[HN Gopher] TV doctors say annual checkups save lives. Real doct...
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TV doctors say annual checkups save lives. Real doctors call
bullshit
Author : paulpauper
Score : 43 points
Date : 2023-05-27 20:08 UTC (2 hours ago)
(HTM) web link (www.vox.com)
(TXT) w3m dump (www.vox.com)
| lr4444lr wrote:
| Uh, no. Hypertension is a silent killer. Mole checks?
| Colonoscopies? Testicular cancer screenings? These are all
| worthless? Preventative medicine has a long way to go, but it's
| currently the best it's ever been. Thank God I don't see any of
| these doctors.
| tapland wrote:
| Those things are checked and screened for even in places where
| yearly checkups are unheard of.
| crazygringo wrote:
| ...when?
|
| If you're otherwise healthy you're not visiting the doctor at
| all. So where are these checking and screenings happening for
| adults?
| spondylosaurus wrote:
| No joke, getting a colonoscopy was the best decision I've made
| all year. I'm incredibly grateful that my doctor twisted my arm
| into getting one even though I'm under 40 and wasn't thrilled
| about the whole prep situation.
|
| (It was IBD, not cancer, but regardless. One of those things
| you'd rather catch before it lands you in the hospital.)
| zouhair wrote:
| That's different from an annual checkup.
| simfree wrote:
| Regular checkups give your doctor the opportunity to
| encourage you to seek relevant services (like OPs doctor
| did).
| mbostleman wrote:
| According to the study cited, they concede that annual checkups
| result in more diagnosis, but not in a decrease in morbidity.
| What you consider worthwhile, or worthless, is up to you I
| guess.
| massysett wrote:
| So to take this to an extreme, if the cohort that got
| checkups lived a healthy life until age 80, and the no-
| checkup cohort lived with diabetes and dialysis until 80,
| this study would say "checkups lead to no decrease in
| morbidity."
|
| More relevant for the insurer (which might help explain why
| an insurer is urging checkups) living until 80 with diabetes
| and on dialysis is much more expensive than living healthily
| until 80.
| runtime_blues wrote:
| Generally, yes; for example, routine colonoscopies are not
| practiced in many developed countries, and it doesn't
| necessarily translate into any difference in overall health
| outcomes. One recent study is described here:
| https://www.cnn.com/2022/10/09/health/colonoscopy-cancer-dea...
| . One explanation is that such cancers are slow-growing and
| tend to be discovered late in life, so treating them doesn't
| actually help much, and any benefits are offset by potential
| harms of the procedure itself, the risk of false positives,
| etc.
|
| Similarly, while hypertension is a problem, there is scant
| evidence that routine treatment of it is beneficial. The drugs
| have health risks:
| https://jamanetwork.com/journals/jamainternalmedicine/fullar...
|
| There is value in targeted screening and education, but annual
| checkups for otherwise healthy people aren't necessarily the
| way to do it. Not to mention, many of these checkups are
| perfunctory.
|
| A lot of the gains in life expectancy have little to do with
| advanced diagnostics and treatments. Sanitation, hygiene,
| antibiotics, and increased standards of living do a lot of the
| heavy lifting here. And when the needle moves in the other
| direction, the causes tend to be mundane too - e.g., opioid
| abuse in the US.
| haldujai wrote:
| > Generally, yes; for example, routine colonoscopies are not
| practiced in many developed countries, and it doesn't
| necessarily translate into any difference in overall health
| outcomes. One recent study is described here:
|
| This overstates the impact of the Nordic study. If you go to
| the original article[0] you can see why, this study had very
| low participation and event rates which limits how strong of
| a conclusion we can draw from this as treatment effects may
| not be accurately reflected (for example in some countries
| the colonoscopy arm only had 32% participation). We also have
| historical studies looking at gFOBT and flexible
| sigmoidoscopy showing mortality benefits which can be
| extrapolated to colonoscopies. For a full picture of the
| evidence behind colon cancer screening I would suggest
| referring to the USPSTF which provides a publicly accessible
| summary and rationale[1].
|
| With respect to developing countries, colorectal cancer (and
| living long enough to suffer its sequela) is mostly a
| developed country problem although this is changing.
|
| In recent years, we have been seeing a surprising rise in
| colorectal cancer rates occurring at younger ages presenting
| with advanced disease which has led to the USPTF lowering the
| recommendation for screening to 45 from 50. With this trend
| in mind and historical data, we would really need extremely
| strong evidence to make the claim that screening
| colonoscopies are ineffective which the Nordic study does not
| provide.
|
| > Similarly, while hypertension is a problem, there is scant
| evidence that routine treatment of it is beneficial.
|
| This is just boldly incorrect and a VERY dangerous statement
| to make. The article you link to is entirely irrelevant as it
| looks at _acute_ hypertension which is a very different
| beast, this article is describing what we call _permissive
| hypertension_ in medicine. We have known for several years
| now that we do not need to tightly control inpatient blood
| pressures (which are often temporarily increased due to
| stress /illness) and that doing so is harmful. This says
| nothing about the consequences of untreated chronic
| hypertension in the outpatient setting.
|
| For treatment (beyond the scope of USPSTF which does provide
| a grade A recommendation for hypertension screening) we can
| turn to the ACC[2] which also helpfully provides an evidence
| synthesis specifically drawing your attention to:
|
| "In a meta-analysis of 61 prospective studies, the risk of
| CVD increased in a log-linear fashion from SBP levels <115 mm
| Hg to >180 mm Hg and from DBP levels <75 mm Hg to >105 mm Hg.
| In that analysis, 20 mm Hg higher SBP and 10 mm Hg higher DBP
| were each associated with a doubling in the risk of death
| from stroke, heart disease, or other vascular disease."
|
| [0] https://www.nejm.org/doi/full/10.1056/NEJMoa2208375
|
| [1] https://www.uspreventiveservicestaskforce.org/uspstf/docu
| men...
|
| [2] https://www.ahajournals.org/doi/full/10.1161/HYP.00000000
| 000...
| JCM9 wrote:
| These are different and called "preventative screening" and
| usually not done at a physical. Your GP isn't going to do a
| colonoscopy or do a skin check. The article is taking issue
| with the standard physical, which for heathy people is mostly a
| few questions to ask if you feel alright and some routine blood
| tests.
| winrid wrote:
| Most of my medical issues I caught were do to me being proactive.
| Even HMO is very lax in actually taking care of people.
| bigthymer wrote:
| > Even HMO is very lax in actually taking care of people.
|
| Makes sense. The premium\cost is largely already paid so the
| less work is done, the higher the profit. It is FFS where you
| have to be careful about doctors ordering too much work.
| hollosi wrote:
| The real question is why the insurance companies are pushing the
| annual exams very hard, not just in consumer ads, but using lots
| of incentives for primary care physicians.
|
| One would assume they would not want to pay for unnecessary tests
| for healthy people.
|
| So either their own research shows they save money with annual
| checkups in spite of what the article says, or more sinisterly,
| they do want to spend money to be able to justify higher
| premiums, because in several states they are required to spend
| around 80% of the premiums, and this is one easily plannable way.
|
| Does anyone know? Perhaps someone working for an insurance
| company?
| omegadeep10 wrote:
| I work at at a large health insurance company, though not
| involved in decision-making around annual exams or rate-setting
| so take that as you will.
|
| A lot the decision-making we do is around trying to improve the
| health outcomes for large populations of members at scale. When
| dealing with millions of members, interventions that require
| lots of effort and time are hard to scale up. If the data shows
| members with annual checkups have better health outcomes on
| average than members without annual checkups, that is something
| that's relatively cheap and easy to do with potentially
| significant impact.
|
| There are other benefits to annual checkups as well - catching
| an expensive condition early can be the difference between a
| $100,000 episode of care vs. a $10,000 episode of care.
|
| To be honest internally I've noticed the tide is shifting on
| annual checkups. Physician time is limited and every slot is
| valuable. I believe we're currently exploring virtual care
| options as a better alternative.
| whitemary wrote:
| I am an ex-SWE at a major health insurance company, and I
| have a bridge to sell you.
|
| "Improving health outcomes" is corporate PR speak for
| "selling more insurance services." If you know the first
| thing about health insurance and capitalism, reading between
| the lines is easy. I can only assume you are not very
| familiar with these things. Frankly, every single minute of
| every single day at my job, the only thing myself or my
| colleagues worked on was generating more profit for the
| company we worked for. If customers ended up with better
| health, it was a side effect of the profit-making efforts and
| nothing else. Please learn to not believe every damn word
| someone says to you.
| haldujai wrote:
| The groups driving "improving health outcomes" are not
| (just or even mostly) insurance companies but rather
| physician societies and government agencies like the
| USPSTF. We can also look to other national agencies from
| countries with publicly funded systems (Canada, UK, France,
| Australia) which share the same mission statement of
| "improving health outcomes" and have very similar screening
| recommendations as the US does.
|
| The statement is a bit of PR speak, but it's not made to
| sell more products. People working in healthcare generally
| do care about improving health outcomes.
| dividefuel wrote:
| I feel it's a kickback to the companies that provide care.
|
| If I bring up any health issues I'd like to discuss at my
| annual exam, it's billed as a doctor visit because it's no
| longer "preventative" care. For the visit to be free, I have to
| stay silent. It also gives providers an opportunity to
| recommend and order expensive tests or procedures that the
| patient might otherwise not have pursued.
| InvaderFizz wrote:
| Wild speculation is a combination of one insurance company
| offering it and it becoming a relatively low cost competitive
| bullet point on one hand.
|
| On the other hand, insurers probably have better actuarial data
| because of annual checkups and can better align their profit
| margins with fees. Thus reducing their own reinsurance fees.
| londons_explore wrote:
| > insurers probably have better actuarial data
|
| Imagine you are an insurer and advise free annual checkups.
| Some of your patients don't bother. Those patients have a
| higher mortality. You conclude the annual checkup is good.
|
| But you might be deceiving yourself - the kind of people to
| ignore health advice about getting an annual checkup might
| also be the kind of people to ignore the health advice on the
| back of a cigarette packet...
| lostlogin wrote:
| There was a case here in New Zealand where the "not for profit"
| insurance company "Southern Cross" was owned by a group of
| doctors.
|
| It isn't hard to see how something that might not be in the
| insurance company's best interest could be in owners best
| interest, particularly if the own the hospital too.
| arisAlexis wrote:
| This is really a bad article, one that can actually have a net
| negative effect on the world. Vox is trash.
| Retric wrote:
| Conveying accurate information is hardly trash, they're simply
| talking about counterintuitive effects.
|
| Annual checkups for healthy people on average cost as many
| lives as they save. It's better for people to know what kind of
| symptoms they need to seek medical treatment for than simply
| suggest an annual checkup is all that's needed.
|
| I just went to the doctor 2 weeks ago and he said I was
| healthy...
| spondylosaurus wrote:
| > Annual checkups for healthy people on average cost as many
| lives as they save.
|
| How, exactly? What's the risk of death at an annual checkup?
| Hitting your knee a little too hard with the reflex hammer?
| Retric wrote:
| It's not the visit's themselves, though there is some risk
| of contacting disease in a waiting room it's not very high.
|
| However, the effect I mentioned is very real. When someone
| gets a clean bill of health and they are more like to
| ignores symptoms right after the visit. Thus there is no
| spike in heart attacks after a cardiologist visit, but
| there is a spike in people ignoring symptoms afterwards
| resulting in a small spike in deaths from heart attacks.
|
| On top of that medical procedures like biopsies carry risks
| and healthy people going for an annual physical are vastly
| more likely to have unnecessary procedures done.
| Spivak wrote:
| "True but misleading."
|
| Telling people information in a manner that leads people into
| take the wrong conclusion from it -- "they're useless stop
| going to them" is really dumb.
|
| You can say damn near anything citing only true information
| along the way.
| Retric wrote:
| Healthy people shouldn't have an annual physical.
|
| That is 100% the correct messaging. There is age related
| things that should be checked regularly but a healthy 22
| year old doesn't benefit from an annual physical. It's not
| just a waste of money but also an unnecessary strain on the
| medical system.
|
| Under the age of 50 and in good health, every 3 years is
| fine at 50 once a year. Data suggests even that may be
| excessive but it's still better than every year.
| Spivak wrote:
| Yes but this already happens, my dad was told by his
| primary at 25, "you look good, see you when you turn
| forty." If your insurance is paying for them it's for
| whatever bean and counting reason they want and they pay
| you not insignificantly to do it.
|
| So if your doc schedules them, usually because you're a
| woman and age related care starts at like 25 go to them,
| and if your insurance pays you to go, go. And generally
| it's an uphill battle to get men to go to the doctor at
| all because obviously they're "healthy" so I can't really
| bemoan the "unnecessary" visits.
| wilg wrote:
| You gotta say why they're wrong so we can evaluate it.
| haldujai wrote:
| This is a bit of a loaded topic and the authors are
| intermittently conflating "annual physical" with what is now
| better called a "periodic health maintenance visit".
|
| Aside from semantics, a periodic health maintenance visit is
| intended to provide an opportunity for age-appropriate evidence-
| based screening and preventive counselling as well as minimizing
| loss to follow-up and missed screening opportunities (pandemic-
| related patient access issues has been a great reminder of why
| screening is important). How often and when to do this is
| debatable, but specific tests have recommendations (the USPSTF is
| a great source).
|
| In contrast, palpating an abdomen in the hopes of
| opportunistically catching an asymptomatic tumor or putting a
| stethoscope on someone's neck to listen for carotid artery
| narrowing as part of an annual screening physical exam is
| arguably negligent and homeopathic at best. Other than blood
| pressure and BMI, I can't think of another component of the
| physical exam that would have potential clinical utility in an
| asymptomatic patient (granted my residency days in primary care
| are many years behind me now).
|
| Using the article's example of an abdominal aortic aneurysm, we
| have evidence-based recommendations on screening[0] which notably
| do not include a physical exam.
|
| Current recommendations (expert opinion, weak evidence) for
| periodic health visits will vary but are typically something like
| every 3-5 years for patients < 49* without chronic conditions and
| annually > 50 which coincides with roughly when we start to
| screen for most malignancies and worry about cardiovascular
| disease. There are many safe and useful investigations (e.g.
| colon cancer screening, cholesterol) and interventions (e.g.
| vaccines) that can be done in this visit so calling an annual
| visit 'bullshit' is facetious although this is very accurate for
| the physical part.
|
| *Women between 40-49 should also be getting an annual mammogram
| although this does not necessarily need an associated visit.
|
| [0]
| https://www.uspreventiveservicestaskforce.org/uspstf/recomme...
| astrea wrote:
| So what's the alternative? Just wait until something bad happens
| to come in? Seems a lot more unproductive.
| dogma1138 wrote:
| I think this isn't about specific screenings rather than the
| most basic physicals people get.
|
| Screenings for specific diseases like cancer and regular blood
| checkups do definitively catch things early.
| chx wrote:
| So if this article is not against regular blood checkups then
| what...?
| xboxnolifes wrote:
| ""From a health perspective, the annual physical exam is
| basically worthless," Zeke Emanuel, an oncologist at the
| University of Pennsylvania, has written after reviewing the
| research.
|
| "Almost nothing in the complete annual physical examination
| is based on evidence," Michael Rothberg, who directs the
| Cleveland Clinic Medicine Institute Center for Value-Based
| Care Research, wrote in the esteemed Journal of the
| American Medical Association in 2014. "Why, then, do we
| continue to examine healthy patients?""
| crazygringo wrote:
| But I would never get screened or do blood work if it weren't
| at my annual checkup.
|
| Your annual physical is where those things happen, or get
| scheduled.
|
| That's what baffles me about this article. My annual checkup
| is pretty much the only time I ever see my doctor at all.
| searealist wrote:
| Or maybe it's exactly the same?
| wkat4242 wrote:
| Well.. I don't know. Early detected illness is usually much more
| easily treated and has much less serious effects.
|
| When I read this counterargument:
|
| > Rothberg, the Cleveland Clinic physician, wrote a journal
| article about his father's experience a decade ago, when an
| annual checkup triggered a number of follow-up tests that cost
| $50,000 and ended up doing more harm than good.
|
| Well, yeah... Not every country has a crazy overpriced healthcare
| system like the US where minor problems cost thousands. Also this
| sounds very much like a 'worst-case example'.
|
| Here in Spain everything is free. Yes, the state pays for it, but
| the state also pays for treatments that will be more expensive
| when things get out of hand. And a yearly check is pretty
| standard and even required by employers. It has happened twice
| that they found a problem in my blood check. Both cases it was
| nothing but if it had been, knowing it early could have saved my
| life.
|
| > In the physical, the doctor used his hands to examine the
| patient's stomach. He thought the aorta felt a bit enlarged there
| and might be an abdominal aortic aneurysm. This led to a cascade
| of tests -- even though the patient turned out not to have an
| aneurysm -- and during one, he nearly bled to death.
|
| Yes medical tests can go wrong. But a scan would have been a much
| safer option here than just to go poking around.
|
| > This means that in the midst of a primary care shortage in the
| United States, doctors are spending several hours on visits that
| evidence suggests are a waste of time and could be harmful.
|
| A primary care shortage should be fixed. Not used as a reason to
| not do checks. Especially in older people cancer is one of
| leading causes of death.
| simfree wrote:
| Physical manipulation is cheaper than a scan tho!
|
| Besides, the insurance would only cover a brisk walk by the
| general vicinity of an MRI machine:
| https://www.youtube.com/watch?v=0URHKdXMmwo
| wilg wrote:
| My assumption is that this is wrong but I guess I can't find any
| evidence that disputes this conclusion. Seems like the AMA
| doesn't recommend them or anything. Surprising!
| synaesthesisx wrote:
| A big problem with healthcare is it tends to be reactive rather
| than proactive; folks generally tend to seek out care only when
| they're having issues.
| searealist wrote:
| What does proactive medicine look like? Or do you just mean
| eating healthy and exercising? Everyone knows you should be
| doing that.
| rqtwteye wrote:
| Correct. Proactive medicine would be to prescribe a healthy
| lifestyle that's customized for an individual. Traditional
| medicine like Ayurveda tries to do that. It's kind of
| baffling that western medicine doesn't really think like
| that.
| haldujai wrote:
| Medicine does care about prevention, in fact we have the
| USPSTF who's sole focus is prevention!
|
| With respects to diet and activity, there is a grade C
| recommendation to provide counseling to patients without
| risk factors[0] and grade B for those with risk factors[1].
| Both (as with all USPSTF recommendations) have associated
| evidence summaries and provide rationales for the strength
| of the recommendations.
|
| [0] https://www.uspreventiveservicestaskforce.org/uspstf/re
| comme...
|
| [1] https://www.uspreventiveservicestaskforce.org/uspstf/re
| comme...
| fooker wrote:
| It's data driven.
|
| You get tested every few years and adjust
| diet/supplements/exercise based on the findings.
| lostlogin wrote:
| The devil is in the detail.
|
| > It's data driven.
|
| Good.
|
| > You get tested every few years
|
| Not always good. Many screening tests just increase
| unnecessary procedure except in very specific situations.
| Eg MRI screening generates a ton on unnecessary biopsies
| and associated complications, stress.
|
| The data says when screening is appropriate, so as you say,
| use the data.
| zouhair wrote:
| Random screening are more harmful than useful.
| Overdiagnosis[0] is a thing.
|
| [0]: https://en.wikipedia.org/wiki/Overdiagnosis
| duffpkg wrote:
| I think there are valid questions about the medical efficacy of
| annual checkups that are heavily weighted by individual patient
| characteristics such as existing conditions, age, weight, etc.
|
| Seperate from medical efficacy there are a lot of reasons why
| insurers want you to have an annual visit with a medical provider
| which has to do with:
|
| 1) Assignment of you to a provider. Many, many people are
| autoassigned a primary care provider by their insurance, they
| often change this when they actually schedule a visit. Allocation
| of patients to providers is a very large aspect of manging health
| plans.
|
| 2) Data aggregation and validation of your information. People
| sign up with unbelievably garbage information and it tends to
| persist, even on employer provided plans.
|
| 3) Baseline medical status such as weight and vitals. Insurers
| aren't looking at this information directly but it comes through
| via billing codes for the exact types of exceptional cases
| insurers want to measure.
|
| These have a huge impact on the actuarial aspects of developing
| and managing health plans.
|
| PS: Depending on the patient pool, for lots of pools insurers no
| longer put much economic weight into prevention as it has played
| out that insurers end up paying for the prevention but patients
| change insurers so often that they change before the insurer
| benefits from the effects of the prevention. Incentives are a
| very messy thing in healthcare between patients, providers and
| insurers.
| neon_electro wrote:
| (2016)
| adhesive_wombat wrote:
| I can also see why people like it when getting an "unplanned"
| appointment takes weeks and you have to do telephonic battle with
| a Combat Receptionist daily at 8am until you get a slot.
| [deleted]
| golemiprague wrote:
| [dead]
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