vary in strength, with scanners in e.g. the Philippines and Malaysia being of considerably lower strength than is common in America [1]. (I couldn't find data for India. There are certainly no 7T scanners there; I believe most are 1.5T and below. In New York, it was a 3T.)
Between that, which might be a 2 or 3x differential between a low and high field strength scanner, and the cost differential of "highly-trained and well-paid technicians [needed] to maintain and operate" [2], 4 to 5x seems explicable.
[1] https://researchonline.lshtm.ac.uk/id/eprint/6700/1/IL9.pdf
Disclosure: I'm a pathologist.
BTW it's very cool that this is a thing> https://www.nlm.nih.gov/research/visible/getting_data.html
These scans aren't magic. Most of the time you need a "contrast agent" to find things.
That means an injection (and attendant infection risk) and circulation of a strange substance in your body. In the case of Gadolinium, there's about a 1 in 1000 reaction risk. So, you don't want to go injecting that into people without a good reason.