[HN Gopher] The madness of reduced medical diagnostics
___________________________________________________________________
The madness of reduced medical diagnostics
Author : dynm
Score : 75 points
Date : 2022-05-20 12:39 UTC (10 hours ago)
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| the_sleaze9 wrote:
| I think the author is correct in the acedemic sense, but ignorant
| of the reality of healthcare.
|
| 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.
| peteradio wrote:
| Presumably the patient can decline the biopsy? What happens to
| liability in that case? Does the doctor then have to decline to
| work with that patient further? What happens to liability if
| the doctor doesn't fire the patient? I agree there needs to be
| trust somehow, yet it seems practitioners hands are tied from a
| level above to toe the line for liability reasons rather than
| patient outcome. Is a doctor able to take into account all
| extenuating circumstances of a patient or only those predefined
| on a checklist passed on by a murky review process? What
| happens to patients who do research and find alternative (maybe
| better) opinions, well are they in network? Can a network have
| differing opinions among its practitioners?
| nradov wrote:
| Generally there would be no potential medical malpractice
| liability if a patient declines a medical procedure. That
| happens all the time.
|
| 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.
| axg11 wrote:
| This is the reality. In fact, the situation is getting even
| more complicated as direct-to-consumer screening becomes more
| popular (e.g. full body MRI scans). Companies that are selling
| the health screenings are only incentivized to sell as many
| screenings as possible. Scans inevitably result in benign
| incidental findings far more often than they identify real
| health problems. Then the patient is directed to a specialist
| who is uninvolved with the screening company. The specialist is
| incentivized to aggressively investigate the finding out of
| fear of malpractice and due to pressure from the patient.
| Nobody has ever thanked their doctor for inaction. The end
| result far too often is a series of expensive and painful
| procedures with a large dose of anxiety. Of course screenings
| also save lives, but nobody is responsible for ensuring the
| benefits outweigh the harms at the macro level.
|
| 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.
| CogitoCogito wrote:
| Also the author seems to entirely ignore patient psychology.
| Sure in some parallel universe where patients can be told "so
| we found something weird on your lung don't know what it is and
| don't really care" and just accept it, then maybe doing the
| unnecessary tests doesn't matter (ignoring extra costs of
| course which _do_ matter). But we don't live in that universe.
| Ignoring how patients actually behave and pretending they are
| just perfectly logical is basically malpractice in my opinion.
| maxfan8 wrote:
| One slightly reasonable common argument I hear for reduced
| medical diagnostics is: "we don't have the resources; it'd
| overwhelm the medical system". While this may be the case for
| some tests, there are probably a great number of tests that could
| be scaled to be done yearly on the whole population.
| CogitoCogito wrote:
| > While this may be the case for some tests, there are probably
| a great number of tests that could be scaled to be done yearly
| on the whole population.
|
| 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.)
| maxfan8 wrote:
| No. Not all screenings/tests are done, even when it's super
| low cost and non-invasive. For example, one factor that is
| used to determine whether to screen for certain types of
| cancer is "Possible harms from follow-up procedures". [1]
| Another factor that is taken into account it the chances of a
| false positive. [1] Both of these factors are irrational,
| since more information is strictly optimal given a rational
| agent. They should not even merit consideration in choosing
| whether to undertake a screening (this information should
| only be used _after_ a screening is done, to determine
| follow-up action).
|
| 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.
|
| [1]: https://en.wikipedia.org/wiki/Cancer_screening#Risks
| CogitoCogito wrote:
| > For example, one factor that is used to determine whether
| to screen for certain types of cancer is "Possible harms
| from follow-up procedures". [1] Another factor that is
| taken into account it the chances of a false positive. [1]
| Both of these factors are irrational, since more
| information is strictly optimal given a rational agent.
|
| Your entire argument here seems to require patients to be
| rational agents. They aren't.
| maxfan8 wrote:
| > Your entire argument here seems to require patients to
| be rational agents.
|
| 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.
| CogitoCogito wrote:
| > 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. This is a case
| of pure paternalism (again, in the formal philosophical
| sense).
|
| 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.
| maxfan8 wrote:
| > 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.
| CogitoCogito wrote:
| > I certainly want to be able to refuse medications that
| my doctor recommends (e.g. opioids) or seek alternate
| advice/second opinions.
|
| 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...
| IG_Semmelweiss wrote:
| The big problem with testing is that it assumes the human body
| can be averaged.
|
| 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.
| sudden_dystopia wrote:
| I have never understood this rationale to not do more
| comprehensive diagnostics. Sure, it costs more up front. But
| wouldn't catching problems earlier save more money and suffering
| in the end?
| ufo wrote:
| That is one of those things that sound intuitively true, but
| isn't necessarily the case in practice.
|
| One example that I am more familiar with: thyroid nodules.
| Recently, the medical guidelines have increased the size
| threshold for a biopsy, where you poke a needle in it to find
| out whether it is cancer or not. We could assume that
| diagnosing these cancers when they are smaller would always
| better, but that is not the case... On one end, it turns out
| when the nodule really is cancer, it is just as safe to wait to
| do the biopsy only after it has grown over the size threshold.
| And on the other end, the biopsies are not 100% accurate. A
| good percentage of the time, it can't say conclusively whether
| it is cancer or not. When that happens the only way to know for
| sure is to surgically remove the thyroid, which might result in
| the patient being put on lifelong hormone medication. One might
| think that in a perfect world we would act rationally over this
| uncertain information and not remove the thyroid when all it
| has is a small nodule with uncertain diagnosis. However, human
| intuition doesn't work well with percentages. When a patient is
| told they have a chance of having cancer, no matter how small,
| they will want to pursue every avenue to investigate and
| resolve the matter, even when the cost benefit is not worth it.
| When they looked into the statistics of how many people were
| getting thyroid surgery we could see that as imaging technology
| improved, more and more people had thyroid surgery, with no
| reduction in the number of deaths from thyroid cancer.
| kayodelycaon wrote:
| Because none of this happens in a vacuum. The tests aren't
| perfect and open to interpretation, but that's the least of the
| problems here.
|
| Sometimes no action is the correct action, but no one is going
| to do that. How many laws have been passed because "something
| needs to be done" even though nothing in the law needed fixing?
|
| Many people, I'd say most, are not happy with inaction. Knowing
| something _may_ be seriously wrong can have an enormous
| emotional cost for some people. Dismissing this as irrational
| is like saying humans are irrational. (Spoiler: they are)
| jjoonathan wrote:
| Exactly, and the human "bias towards action" is amplified by
| legal mandate. A doctor can't recommend inaction if a pack of
| lawyers is lurking in the bushes waiting to pounce if the
| situation worsens.
| dwelch wrote:
| Agreed. I think the article and parent comment seem to be
| from the perspective of someone who has never had to, say,
| read or interpret a chest CT. Or had to tell someone that
| they have an indeterminate module that may be cancer but may
| be nothing.
|
| The article also seems to imply that their is one entity or
| person who controls all aspects of diagnosis (hence the meme
| at the top), from taking a history and doing a physical exam
| to perfectly understanding the intricacies of all additional
| diagnostic testing. Of course, your primary care doctor may
| not understand exactly what percentage of people in a low (or
| high) risk cohort with this lung nodule with certain specific
| imaging features turn out to have cancer. Hopefully the
| radiologist does--but they didn't talk with the patient to
| assess their risk tolerance and data-collection preferences
| before saying "consider further evaluation with tissue
| sampling" in that report.
|
| At the end of the day, respecting patient autonomy matters.
| It sounds like whoever wrote this article would lean towards
| asking their doctor to collect as much information as
| possible. Others wouldn't. In a perfect world, the patient
| will be well informed by their doctor, be well-counseled on
| the risks and benefits of a test / intervention, and will be
| capable of understanding things like statistics well enough
| to come to an informed decision that works for them. In
| reality, that often does not happen for a number of reasons.
| CogitoCogito wrote:
| > Sure, it costs more up front. But wouldn't catching problems
| earlier save more money and suffering in the end?
|
| No? That's even shown clearly in the anecdotes of the original
| blog post.
| petercooper wrote:
| I get a full MRI imaging every two years so I spent a lot of
| time researching the ethics around it just to be prepared, and
| there are two things I could bring up.
|
| First, false positives. There can be things that looks like
| problems but aren't, or that _are_ problems but with
| complicated risk profiles around their management or resolution
| (especially true of aneurysms). For heavily studied situations
| where imaging is low risk and hugely effective with low false
| positive risk, most countries _do_ have screening programs,
| such as regular cervical smears or mammograms for women of
| certain ages, as well as aortic aneurysm screening for men over
| 65 (in the UK, at least).
|
| Second, psychology. A surprising (to me) number of people do
| _not_ want to know about their medical status until a problem
| actually occurs. But then once they _do_ know, many folks can
| be prone to undue worry or hastily made emotionally driven
| decisions that run contrary to data.
|
| I'm going to totally make up these figures but as a
| demonstration of the _idea_ , imagine that brain aneurysm scans
| tend to find aneurysms of concern in 5% of people and that of
| these 5%, 4% are likely to die within 5-10 years due to that
| aneurysm. Scan the entire country and you now have millions of
| people potentially terrified of an aneurysm that won't kill
| them. If an aneurysm is found and you are offered an operation
| with a 5% chance of mortality, are you taking it? The research
| I saw when I was looking into it is that, yes, most people want
| to get rid of the "problem", despite a higher risk of short
| term mortality rather than sitting it out. This is just one of
| the reasons doctors grimace when people want to get such scans
| without cause, but there are many others beyond the scope of
| this reply too.
| throwaway18451 wrote:
| I want to get regular imaging; I've never done it. I don't
| even have a PCP, I've been frustrated with previous PCPs not
| paying attention to detail or waving my symptoms as
| psychosomatic. I'm not sure how to assess whether a doctor
| ahead of time would actually be willing to work with me
| rather than say things that they think make me feel better.
| These doctors keep running me against the 99% heuristic
| [https://astralcodexten.substack.com/p/heuristics-that-
| almost...].
|
| 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?
| SemanticStrengh wrote:
| > Although cardiovascular disease is widely recognized as the
| leading cause of death, a lesser known fact is that aortic
| aneurysm is the 15th leading cause of death over the age of
| 65 years in the USA.
|
| I was not aware of this. non-surgical interventions: https://
| www.jstage.jst.go.jp/article/circj/advpub/0/advpub_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)
| thaeli wrote:
| MRI isn't ionizing radiation, so much lower risk profile
| there. You may be thinking of CT scans?
| SemanticStrengh wrote:
| The idea that only ionizing radiations induce damage has
| to stop bruh https://pubmed.ncbi.nlm.nih.gov/35237875/ I
| mean it's much safer but still a concern.
| hfsh wrote:
| That has nothing to do with NAC. NAC supposedly helps
| protect against possible kidney damage caused by the
| _contrast agent_ , nothing to do with radiation, ionizing
| or otherwise.
|
| 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.
| SemanticStrengh wrote:
| > nothing to do with radiation, ionizing or otherwise.
|
| bruh radiations induce oxidative stress and free radicals
| which is the major cause of damage, which the antioxidant
| GSH (NAC) prevents/reduce
| incongruity wrote:
| A number of reasons come to mind:
|
| 1. Not doing anything in the face of "evidence" is ripe for
| malpractice lawsuits, rightly or wrongly
|
| 2. Not doing anything in the face of "evidence" can drive
| anxiety for patients and many clinicians want to be seen as
| having some answer or path forward, however:
|
| 3. Not all diagnostics are risk or pain free
|
| 4. Not all diagnostics are precise enough to make treatment
| decisions clear, correct, and authoritative - so more
| diagnostics will lead to more false positives which, when
| paired with the previous points lead to trouble for the
| clinician and possibly the patient.
| aaron695 wrote:
| h2odragon wrote:
| If a test shows "narrowed arteries" or whatever but it's not
| currently impacting you; _inaction is an option_.
|
| 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.
| bell-cot wrote:
| My understanding is that, for typical "retirement age" humans,
| _any_ major surgery (including "physically minor, but you're
| under general anesthesia for a while surgery) carries a high
| risk both of very slow recovery, and of very slow _or obviously
| incomplete_ recovery of pre-surgery mental capabilities.
| SAI_Peregrinus wrote:
| I had a brain surgery (craniectomy to remove a colloid cyst
| in the interventricular foramen of Monro) at 22, and while I
| was home from the hospital after 2 days it took over a month
| to get back to normal. It'd surely be hellish after
| retirement age. Anything with general anesthesia is high-
| risk, no matter how minor the rest of the procedure.
| hammock wrote:
| Brain surgery is safe and effective, and prevents severe
| disease and death. I encourage everyone to stay up to date on
| their brain surgeries. I'm sorry to hear about your friend.
| pfisherman wrote:
| I get the satire and I hate to be pedantic... BUT
|
| 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.
| meepmorp wrote:
| Nah, we should all assume that of any and all medical
| interventions are unsafe and ineffective based on individual
| second-hand anecdotes we read in the comment sections of
| websites.
| cma wrote:
| Do you know the medical term for what he had? Was it one of
| these?
|
| https://en.m.wikipedia.org/wiki/Cerebral_arteriovenous_malfo...
| h2odragon wrote:
| Could have been; but I don't recall what it was even if i did
| hear it.
|
| 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.
| chasd00 wrote:
| it's a nice, fat, and juicy billable event, of course it
| was a "time bomb".
| hirako2000 wrote:
| Since we've accepted to let healthcare be a business, we
| can only blame the logical consequence of that system,
| health professionals are running a business, they will
| scare off the siblings son and grand kids of a senile
| elderly if they can bank 20k for some unnecessary surgery.
|
| 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.
| [deleted]
| SemanticStrengh wrote:
| edit: my comment is not adequate for aneurysms
|
| 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.
| greggsy wrote:
| While I'm sure you know what you're talking about, and it is
| very interesting, it's poor form to suggest treatments for _a
| cardiovascular brain conditions_ , after being given second
| hand information of a _single symptom_ with no further
| history or context.
| SemanticStrengh wrote:
| well yes I was talking in general, actually for brain
| aneurysms the recommendations I made are likely to increase
| mortality because the aneurysm has more likelihood to break
| with a vasodilated overflow.
| IG_Semmelweiss wrote:
| Incentives have a powerful effect in healthcare:
|
| - 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
| rayiner wrote:
| > What? If the harms of the biopsy outweigh the benefits, don't
| do the damn biopsy!
|
| 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.
| adgjlsfhk1 wrote:
| Also, if you know that you won't do a biopsy even if the test
| comes back positive, then the screening isn't helping anyway.
| xsor wrote:
| One reason behind why doctors can't simply do tests then not
| follow up is simply medical malpractice suits. Often times, once
| you do the test you're locked into figuring out everything even
| to the detriment of the patient for fear of getting your license
| revoked.
| tylerrobinson wrote:
| > And I'll wearily pretend to accept that people are emotional
| and couldn't understand Bayesian reasoning or false positives and
| so we need to worry about stressing them out (#2).
|
| > 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.
| pfortuny wrote:
| Thanks for saying this. There was an article the other day here
| on HN about someone totally obsessed with "fulfilling" his
| iphone app's health "objectives".
|
| Anxiety is one of the worst outcomes of over-diagnostics.
| jchw wrote:
| This. I don't want to know there's a nodule and then hear "but
| it could be nothing. Don't worry about it."
|
| 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.
| DeathArrow wrote:
| But the best way to proceed is still to make the CT and let the
| patient decide.
| greenglass wrote:
| Could having doctors refuse to run diagnostics also lead to
| anxiety? It has for me personally but I may not be the typical
| patient. Some people want zero information about medical
| issues. They just want to leave all of it to the doctors, no
| desire to research their condition or understand the details;
| just trust the doc. I am the sort of person if my mechanic
| tells me I need an expensive repair, I want to know why. Once I
| had a dr tell me that I was wrong to feel less anxiety after
| getting an abnormal brain scan, than I would have felt had I
| not had the scan at all. It was an absurd conversation and very
| clear to me that the dr was more invested in his opinion on the
| matter than he was in listening to my reasons why the scan was
| reassuring to me. It was an mri, so no radiation. But he
| insisted that my anxiety would be worse having had the scan
| than if I hadn't. A bizarre moment. Anyway, maybe doctors
| sometimes get too stuck on their own opinions and don't fully
| appreciate that there are more than one type of patient? Some
| people like to change their own oil, some do not. Doctors may
| also underrate the anxiety of having no clear diagnosis when
| life changing problems occur. One size fits all mentality is
| probably wrong.
| n8henrie wrote:
| Did you offer to pay for the MRI cash (roughly $5k I would
| bet)?
|
| 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.
| greenglass wrote:
| HMO so yes, costs are a factor. But it was a small cost
| relative to repeated doctor visits, hospital costs, etc...
| MRI for massive HMO are not $5000 due to economies of
| scale. The dr in this case was angry because the MRI
| revealed brain tumors which needed to be monitored.
| cflyingdutchman wrote:
| I was squarely in the author's camp and am now a little less so
| having seen the impact of false positives on my family. Anxiety
| is real and harmful, and humans are generally very bad at
| responding to tiny, explicit risk of big harm (small nodule in
| lung that may be cancer or not, covid, vaccine side-effects,
| shark attacks).
| [deleted]
| OrvalWintermute wrote:
| This article is rather funny because it misses out on key facts
| of how doctors practice medicine these days.
|
| 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.
| kyleee wrote:
| wow, really gross that they don't take vitals
| psyc wrote:
| Not for the reasons central to the article, but my favorite is
| the No HPV Test For Men stance. Because men usually don't have
| symptoms and have far less risk of cancer than women..... Just
| take 10 seconds to ponder how myopic that is. But that's how the
| medical establishment thinks about health care.
| teekert wrote:
| This is so true. And I think we need more Bayesian models in
| Hospital IT systems to help with this. The probability needs to
| be updated, you shift to a new population with new evidence. It
| seems so clear, yet somehow it is so intuitive. Why? In many
| respects, Bayesian reasoning is just what we do, but then
| sometimes it fails us. We are just not good at accepting risks of
| any kind I think. Better to not put ourselves into this position
| seems to be the reasoning. Avoid that "The test told you so!"
| feeling...
| PaulKeeble wrote:
| The NHS has gone the other way and wont run diagnostic tests it
| really needs to. The end result is growing legal action over
| failure to diagnose conditions. Long covid is diagnosed in just
| 28,000 patients and yet the office for national statistics says
| by the symptom studies 1.8 million have it. There is no where I
| know of, certainly not on the NHS, where you can get a test for
| microclots, a condition found in the bulk of Long Covid cases and
| easily treatable but doesn't show up in normal clotting tests.
| You can get micro clot tests throughout a lot of Africa but such
| is the reluctance to run tests in the UK no labs have bothered.
| Its something we have known can be tested and treated for 17
| months at least.
|
| 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.
| refurb wrote:
| But this is how population medicine works.
|
| 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.
| starkd wrote:
| And yet I seem to remember we were told government would not
| be making vital healthcare decisions like the greedy private
| sector corporations. That was supposedly a chief selling
| point to government managed care.
| pfortuny wrote:
| That is why population "medicine" is anything but "medicine".
| The State is not a physician. But turns out that it IS.
| refurb wrote:
| People point to the US, but every country in the world is
| struggling with healthcare costs and how to contain them.
| As technologies develop, costs will only continue to rise -
| the question is how to control costs and get the maximum
| benefit.
|
| 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.
| hammock wrote:
| > But this is how population medicine works. You're willing
| to trade off a few extra deaths if you can save a certain
| amount of money.
|
| Or even make a certain amount of money:
| https://www.openthebooks.com/substack-investigation-
| faucis-r...
| tuukkah wrote:
| > _dies from lung cancer that could have been detected early
| but NICE said the 50GBP test isn't cost-effective._
|
| It would be awesome if in cases like this, the doctor would
| suggest the patient to pay this 50GBP out of their own
| pocket.
| axg11 wrote:
| Compare the UK vs. US [0]: life expectancy is higher in the
| UK _and_ expenditure is lower. As much as people love to dunk
| on the NHS, population-level optimization works.
|
| [0] - https://ourworldindata.org/grapher/life-expectancy-vs-
| health...
| refurb wrote:
| I'd be very cautious assuming 100% of life expectancy
| differences are due to healthcare system alone.
| nradov wrote:
| The UK has a lower obesity rate than the USA (although
| still relatively high compared to other developed
| countries).
| bell-cot wrote:
| Amusing Idea: Let people apply for "Always Full Diagnostics"
| status, and accept ~0.01% of the population. The "lucky" AFD's
| would get every test, scan, biopsy, follow-up, exploratory
| surgery, etc. that was remotely plausible. The anonymized results
| from all those (mostly unwise) things would be a gold mine of
| public health data. And I suspect there'd be more than enough
| obvious adverse outcomes to convince most of the other ~99.99%
| that "more is better" does not apply to medical diagnostics.
| mdrzn wrote:
| I am in a similar boat, I _feel_ healthy but I would like to do a
| full body and blood checkup to know if there 's anything coming
| down the line or if anything's out of order at the moment but I
| do not yet know.
|
| 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.
| swayvil wrote:
| You imply an interesting assertion.
|
| _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_
| mreiner wrote:
| From what I understood about how the system works in most
| European countries:
|
| 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?
| edarchis wrote:
| That's all nice but we used to recommend systematic PSA screening
| for all males over 50. We later realized that there was a lot of
| false positives and that the intervention often brought more
| risks than it cured actual cancers. So it's only recommended for
| patients with risk factors.
|
| 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.
| a_c wrote:
| What about the other extreme, let everyone do all the tests
| imaginable? Or course it doesn't make sense. The balance is on
| how mych evidence available before a test is suggested. Evidence
| is the incident rate among the population and the false negative
| rate(specificity). I'm using very loosely defined terms here
| because I'm too lazy to quote the definition. But no need false
| dichotomy.
| gumby wrote:
| There is an easy fix but nobody would stand for it: do full
| longitudinal surveillance of all tests. That is, the gent with
| the "narrowed" arteries could be followed to see if it becomes a
| problem (a lot of the metrics are, to simplify, fairly arbitrary
| and based on a small observational _n_ ). Perhaps he does have a
| stroke, perhaps not.
|
| Of course no one would stand for such an intrusive system. But
| over time it _would_ improve diagnosis.
| cryoz wrote:
| > the gent with the "narrowed" arteries could be followed
|
| How exactly would you follow? Stress testing, angiography,
| cardiac MR, CCTA??
| SemanticStrengh wrote:
| anonymised data about prescription correlations and symptom
| metrics is the #1 missed opportunity of mankind progress. The
| tragic fact is, for most drug we have zero clue what they're
| doing to your body after a 6month-1 year period, nor do we know
| what do the combinatorial explosion of polypharmacical
| interactions do. There are people currently living the dream of
| increased lifepsan/healspan by getting lucky on that
| pharmacological lottery ticket and other (most) are living the
| invisible damage nightmare.
| gumby wrote:
| There's a baseline issue here which is insurance companies and
| actuaries.
|
| 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.
| SemanticStrengh wrote:
| in countries that have public paid medicare (such as France) it
| really shows that it leads to a strong lag in adopting modern
| medical practices and drugs. I'm not advocating against free
| medecine, however this limitation should be more highlighted
| than it currently is. Too many people think they're getting the
| best treatment..
| pfortuny wrote:
| Same here in Spain "the best medical service in the world"
| (as all piliticians boast, from left to right and back
| again).
| SemanticStrengh wrote:
| Make medecine great again /s
| gumby wrote:
| That kind of lag is not always a good thing. I'm OK with
| medicine not being an early adopter domain.
| SemanticStrengh wrote:
| The patient should have a right to be an early adopter if
| he wants to. Besides, drugs will never leave alpha status
| if we never let them flow on the market. Although yes
| obviously a gradually titrated A/B testing scheme would be
| much more reasonable than the current illegal/legal shift.
| Moreover cf my other comments, anonymised statistics are
| needed.
| PragmaticPulp wrote:
| I hear this repeated a lot but it's not necessarily true.
|
| 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.
| hammock wrote:
| You got scammed. Sounds like you know that. I've seen
| functional medicine docs like this too, it's a part of their
| business model to sell you overpriced supplements that they
| get kickbacks from.
|
| 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.
| Spooky23 wrote:
| Yup. Dermatologists are big into this too.
|
| 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.
| gumby wrote:
| > a doctor who was supposedly so prestigious that she didn't
| accept insurance.
|
| 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.
| kyleee wrote:
| why do you bring your dog to a doctor visit?
| SemanticStrengh wrote:
| More generally I had read on HN a while ago that this is the
| reason why doctors don't do a Full-body radiography/scan. Because
| many humans have bugs/anomalies that are mild/non-issues but are
| ambiguous and anxiety prone. The latter (and most salient reason
| tragically) is that the doctos by covering much more data, would
| become legally responsible for not seeing (e.g. a tumor found in
| a place that wasn't the tissue/region target of the original
| investigation) I find those really sad and I want to have a whole
| body radio (and disclose that I take the anxiety cost willfully
| and that I abandon my right to sue the doctor for this specific
| radio), is it possible? Is there a place where this can be done?
| thaeli wrote:
| In the US, many "concierge" doctors (the ones who don't take
| insurance) will order this type of scan if you want it.
| SemanticStrengh wrote:
| I wasn't aware, how does that even work, radio machines can
| fit a whole body field of view? Thx I'm in EU unfortunately.
| JumpCrisscross wrote:
| > _how does that even work_
|
| 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.
| SemanticStrengh wrote:
| > Costs a couple thousand dollars
|
| Why such scaling with the size? Pure greed? The guy has
| mostly to push a button..
| cryoz wrote:
| A radiologist would need to interpret the MRI.
| SemanticStrengh wrote:
| 1) well 1000 dollar per hour seems like a non-reasonable
| price.
|
| 2) one should have a legal right to command a MRI scan
| without paid analysis.
| JumpCrisscross wrote:
| > _1000 dollar per hour seems like a non-reasonable
| price_
|
| 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.
| AnIdiotOnTheNet wrote:
| > Google Query: cost of an MRI in India
|
| > 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.
| JumpCrisscross wrote:
| > _Why does an MIR cost $5k?_
|
| 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.
| SemanticStrengh wrote:
| answering you next comment since HN has a lag.. I don't
| think american radiologist read this paper
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265198/ but
| hey one can hope the myth that occidentals are better
| trained, it might be actually true who knows
| AnIdiotOnTheNet wrote:
| $5k is a number that's been thrown around in this thread
| so I guess it stuck in my head.
|
| > 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.
| JumpCrisscross wrote:
| > _this expense was inherent to the machine and had
| little to do with cost of related labor_
|
| 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/I
| L9.pdf
|
| [2] https://news.ycombinator.com/item?id=31449409
| [deleted]
| AlphaOne1 wrote:
| The question that needs to asked though is: what would you do
| with that information? Would you be willing to undergo biopsy
| (which is the standard for diagnosis) knowing there is a non-
| zero risk of complication. What if the biopsy is not
| conclusive? Do we then do a major surgery which includes risk
| of death? Imaging is NOT diagnostic for tumors. For most
| lesions, you have to take tissue samples.
|
| Disclosure: I'm a pathologist.
| SemanticStrengh wrote:
| > what would you do with that information? Well for starters
| anyone should check he has the right number of each organ,
| and at the right place (not ectoplasmic), and that their
| shape and volume is not pathologic. You should also check
| your bones joints to check wether you have metallic
| accumulation or not. It's not just about tumors. In any
| cases, there are generally many possibles diagnosises that do
| not involve a biopsy, such as blood/urine/lymph/fecal
| biomarkers, and DNA testing. In some cases you might even
| consider biofluorescence. Secondly, if a thing look like a
| tumor, I would study the risk and if very low I would proceed
| for a biopsy (risk seems OK) or otherwise use
| anticarcinogenic drugs. I would not proceed to a risky
| surgery unless necessary though, especially in an era where
| potent anticarcinogenic exists such as PNC-27
|
| BTW it's very cool that this is a thing>
| https://www.nlm.nih.gov/research/visible/getting_data.html
| norswap wrote:
| > If you do a CT scan and it shows a mass, you'll order a biopsy.
|
| > 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.
| gpt5 wrote:
| The author is not arguing against efficiency in the medical
| system, but against the reasoning of - "if we test for X bad
| things will happen"
| j-pb wrote:
| In a "perfect world" we'd all get routine checks, this would
| have two advantages:
|
| * 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.
| cryoz wrote:
| Why do the CT scan in the first place if you are not going to do
| a biopsy if you find something?
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