How do you know if you’re at high risk for something? This assumes a medically literate and motivated person will seek care based on … what? Realizing that grandpa, great-grandpa and dad all didn’t live past their 60’s? High cholesterol and hypertension can be “silent killers” - how do you know to check for them?
According to the AHA, blood pressure is supposed to be taken with feet flat on the floor, relaxed, and quiet for five whole minutes before, on an empty bladder, without caffeine and not having exercised within 30 minutes. I can count on zero hands the number of times I've had my blood pressure measured in accordance with this procedure in a doctor's office during a check-up. [1] It's a highly variable thing that can spike instantaneously and take a long period of time to return to normal without issue.
Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical.
The optimal way to make a hypertension determination is a 24-hour continuous blood pressure monitoring cuff. You should take your blood pressure at home, on your own time, in a relaxed environment and if you see a consistently elevated reading, only then reach out to your doctor and set up an appointment to confirm with a 24h test.
[1] https://www.heart.org/-/media/files/health-topics/high-blood...
My favorite conspiracy theory is that this is why we always have to wait so long after we're in the exam room but before the nurse comes in to take BP. My BP monitor's instructions say to sit calmly for 15 minutes for an accurate reading and I think that's what they're doing.
Meanwhile, since the kids are so hyper it's not even worth trying the delay tactic so the pediatricians come in much faster.
It's not "calm" to be on edge for 15minutes wondering when the provider will appear.
Also my office takes my BP as soon as my appointment time starts and then we sit waiting for doctor.
Baseline blood measurements can also be invaluable. When getting sick you don‘t want to go down rabbit holes.
The US has a comparatively high hurdle to access to doctors. When doctors see patients they need to assume it is bad (liability another factor) driving costs up. Also people are not used to reach out to doctors letting them hesitate when they should not - regular contact can help here.
Every year major bloodwork and investigations may not be worth it but seeing your doctor regularly, being able to communicate effectively, doctor having a baseline of you as a person and some bloodwork too makes other countries a lot more efficient in providing health care.
In other words, building a relationship. Continuity of care improves health outcomes.
FWIW, my cheap OMRON blood pressure thing has agreed with the pro results, thus far.
https://www.mayoclinic.org/diseases-conditions/high-blood-pr...
I just meant it may also be a factor in elevated office BP measurements even if done properly, hence “potential contributor”.
If you have multiple documented normotensive measurements on your home BP monitor that’s more reliable than even proper technique in a medical setting to be honest.
The hierarchy of BP measurement accuracy is:
24 hour ambulatory measurement > multiple home patient measurements > in-office automated BP cuff (with proper technique) > in-office BP measurement with auscultation (not sure why this was suggested as more accurate to the commenter you replied to).
Automated cuffs are great and reproducible.
For stats like blood glucose, heart rate, blood pressure, etc.
I last worked in primary care back in 2016 but even back then we would either do multiple visits or ask the patient to check multiple times at a pharmacy (or at home if they could afford a cuff).
24 hour ABPM is the preferred method for diagnosis as you stated but has limited (albeit growing) availability today.
Fortunately consumer health-tech advancements has resulted in cheaper accurate BP cuffs but this is a recent-ish phenomenon.
Suppose you have a test looking for an extremely rare genetic condition (say, 1 in 1 billion people have it). That means that the test needs to be extremely accurate (in this case, accuracy of .999999999) to avoid having so many false positives that it's worse than a coin flip about whether you have the condition or not. Therefore, in most cases you would be better off making a fake test that just says "no" every time.
For example, genetic parental tests are very accurate... unless the parent being tested has chimerism, in which case you'll get the very confusing result that the child isn't your own, even under repeated testing.
The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.
It helps eliminate benign anomalous results in emergencies. I have a low neutrophil count. It is totally uneventful. Having that baseline means if I’m sick and have the works run, doctors need not start treating my neutropenia—that wasn’t caused by whatever is going on.
More broadly, catching a vitamin D deficiency and allergy early probably saved some years of life and definitely improved my quality of life.
Some doctors are test happy. Most are not. Finding the right fit is part of being a human in the midst of modern healthcare.
Nope. Indoor lifestyle and and a proclivity for cold weather. And, like, allergies.
I think it was a bit jarring to have that comment on the covid chain since their experiences are not related.
In my family we detected lung cancer in stage 2b instead of stage 1 because we spent months fighting a doctor that didn't want to do tests.
If we 'listened to the experts' my family member would be dead.
On this note, get a second opinion for things. I went into brain surgery under a misdiagnosis from one doctor. Appointments take time, especially with specialists, but try hard and maybe carefully reach out to over-seas doctors as well in the meantime.
Any lab value flagged as abnormal is typically >95%ile meriting some form of further investigation (whether that’s continued follow up/repeat blood work or a different test depends on what we’re talking about).
The tests that could be physiologic for a patient outside of reference ranges (e.g. mild LFT elevations) will often just get repeated to establish stability as you propose. There isn’t a compelling argument to do this prospectively before symptoms start.
(asking for info, not doubting anything!)
> asking for info, not doubting anything!
sure, just hesitant to answer because im not looking for a debate on this stuff anymore, got enough of that in my day-to-day while i was symptomatic. after the last 3 years i just want to put it all behind me and get everything back to normal.
People need to push back and ask questions not just accept everything the doctor says at face value..
If I take my car in for routine maintenance and the mechanic comes back with 1000 things they want to do I am not prone to just say "sure do what ever you think is best, you are the expert"
It would be malpractice and I would be sanctioned if I were to willfully ignore validated guidelines without strong medical evidence to support me.
It’s a good thing to ask questions but “pushback” suggests an adversarial approach. If you feel like your physician is attempting to fleece you find a different one, in my experience most of us aren’t like that. Physician-patient trust is critical.
If you’re unsure of where to look a good starting point is an academic-affiliated practice which will have more oversight and reimbursement structures that don’t align with over billing.
to me however that means my personal care is not the only concern, with the mechanic the motives and incentives are clear. With the Doctor they hidden with a split set of masters and at the end of the day the patient is not the primary concern or factor, the Licensing board is, the insurance company is, the government regulators are, but not the patient.
These over lapping authorities you think make the system less adversarial to me makes it more adversarial, as now I have to ensure the motives of your decision making is about me, the patient, and not the government authority that told you what you have to do... not the licensing board, not the insurance company, etc.
See COVID response as a recent example of this, but history is fraught with other examples where patient care suffered under the weight of authority.
this is with out going into the pure corruption that influence many health policies from diet to drugs... Making it less "evidence-based" then I think you are asserting.
As an aside the “agenda” of these authorities is to ensure we practice safely (i.e. evidence based medicine) in the interest of patient care and not based off our own personal gain or thoughts (as you posited with the mechanic analogy). An example of a sanctionable offense is performing an unnecessary procedure because it pays well, like in your mechanic example.
Where there is no compelling evidence, or when there are unique patient circumstances, I practice with more latitude (e.g. I commonly biopsy lesions that don’t need one when it’s causing patient anxiety and the risks are low, despite not adhering to guidelines, and have no fear of being sanctioned as it is justifiable as reducing anxiety/for the patient’s mental wellness. What I can’t do and will be sanctioned is if I unnecessarily biopsy a benign incidental lesion for the $90).
With respects to insurance and pharmaceuticals I couldn’t care less what their interests are. As part of my job I fight with them routinely and we take industry funded evidence with a grain of salt.
The primary guiding interest in any patient encounter is unequivocally the patient’s health. We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
COVID is a perfect example of why science-based medicine doesn’t work as the response was not evidence based at all, largely because it’s impossible to acquire evidence during a pandemic.
As someone who was critical of the response, you’re right that the authorities limited us (not that I practice primary care) but that period of time was the medical equivalent of martial law. This has been the only period in my lifetime where medical practice was dictated by an authority to such a degree.
Mistakes will happen in exceptional circumstances. Most medical encounters are not exceptional.
Rather than pointing out to exceptions which don’t disprove evidence-based medicine we can look at every other facet of medicine which is almost all still driven by evidence.
That being said, the structure of medical practice in the US leads to mediocre and expensive outcomes for patients because no one cares to address systemic issues because no one is incentivized to.
> We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
Another anecdote: my uncle was a doctor in South America and he is appalled whenever he sees doctors in the US. Doctors in the US do not care to learn anything about you beyond your symptoms, vital signs, and blood work. They see you like a car engine and follow a cause and effect flow-chart to decide on a treatment. In South America, he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc. to understand if the patient's self-identified symptoms are consistent with other patients with similar backgrounds. Seeing each patient took more time, but he and his patients were much more satisfied with the exchange than in the US. The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
> because no one cares to address systemic issues because no one is incentivized to.
I'm not sure that's true having practiced both in the US and Canada which are both very similar. Speaking to my own specialty (radiology) there are several academics working to build evidence to reduce unnecessary and expensive follow-ups that seem to have low clinical utility.
I'll give you an example, current follow-up regimens for pancreatic cysts are unnecessarily long and expensive with very high probability although all societal guidelines (US and international, with the US version actually the shortest) have very long and expensive follow-up recommendations based on limited evidence from Japan and expert opinions.
When I report a pancreatic MRI although I don't personally want to I still recommend "follow-up in one year per ACR guidelines" as that is currently the standard of care and in the chance that I'm wrong (no compelling evidence on either side at this point but the status quo is to follow-up) the outcome (pancreatic cancer) is devastating.
Simultaneously, several groups (including myself) are looking at long-term evolution of these cysts so we can one day stop doing these probably unnecessary studies with confidence. This is despite the fact that I can bill $130 for a "stable pancreatic cyst" MRI that takes me 2 minutes to report.
Within my own specialty the same thing has been done for breast masses, liver lesions, ovarian masses and renal masses within recent memory and we have dramatically reduced investigations at financial cost to ourselves in the interest of patient care.
> That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
There's a time and place to fix systems-level issues (which are very hard to objectively evaluate and obtain evidence for fixes), during a specific patient encounter is not one of them.
Inertia in healthcare is real but we also have to remain cognizant that the consequences of mistakes/poor decisions are far more significant than in most other areas of life.
> Another anecdote...
Primary care is broken in the US and Canada (can't speak to elsewhere) due to several issues, the funding model being one of them which greatly limits how much time a GP can spend with a patient while still eating/being able to sustain a practice. Hospital-based specialty care is a lot better on average as we have more resources.
> he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc
For example we do this in oncology where I mostly reside professionally. Treatment decisions are influenced by these factors and every cancer center I've worked in has allied health professionals as part of the team to also help evaluate these factors.
> The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
The issues you describe are most prominent in private practice environments which are very heterogeneous and there are definitely toxic physician groups that optimize billing, but I wouldn't say the system as a whole does not care. I suggested somewhere that patients try to find academic-affiliated practices (ironically my clinical work is private practice) if they are unhappy with their care as these groups have far less financial considerations and are generically speaking a better choice.
Overall I'd say the system is far from perfect and there are many inefficiencies but the majority of physicians I've worked with do in fact care about patients more than financial incentives. There is no easy fix for these very complex issues.
Most people don’t experience 3 until there is a serious enough problem, but when they do their care is far better than anywhere else in the world.
However, I will say some healthcare systems do try to get to the root causes. Once upon a time, I worked for a healthcare system in a “process engineer” role, for a lack of a better term. There was a team of us, and the whole point was to take a systemic look at healthcare outcomes so we could mitigate root causes that led to less than optimal patient outcomes/quality of care.
Can't manage what we don't measure.
Attention should focus on what's changed. Instead of playing 20 Questions for each new problem. [1]
High LDL? Well, it's always been high, and stable. We don't have to treat it.
Bone spurs (on spine)? Well, most everyone has them and they're not bothering you.
Oh, new sciatica symptoms? Hmmm, looks like you've got a new bone spur which may be impinging. Let's try some PT, get you a standup desk for work, and reassess in 6 months.
Etc.
--
Concern trolls claim more testing begets false negatives, begetting unnecessary treatment, which has its own risks.
Fine. Change healthcare from transactional to relational. Change from our current fee-for-service to continuity-of-care (or capitation, prevention, whatever we end up calling it).
Like u/JumpCrisscross says elsethread, only treat anomalous results per new symptoms.
I believe periodic baselines with regular checkups would reduce testing and unnecessary treatments, overall.
--
[1] Monitoring, logging, anomaly detection, and RCA... Starting to sound suspiciously like engineering and operations. Of course, some orgs treat each incident as unforeseen one-offs, aka The Condi Rice Defense™. But high functioning teams plan ahead.
Only if you particularly want to die of a major adverse cardiovascular event[0], then we don’t have to treat it. Note that treatment begins with lifestyle interventions and not necessarily pharmaceuticals.
We have reference ranges with lab tests for a reason. There is no such thing as a “normal” high LDL and there is growing evidence that statin therapy is beneficial even in those without other cardiovascular risk factors.
Again keeping in mind that lifestyle interventions are the first step. Dismissing dyslipidemia as “stable” is flatly incorrect.
N.B. This evidence synthesis is outdated now but presents the risks in an accessible format, interval evidence is even more supportive of intervention.
[0] https://thennt.com/nnt/statins-for-heart-disease-prevention-...
The risk of cherry picking examples is they'd distract from my thesis. So I used two from my own life. I am fail. (Also, I have mo medical training and cannot advise others.)
As for LDL, mine is borderline, I'm very worried, it's unchanged by statins or diet, and I guess the plan is to monitor it. Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux. I'm currently eating buckets of fiber (oatmeal, beans, etc) and misc fish & krill oil, and recently added cocoa butter. Next I'll prob try that Fire In a Bottle stuff (some kind of tea extract).
I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?). And they'd know best, right?
YMMV.
No problem, NNT and NNH are the most important measures we look at when deciding on interventions on a population level and easily understandable. "https://thennt.com" is a high quality resource intended for physicians but is fairly accessible to an educated reader and covers many common interventions one may face.
A lot of proposals have sounded great during my medical practice until the numbers come back with a NNT of 100,000 and NNH of 1000.
> Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux.
We used to have "LDL target < 2" when I was in training but my understanding is the general consensus amongst experts (and some recent evidence, but not enough to make a general recommendation) points to a stochastic relationship rather than a deterministic one/specific threshold with continued benefit scaling to 0 (found looking at hunter-gatherer indigenous populations).
> I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?).
This is beyond my scope of practice (i.e. don't take this as medical advice) but anecdotally I also recently asked a cardiologist I greatly respect about a family member and his response was similar to what you were told, he started statins himself in his late 30s as male with "normal" cholesterol and no risk factors although the evidence is not yet there to support such liberal use and the guidelines don't recommend this (yet).
Beyond cholesterol reduction statins coincidentally also have plaque stabilizing effects that reduce the risk of MACE.
Given that there is next to zero harm with statin therapy and they're cheap, it seems like a reasonable intervention en masse in my non-domain expert opinion. The diabetes risk was overstated in earlier literature but we have better data now that their use is so widespread, myopathy is a self-limiting nothingburger that goes away when you stop/switch agents.
Personally, I'm planning start a statin soon as well regardless of my LDL levels (typical disclaimer of this is not evidence-based and a personal decision, discuss with your physician etc).
> And they'd know best, right?
Either endocrinology or cardiology would be good experts to ask as they live in this world. I would/did trust a cardiologist when I needed expert opinion on this personally.
> The risk of cherry picking examples is they'd distract from my thesis.
I mostly wanted to address the LDL as that has a strong body of evidence behind it.
The issue with your thesis otherwise is that most tests have no relevance without appropriate clinical context and if they won't change management what's the point?
Consider radiology which is the land of meaningless incidentals, the issue we often face is "oh great, there's an incidental adrenal adenoma on this appendicitis scan that's probably nothing but could theoretically be an adrenal cancer what the hell do we do now?".
A single baseline would often be nice in the sense of if a patient did develop a non-adrenal cancer I could look back and say "oh this was there before, it's not metastatic" but there isn't enough evidence to support this statement considering the potentially life-threatening harms from over-investigating benign findings with biopsies/surgery. This has been the main criticism of whole-body screening MRI but the literature is just starting to come out.
I forgot to mention a huge reason I support regular baselines of some sort: eldercare.
In the case of our mom, now 85yo, it would have been really useful to have done cognitive assessments and bone density and maybe image likely arthritic joints when she was 65.
Divining when, which, and how much brain pills to give her has been pure guesswork.
And deciphering her chronic back pain has also gone poorly. Resulting in a lot of trial and error. With no real improvement. IMHO. (Experiencing chronic pain myself, I know it's wicked hard to treat.)
Ditto the 3 other elders us siblings have been responsible for. We were just guessing how to best care for them. We didn't know their rate of decline, so weighing risk/benefit was just guesswork. So maddening and wasteful. It really felt cruel and inhumane.
Maybe having better medical history, perhaps in the form of baseline assessments, would have helped.
Hopefully the research you mentioned will help future care givers make better decisions.
Thanks for the informative, thoughtful replies. Peace.
Your attitude is actively harmful, real people suffer with uncaught diseases because we don’t routinely test “”healthy”” people.
Just because some tests might have alarmingly high false positive rates doesn’t mean all, or even most do.
The way to make a checkup cost less is to pay doctors and nurses less. There are no pharmaceuticals, no surgeries, no complicated specialist medical equipment, and no expensive labwork involved in the price.
Society generally doesn't agree with the notion that doctors and nurses should be paid less. Therefore, checkups are more or less priced appropriately. Paying high skilled labor for their advice simply costs a lot of money. Ask any dev contractor here on HN.
All of these factors (except maybe rent) are higher or even unique to healthcare in the US. Capitalism isn’t even to blame for most of these. A free market would have price transparency, and would incentivize direct billing over billing through insurance due to lower overhead. Just because it’s the USA doesn’t mean it’s capitalism. That said, nationalized healthcare also seems to be able to solve some these problems through collective bargaining on drug prices, and reducing the billing overhead.
Proactive care is good. Testing is good.
However the insurance / healthcare cartel behaviour that's fuelled as a result is devastatingly expensive.
Not always. It depends on the performance characteristics of the test, i.e. the sensitivity and specificity. Tests with high sensitivity and low specificity often reveal indeterminate results that, in an effort to gain more certainty, expose the patient to significant procedural risk.
What does this mean? Which issues? How many thousands of diseases are there?
I have a friend who has low level of energy, everyone was calling him lazy his entire life. He thought thats just how life is. He cannot compare how it feel to be him with how it feel to be someone else.
I convinced him to see a doctor about this at the age of 25. First doctor didnt take him seriously, didnt want to do any tests. The complains are very non-spesific. maybe you are lazy, maybe you are depressed.
After weeks of fighting the medical system he discovered that he had a digestive issue, which led to low level of iron and low level of enegy. His entire life he was suffering from an easily treatable problem.
Imagine he treated this at the age of 12, how many sports did he miss out on, how much academic achievement was missed, maybe his career and life trajectory would be different.
A friend of mine struggled with back pain for 3 years. He coupst find the cause. It got so bad, he thought he'd become disabled. He left UK and went back to Romania to have support of his family. Suffenly in Romania he started getting better. Turned out it was vitamin D defficiency.
I started taking Vitamin D agressively, 2,000 units daily, 5 times the recommended amount by the NHS. After taking it for 6 months I went private and did a first vitamin D test in my life - my level is 1/3 of normal.
So how doea one know what is normal, if most people gp their entire life without ever doing a full blood test
The article kind of hints at this, but it comes down to Bayes theorem [1]. The general population has a relatively low incidence of disease, so even tests that are fairly reliable in a population with a high incidence of disease become super inaccurate when applied to the general population.
Worse, false positives generally - especially in the US, due to high financial liability risk - end up involving expensive, invasive medical follow-up tests, and the probability of a false positive multiplied by the risk of the exploratory procedures outweighs a later diagnosis.
No wonder annual physicals don't do much good.
High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. However testing otherwise-healthy people for things they probably don't have isn't likely to yield good results. It's just math.
[1] https://en.wikipedia.org/wiki/Bayes%27_theorem