Medical tests can also be counter productive. Hear me out. There's studies that regularly show the optimal age for i.e breast cancer screening. Screening too early can cause an increase in misdiagnosis I believe. There are other such cases for not just cancer screenings - I know not exactly what you're talking about. EEG and blood test make sense. But for more advanced tests, you could be right in saying "there are legitimate safety reasons" - maybe not so much from the test itself but from the impact of a false positive.

I'm so fucking tired of this perspective. Yes, it's technically correct. Many of us have done the canonical "cancer screening false positive / false negative" example demonstrating the problem in a statistics class.

But at the end of the day, I'm paying a doctor to care for me, not the general public. I may be a member of the general public, but the public interest and my interests are not identical.

If I'm willing and able, I should be able to pay to have a test done (anonymously), and be left alone to deal with the statistics of what the results actually mean for myself.

The fact that I have to fight my doctor to do this is condescending bullshit.

PREACH!

It's a bunch of gatekeeping bullshit and drives me crazy. My wife went through two years of misery and the number of times I had to argue over getting labs done that ultimately influenced her treatment left me with a rather deep mistrust and skepticism over the medical community that is going to take a lot of time to repair.

The reason you don’t want to do “all of the tests” and “deal with the results” is not about the probability of a false positive, but the consequences of getting one:

“In the United States, estimated deaths per year include: [26][27][28][29]

12,000 due to unnecessary surgery

7,000 due to medication errors in hospitals

20,000 due to other errors in hospitals

80,000 due to nosocomial infections in hospitals

106,000 due to non-error, negative effects of drugs

Based on these figures, iatrogenesis may cause as many as 225,000 deaths per year in the United States”

https://en.m.wikipedia.org/wiki/Iatrogenesis

This is exactly what the doctor parrots back at me. Again, these are outcome statistics for the general population. I'm well aware of these numbers, but I am not an average patient.

I'm not going to look at the outcome of a single test and blindly decide to take a strong medication or to get surgery. If I want a test done, it's because I'm doing research to try and figure out a complicated issue that doctors have not been able to help me with, usually due to their own time and resource constraints. I have all the time in the world, and if a condition is affecting me, I'm going to care more about addressing it correctly than any doctor. I'm completely aware that a test is just one data point, that tests have error rates, and that interventions have risks.

I was one of the first ~1000 to get whooping cough (pertussis) during the 2008 outbreak, before they knew that the vaccine cocktail that my generation was given needed more frequent adult boosters. I figured it out after a few days of digging. Do you want to know how many doctors I had to yell at to finally convince one of them just to run the test? And this is a test with zero intervention risk -- they can't do anything if it comes back positive, they just tell the NIH.

Doctors have gone off the deep end here. Yes, testing has risks, but they should focus on the intervention risks. You should be allowed to run as many tests as you want for informational purposes if you're just trying to figure out what might be going on, especially if you're aware that errors can happen and are capable of acting responsibly with the resulting (single, noisy) data point.

You might have a case if you were paying for the test out of pocket, but I presume you have health insurance. In that case, it is also the doctor's duty to prevent unnecessary spending.

Combined with the fact that most patients are not well informed and will demand pointless or even counterproductive, it is better to leave treatment and testing decisions to doctors, not patients. Even if doctors sometimes get it wrong it is still better than the alternative.

I'm not saying you shouldnt be allowed to pay and pick your own tests or your loved ones tests. You have a good point, population statistics can't be extrapolated back down to an individual on a case by case basis. I had to deal with doctors recently, so I understand where this frustration comes from. I only mean to say that there could be some negative effects from people doing this in aggregate.

This attitude is another example of why private healthcare is a very bad idea.

You might change your mind if you'd ever met an arrogant doctor whose biggest concern was their own ego and you didn't have a second option. I'm met a few doctors who are so rude and arrogant they wouldn't even pass the HR screen at anywhere I've worked. Depriving people of choice just gives assholes even more of a chance to be assholes, because people have no other alternatives than to go to the assholes.

You're right - depriving people of choice can cause bad doctors to stick around longer because patients are forced to go to them.

This is why we need something like single-payer - no one should be forced to go to a bad doctor because their private insurance decided to only have one or two options in-network locally.

Yes, but that argument would prove too much. People get very anxious just from browsing medical information on the Internet and matching up their easily observable symptoms.

> I would gladly even pay $50 per month for unlimited access to a place to just come in, get my blood sugar, kidney function, heart function, liver function, etc. tested once per month!

Walk-in labs like AnyLabTestNow and Quest will gladly do a CBC as often as you want: https://www.anylabtestnow.com/tests/complete-blood-count/ , https://questdirect.questdiagnostics.com/products/complete-b...

Other tests: https://www.anylabtestnow.com/test-finder/

(I agree with the other commenters that frequent asymptomatic blood testing is unlikely to help, even more so when done alone - not because of false positives, just because CBC results vary a lot for no detectable reason/problem)

Just checked the price on CBC from any lab test now, $50. That's still pricey for most people, especially for a half-dozen similar tests per month. Walmart has historically proven very good at forcing prices down through economies of scale.

No one without symptoms needs these tests every month. Meaningful changes manifest with symptoms or happen slowly or both.

As an example of the first case, a person’s white blood cell count isn’t going to go haywire overnight with no other symptoms. An example of the second case is fasting blood glucose: it's important to know before symptoms appear, but is not going to change dramatically (beyond the draw-to-draw/day-to-day variation) in a month, or even in 3-6 months.

Getting these monthly with no medical need is like telling someone you’re aiming for 300% test coverage :-)

Thank you. Making a note of these.

It's a massive waste of money and resources to get an EKG without a clinical presentation. It's a massive resources to get a CBC and CMP without some positive predictive value. Why don't we throw every test at you? Because there's a significant chance you will be a false positive/negative. This is dangerous to look at this way.

What are those risks, like, what do they look like quantified?

"Waste of money and resources" is relative if you're only blowing ~$200 bucks. Even if there is a 8-10% chance of a false positive, they're cheap enough to do two... or 8. Kinda like how people by multiple cheap birth control tests.

Anecdote: I've had hernia problems off and on courtesy of the USMC and did no less than three (3) sonograms after being referred by different GPs to do so -- and they found nothing. Symptoms didn't go away and I kept going back. This was in the Inova system around Washington DC, one of the better systems in the US. One afternoon I double over in pain and end up in emergency surgery because, low and behold, I did actually have a hernia and it was strangulated; my intestine was literally dying one inch at a time. Emergency surgery saved my life, but I paid ~3-4K for all of those sonograms & consults + more for the actual surgery. All in maybe $8-10K.

Walmart-tier medical may not be great, but one of the better health systems in the US failed me just as effectively, and at a greater cost. Would 5 Walmart sonograms have found it? 10 scans? Maybe not, but I probably could have done 10 scans and still saved money.

If a test has 5% false-positive rate, you can't just test 5 times and expect to have a <0.000001 false positive rate, maybe not less than 1% or even 4% - depends on the test and how you repeat it.

If they test you for antibodies, and your blood reacts, doing the same thing 5 or 50 times is not going to help. If you have a wobble on your EKG, it's not going away just because you measure it 10 times. Though it might, if you were just stressed the first time. Or they might find something 2 out of 10 times and then what - do you just ignore it?

To be clear, I'm not against non-invasive voluntary testing, but procedures need to be adjusted, otherwise people get treatments they don't need and suffer the effects (while also tying up actual doctors and equipment).

BTW sorry about your issues. Those were false negatives, and you had symptoms, where better/additional/more tests are warranted.

Medicalidiot, the most an EKG machine costs is a few thousand dollars if that. Running the machine costs probably less than a penny in electricity. What is the "MASSIVE" waste of resources here?

Reading the EKG gets billed at $200-%300 because you want a board certified cardiologist who can look at the nuances of an EKG to tell you whether your right bundle branch block is part of the 99% that is likely benign or if it's that 1 in 100 that we are going to put you under intense therapy so you don't die.

It’s easy enough to give out a sheet with instructions, and they already do.

CVS has already provided this for over 10 years: https://en.wikipedia.org/wiki/MinuteClinic

Because it fell off everybody's radar, I assume CVS MinuteClinic hasn't been as revolutionary as originally hoped. OTOH, if Walmart is joining the fray then either the retail clinic market has been steadily growing in general, or Walmart thinks they can do something different.

I tried it once in 2007 and it was quite pointless. The person in charge at that location was I think a real MD but she appeared to be encumbered by hard policies that restrained her from pretty much doing anything. I regretted wasting time there since I had to go to a regular doctor anyways and haven't been back.

I've only ever used them for flu shots and a tetanus shot once. They're a perfect supplier of those kinds of services in my experience. I think if I were actually ill or something I'd try to bump up to the next tier and at least go to an urgent care if I can't get into my primary care physician.

Problem is MinuteClinic is just that, a clinic, it's just a nurse that can do "office treatments" such as vaccines, shots, prescribing blood tests, bandaging wounds, etc. But ultimately anything else has to be referred out.

Prescribing blood tests might already save doctors time. Most of the time when I'm sick the doctor just asks broad questions and takes a blood samples... and I'm told to come back tomorrow when the results are back from the lab.

Right, but that seems to be exactly what the parent comment wants.

Maybe it is different where I am but in my experience, it is always an MD on staff.

This argument is comparable to thinking that a painting is only worth the materials it’s made out of, and everything else is worthless. A doctor and their staff have trained for decades in order to handle your health, why in the world do you think you can do it after some googling?

Compare it to your own job - if I had the same tools as you, could I walk in and do the same job you do?

>Compare it to your own job - if I had the same tools as you, could I walk in and do the same job you do?

Should access to a compiler be gated just because amateur programmers probably don't know as much as people with a degree?

The fact that you need to go to a doctor, to get referred to a facility which will run a test, which will then send that test data back to the doctor, and at the second appointment the doctor will go over the data with you to see if you needed to go to the doctor in the first place...is just an absurd waste. It shouldn't be so hard to get a few measurements done on your own body.

My point is that a random person with access to any highly specialized tool will not output usable results. If I try to use a compiler and mess up, nothing bad happens.

If I go get myself an EKG and mess up the reading, well.. death is somewhere in the list of possibilities.

(To be fair, I fall into the group of people who believe in very strong government regulation to protect people from themselves, because the world is too complicated to make well-informed decisions. Easy example is seatbelts - if Ford could sells cars for $1500 cheaper if they didn't have seatbelts then some people would buy them and they'd die. Not everyone will do the proper research, so everyone needs protecting.)

> A doctor and their staff have trained for decades in order to handle your health, why in the world do you think you can do it after some googling?

Counterpoint: Doctors have an average IQ of 115, and train across a huge variety of disciplines; mostly while sleep-deprived. Many doctors' training was decades ago.

Anyone with a somewhat abnormal condition, access to Google Scholar, and able to learn how to follow citations and simultaneously weigh competing models can outdo anybody except a dedicated specialist.

The relevant job comparison isn't to a painter, it's to a programmer with a hundred clients, each of whom he talks with for 30 minutes, once a year. Sure, the programmer has much more knowledge and skill--but is he really going to be able to adequately replace the every client's home-brewed solution spread across 4 excel sheets, 3 batch files, and an archived website?

Should the client really be restricted from downloading Python or Visual Studio for their own use, unless a real programmer signs off on the requirement and supervises them?

The variety of disciplines and sleep deprivation is only about 2 years early in the training. After that the training is highly focused, and again only 2 years or so are sleep deprived. And today, the majority of doctors in practice are less than 20 years from their training. You make it sound like doctors are an outdated mass of idiots, and I can only assume your personal experiences have biased you.

The real training is objectivity, which is very difficult for even doctors to maintain, despite knowing just how misleading research results can be and so how they must be wary, how to rationally follow the literature, etc.

I seriously doubt more than single-digit percentages of people googling things, even intelligently, are going to be following citations and weighing competing models. Likely less than a fraction of one percent. And, unless they have personally done similar research and so can understand the data and potential pitfalls more clearly, even that enlightened fraction is highly likely to make some biased misinterpretation.

How can they not, when it is their own health they are investigating? Even a genius layperson examining the literature flawlessly would benefit from an interpretation provided by a neutral third party.

The comparison isn’t to the tools. Visual studio is the doctors blood analysis. The stack trace that visual studio spits out is the results of the blood analysis. Can anyone with some googling figure out what a stack trace means and what to do about it? MAYBE at best but realistically no. Now do you want to do the same with your heart? Brain?

You mention the average doctor but what about the average patient? How many people out there do you think will take the time to read through papers and citations and have the understanding to weigh options vs googling symptoms and going with the first result?

Why should the behavior of "the average person" limit everyone else?

If you gave a common health problem chances are your doctor is more than capable of handling it.

If you have a difficult to diagnose problem that’s the time to take control over your health. You have to put in the time to trust but verify your own care.

Same thing with a difficult to debug code problem. It’s typically a function of time.

Right. This is why we don't allow consumers to access the Internet unless under the supervision of an IT professional never of the American Sysadmin Association guild. Lives are too important to be entrusted to the people who live them.

> Like, if I want an EKG, why can't I just walk in to a place and get it done at a reasonable price? And without a doctor's approval?

You're also paying for interpretation of your EKG at the same time. There are plenty of places happy to sell you home BP/HR/EKG monitoring kits, but you have to remember that you are paying for a doctor's time and clinical expertise when getting them in a hospital. It's not like a single EKG will tell you all that much about your heart anyway.

This is precisely the reason: a doctor’s interpretation as well as the liability that comes with it.

Good luck on reading an EKG graph yourself. It is apparently not even easy for a trained doctor to discern what exactly is going on.

Source: I worked on a long term ECG holter monitor sold by GE.

Well if it’s just an EKG you’re after: https://www.alivecor.com/

But I agree with your overall point regardless

> As important as health is, and as much as Americans spend on it, it is shocking to me how gated everything is.

Agreed I had this issue as an uninsured university student with an Xray, and as one covered by my employer's insurance with an MRI.

In both cases I was stone walled to just get either, in the former I had to go to a clinic see an MD, come back get a physical and then get a referral for imaging off-site. And in the latter, I had to see 3 specialists, get a physical, have several weeks of Physical therapy and Xray imaging before the Insurance would cover it.

> Again, I pay for health insurance, but I still feel like if I want a quick EKG, it will take me 3 weeks to see a doctor, and by then I might be dead.

It was so exhausting just trying to make all the appointments and follow ups with a full work schedule that I haven't been able to get that MRI after all. I just assumed the worst and started to take matters into my own hands and started to do my PT exercises into my daily gym routine and will monitor the results myself.

> What am I missing? Are there legitimate safety reasons these mundane diagnostics are so locked down?

Its a protected Industry, the very supply of MDs is drastically capped in this country, its a controlled cartel.

MRIs are actually very expensive. Like they are just expensive... even in Europe. They’re costly to own and operate and maintain correctly.. just the labor alone. Unless you’re willing to pay out of pocket, I don’t see a problem with exhausting other options before jumping to MRI.

Also as for X-rays.. I think people freely getting Ionizing radiation isn’t exactly the brightest thing ever.

Also who pray tell, is going to read these studies?

Because they are too incompetent to be trusted to handle anything more complicated than shoes and canned food. As a former employee I could tell you stories.

> I would gladly even pay $50 per month for unlimited access to a place to just come in, get my blood sugar, kidney function, heart function, liver function, etc. tested once per month!

I've noticed my gym offers somewhat regular screening days which offer some (or all?) of that stuff, but it still costs extra. Reasonable (~$30?) but it would probably be something used more regularly if it was just part of the membership, and considered a normal thing. I don't even think they offer it monthly - I think it's quarterly.

As a physician, please, get more tests. My wife wants some new shoes!

I'm absolutely fine with that. :-)

After all, businesses exist to provide a service, and when I pay for that service if the owner gets to buy his wife shoes, that doesn't bother me.

What does bother me is that I can't walk into a clinic, let's call it "EasyLabs", and ask for an EKG right now, for $100, $200, $300.

It's the immediacy and tranparency of pricing, that's lacking and eliminating the doctor as middle man for tests and diagnostics that aren't harmful.

Money is not my concern.

The inefficiency is what is shocking to me.

To put the inefficiency of medical diagnostics in perspective, it is likely faster and easier for me to go out right now and buy a new $50,000 car, than it is for me to order my own MRI.

To me that just seems crazy.

But, as I said, maybe I'm missing something about the danger of getting tests like an EKG or an MRI needlessly.

For example, we know accumulated radiation from unnecessary x-rays would be harmful. So clearly not every medical diagnostic is safe to self-request.

MRIs are harmful for patients without symptoms.

https://www.amjmed.com/article/S0002-9343(13)00967-4/pdf

http://www.lessismoremedicine.com/blog/video-do-more-screeni...

(There are lots of posts about over testing on the Less is More site: http://www.lessismoremedicine.com/blog/tag/overtesting )

Take a patient who has smokes about five cigarettes every day. Should we MRI their lungs to see if they have lung cancer?

The patient has the MRI, and doctors see some small spots in the lungs. Is this cancer? Or is it something that is completely harmless, such as scarring from childhood disease? To find out a needle biopsy is used. This is low risk, but it isn't no risk. The biopsy comes back clear. Does that mean that these spots are harmless, or does it mean that the person doing the biopsy missed them? At each stage we're perhaps causing fear and alarm and distress, and not really getting any useful information.

But we do know that this person smokes, and we do know that their health would be improved if we could help them stop smoking, and we know that nicotine replacement and support is an effective way to stop smoking for many people. It's probably a better way to spend the money.

Your example does not show that MRIs are harmful. It only shows that overreacting to the result of an MRI may be harmful. If you can just avoid overreacting then having more information can only help, never hurt. The results may seem useless now, but combined with other test results, advances in our medical knowledge, and tools like Machine Learning we may be able to draw useful inferences from that information later.

The discussion is about testing now, today. It's not about testing in 10 years time.

> can only help, never hurt

This is simply untrue. Assuming for a moment that people can avoid overreacting you're still ignoring the stress caused by getting a partial dx.

And if you're not going to do anything with the information it's pointless doing it: you've exposed people to risk (hospitals are low risk, not no risk, environments) for no purpose.

I've linked to doctors and statisticians and healthcare researchers all saying the same thing. Here's a UK Cancer charity which repeats the point: https://scienceblog.cancerresearchuk.org/2018/03/06/overdiag...

What you chose to do with your body is, of course, totally up to you. But you should stop spreading the FUD that imaging is harmless or that more information is always better.

> The discussion is about testing now, today. It's not about testing in 10 years time.

Indeed, and the results of tests done today may be relevant in ten years, even if we don't have the ability to draw useful information from them right now. If nothing else it may at least provide a baseline for comparison.

> Assuming for a moment that people can avoid overreacting you're still ignoring the stress caused by getting a partial dx.

Stressing out over an inconclusive test result would be overreaction. It's not as if stress is automatically a bad thing anyway, in moderation, or as if not knowing (or worse, being prevented from investigating) doesn't cause stress of its own.

> And if you're not going to do anything with the information it's pointless doing it...

I agree, so it's a good thing I never suggested that the results should be completely ignored. Just don't overreact.

> ...hospitals are low risk, not no risk, environments...

There is no such thing as a no-risk environment; moreover, imaging doesn't need to be performed at a hospital. A clinic is sufficient. Not doing the tests conveys its own share of risk; many conditions are much easier to treat when detected early, but you won't detect them early if you don't start looking until after symptoms manifest.

> ...FUD that imaging is harmless...

You have yet to provide any evidence that imaging is harmful, which hasn't stopped you from attempting to spread Fear, Uncertainty, and Doubt on the subject. The only FUD here is your own.

Well there are lot of rich health conscious people in this country that would love to do that for your wife.

Now there's a comment you don't want taken out of context.

> and as much as Americans spend on it, it is shocking to me how gated everything is.

It didn’t always use to be this way. Then people started getting poisoned, sick and dying. It’s not like the FDA existed when they ratified the constitution. The opium epidemic proves the system is flawed and broken, it does not however prove that just throwing everything away will make things better.

>Are there legitimate safety reasons these mundane diagnostics are so locked down?

Healthcare is not my area of expertise either, but my understanding is that the short answer to your question is yes.

For a longer introduction to the issues surrounding letting anyone get whatever diagnostics they want to pay for, this Medlife Crisis video that came out today seems appropriate: https://youtu.be/yNzQ_sLGIuA

This crazy. It's like saying no one should have access to medical tests without a doctor's approval because some people will misinterpret their tests.

Time on an MRI scanner (and to interpret and communicate the result) is a limited resource.

I fear unrestricted access would lead to over utilization by some people at the cost of less utilization by others. It could also lead to nontrivial psychological stress for people who can’t get a full understanding of the results. But I do think we need to strive for increased transparency from price lists to EHR interoperability to patient access to their own records.

MRI is profitable and not made from scarce materials. Increased demand will increase production.

Doctors are only scarce because they are members of a guild that uses monopoly power to restrict competition to prop up prices.

MRIs depend on liquid helium, a scarce material by definition, but that's besides the point.

There is a high bar to becoming a physician because the consequences for error can be so incredibly high. I want there to be more physicians/access to medical care than ever but I don't think compromising on quality is the way to get there.

Actually helium being scarce is a myth.

Are you sure? Seems to be pretty well documented that there is a shortage?

https://priceonomics.com/the-increasing-scarcity-of-helium/

http://www.heliumscarcity.com/

When it's cheaper to keep refilling an MRI scanner that boils off lots of helium, than buying one that loses only a little bit, then yes, you use a lot of helium.

It's not like we haven't discovered higher temperature superconductors that could be used, even if we didn't have helium.

EDIT: You can permanently fill 100 of these[1] per year with the boil off of one shitty MRI. Is uses about 1kg of He, so one year of world helium production would be enough to make one MRI machine for every 200 people. We are not constrained by helium.

[1] https://images.philips.com/is/content/PhilipsConsumer/Campai...

> Time on MRI scanner .. is a limited resource.

It's a limited resource similar to houses and carpenters. If it is permitted and there is funding, more can be built/trained.

How many "well educated adults" can convert 1 in 1000 to 0.1%?

It's not just members of the public who don't understand stats, it's some doctors too.

https://www.stat.berkeley.edu/~aldous/157/Papers/health_stat...

This quote is from p61 but the whole thing is interesting)

> Note again the great difficulty large parts of the public, like the female veterans, have with translating small frequencies into percentages. Only 25% of the population could correctly convert 1 in 1,000 to 0.1%. Even among the highest education groups, at most 30% could solve this translation task. Lipkus, Samsa, andRimer (2001) even found that only 21% of well-educated adults could answer this question correctly.

You have prostate cancer. It's definitely cancer, this isn't a misdiagnosis.

Do you want the treatment, or do you want to do nothing?

This is a real choice faced by many men, in part because of the over-use of PSA testing.

https://www.cdc.gov/cancer/prostate/basic_info/benefits-harm...

That seems like a perfectly reasonable reason to me

It's a perfectly patronizing reason. If they're so concerned that test requires may be misinterpreted then the solution is better education. It is not their place to serve as gatekeepers.

More than “like”, I’d say “equivalent to”.