I just wanted to drop a line and thank the entire sensible medicine group for providing such great content. I am a 6th yr MD/PhD student and have been an avid podcast listener since you all started. I really appreciate the critical discussions and I love the Friday reflections. Keep up the good work, you all inspire me to work to be critical and thoughtful about medicine and research.
People seem to enjoy living at a doctor’s office. That is not living to me.
I am a gastroenterologist who performs colonoscopies, mainly for screening and surveillance. I am starting to feel like a hypocrite bc I’m not really sure I’m helping anyone.
I have not had colon cancer screening myself at age 54. I literally don’t care. 5% lifetime risk of colon cancer is not worth all the rigmarole to me
I’m sure this will cause any GI on here to have a stroke.
People don't enjoy living at the doctor's office but sometimes the fear of a bad health outcome and unfair healthcare marketing can drive the ill-informed consumer to the clutches of a physician who is the hammer that sees all nails.
I'm also past the age of colon cancer screening as a physician and it's not because I don't care, in fact, I care a lot, which is why I haven't gotten screened yet.
I don't get the point of this article. If as a patient you keep looking, you will eventually find ... something ... no matter how clinically relevant or irrelevant. The horse is out of the barn. Every for-profit entity is pushing "preventative" "well-being" medicine as a commodity. So expect people to show up at the clinic with greater frequency with some "findings" from recurrent unregulated often unnecessary testing based on anecdotes to prevent death. No one wants to die. Iatrogenic harms be damned. However, it would be interesting to know how much the government pays out for medical misadventures driven by the for-profit sector.
I was surprised not one of the hypothetical vignettes included a procedural or treatment complication. These are really the best case scenarios for erring on the side of being seen to be “doing something”.
While the absence of evidence of benefit is not the same as the evidence of absence of benefit, it also seems that the incontrovertible evidence of benefit in all these cases has only accrued to the treating physicians.
GJTL is correct. BUT it can teach the wrong thing. As physicians and economists know, there is no such thing as 100% or 0%. Advocates of a policy that research has shown hurt the majority of the population, can always find that person in the 1% of the population to tell their story to policy makers. As someone who advocates evidence-based policies, it is difficult for us to find the 99 people who benefit from the policy. So we use stories AND data.
If Bill has UnitedHealthcare, his new diagnosis of peripheral arterial disease will mean big bucks for his insurance company! They will be thrilled. UnitedHealth Care will get about $2,500 extra dollars from CMS. Save themselves the trouble of a home visit.
“The corporation views patients as entities that have money attached to their bodies,” said Michael Good, a retired physician who worked at a Connecticut practice where UnitedHealth tested older patients with the device, called QuantaFlo. “They want to use the clinicians to mine the money that lies within the bodies of the patient.”
The unnecessary screening may have served no purpose for Bill or his physician, but it sure helped UnitedHealth. So there's that.
It's not quite the same thing as population-based screening, but it has always been quite surprising to me how few people get tested for Huntington's when they know they are at risk.
-my psychiatrist uncle once said the problem with screening is people live longer and with all the disease being treated along the way. Before screening, people got sick and died; we saved a lot of money pre-screening days.
-my mom was a DNR at one point in her life (PMH complicated for oral CA treated with radiation, post op back surgery staph infection with nonhealing wound due to malnutrition as a result of oral CA treatments that then resulted in osteomyelitis from a secondary infection into her neck at the are of radiation damage, AFib and CHF caused by a meniscectomy in which she was dehydrated due to lack of saliva (due to oral CA treatment) and water restrictions prior to surgery. So when the docs wanted to do cardiovascular studies (after she contracted Afib and CHF post op which both resolved with proer medical treatment), I asked her if they find something did she want surgery? And since she had many years of battling to live after her oral CA treatments, she said no. She strangely and beautifully died of a heart attack 6 months later. It was quick, she did not suffer. Thank God because she had 17 years of suffering after oral CA diagnosis and treatment. I am not sure if she knew the amount her life would be negatively and irreparably impacted by oral CA treatment that she would have had treatment. I think she would have smoked herself to death and traveled the world until she died.
-93 yo friend whose PMH was significant for colon cancer 20+ years ago, diabetes controlled with insulin, gets all the screenings, carotid arteries, skin cancer etc; her PCP wants her to get bone mass density test and also cardiac screening because her voice is weak and thinks she needs a pacemaker (based on what information I have no idea). I scratch my head because at 93 what would you do if you now found she had osteoporosis? Maybe her voice is weak because she has had silent reflux burning her vocal cords for many years (she is 83!), or because she is losing height and sits a lot and slouches so her voice is weak due to her diaphragm and core being compromised? And at what point do we say some of this is normal at 93? And this 93 yo woman also worries about her credit rating! I am not sure what she needs a credit rating for since she isn't planning on buying anything that would require credit beyond $1000. So I guess the fears get embedded early and we take them with us as we age.
-and then there is the person who gets osteoporosis treatment and ends up with bone degradation to the point of nonhealing fractures and a fracture that was spontaneous; maybe this person would have benefitted from a gut consult, proper dietary changes, weight bearing exercise, sunshine and fresh air because now her bones are fracturing while being post-op nonweight bearing! And the fracture is above and away from the surgery redo for the fixation of the non-healing fracture. And this probably is the segment of the population that says thank goodness I took those osteoporosis meds, imagine if I hadn't!
exactly right. At 93 y/o, the less you interact with the medical system and stay in good balance on your own, the better you are. Not a time for "screening"
Couldn't agree more I can't tell you how many times I had 90 yo + patients show up for screening mammography, some for the first time. I would send them out the door without the study withe advice that the next time they had the urge to have a screening mammogram, go have an ice cream sundae instead! For heaven's sake if you get to over 90 without consulting us, for goodness sake, don't start now. There's no question we can do a lot of harm.
But when is a good time for screening? Sounds like "Never." . . . When one sees blood in one's urine and goes to the doctor, I don't think we call that "screening."
Screening makes sense at certain ages, when the condition is common enough, life left to live is reasonably long enough (most screening recs suggest "10 years"), and we have an appropriate test. very late 80s and 90s is not a time for "screening" - and frail elderly bodies are high risk for adverse events and side effects. The more they stay independent and have good quality of life on their own, per their own habits, serves them best.
And you are correct - evaluating symptoms is an entirely different issue and is not considered "screening"> there is no age limit to evaluating symptoms (though treatment options not appropriate for everyone).
There are some standard screening tests that I think people within those age parameters should consider and discuss with their doctors (I certainly recommend screening!)
Often, the silent harm is there, but the patients (who survive the treatment) think they had great care, and that they owe their survival to what was probably unnecessary treatment.
These cases are great for showing the nuances of medical management. The data generated by medical studies will always be at a population level. The art is in applying it to the patient in front of you, i.e., discussing risks vs. benefits and patient values before ordering additional tests.
Cancer screening is especially fraught due to the high chance of morbidity and mortality. This invokes emotional responses, and we often don't factor in the best available evidence, leading to impaired judgment. I have many people in my practice who have been treated for "cancer" that was likely overdiagnosed. These patients feel that the oncologist/surgeon saved their life—and in a small fraction of cases, this is probably true. However, many of them are now living with side effects of treatment such as neuropathy or incontinence.
Additionally, quality metrics force providers to perform screenings without having a risk-benefit discussion, leading to overdiagnosis and overtreatment. This becomes the new norm and changes patient expectations (like the last patient mentioned). In turn, this makes the doctor's job much harder as it takes longer to make nuanced decisions during an office visit. Busy providers then fall back on ordering tests as they meet quality metrics, take less time, lower the risk of medico-legal liability, and reduce the chance of losing the patient. This vicious cycle continues.
Another challenge is that we call our profession "healthcare." It should be called "medical care," as we are good at treating illness. Health begins "where you live, work, and play." I wrote about this in my first article, "From Doctors to Social Workers" https://www.pcplens.com/p/doctors-to-social-workers?r=5c1wm.
As humans we seem to put a lot of faith in the anecdote. I am non-clinical and work in a national bowel screening program. I’ve read the literature and have the data from the program, and it seems at a population level useless and a very poor investment.
I like your comment that calls for calling it medical not healthcare. Health is avoiding medical care until nessecary. Unless I have known factors or suspicions - as I age I’m choosing to skip screening.
That was a well laid out showing of what medical advice can do. It works in reverse too. I've had to tell families that their loved one has weeks to live not months and years as the doctor said. Those were the cases where MDs were uncomfortable telling the truth and passed the buck. As for me? I don't want to know, I want no tests, leave me alone. Now should I be in the throes of extensive s/s of a disease, then test me, let me know what it is, and let me go on living my life till I can't.
I am a case that makes one scratch their head and rethink all of these. I’m 61. About a year ago I had a screening mammogram and they called me back to recheck a suspicious area. I thought “oh great, another radiology revenue enhancement opportunity.” It was actually a 1.8 cm invasive ductal carcinoma. My breast surgeon heard my concern for my daughter, whose father’s family has very concerningly high rates of breast and ovarian cancer and ordered genetic testing, even though I meet zero criteria for the testing ( my paternal grandmother had breast cancer in her 60’s, but that’s it). I have a BRCA2 mutation. Fortunately, because my tumor was found early, my disease has been managed by surgeries both for treatment and prevention and aromatase inhibitors, but no chemotherapy or radiation. My 26-year old daughter was recently tested and diagnosed with the same BRCA2 mutation, inherited from my father, a healthy 90-year old. Yesterday, she saw a physician who specializes in management of heritable cancers and hopefully, with the guidance that provides, will avoid cancer diagnoses in her future.
Yesterday, I also read a JAMA paper from September 2023 that posits that sentinel lymph node biopsy did not provide benefit in women who have small (<2 cm) breast tumors and no lymph node mets obvious on ultrasound. My tumor was 2 cm and no mets were seen on ultrasound of the regional lymph nodes. At surgery my breast surgeon did do a sentinel lymph node biopsy and one of 3 nodes taken had a 0.5cm metastasis. In a subsequent surgery, 13 more nodes were taken with no more tumor cells found. Again, I have avoided both chemotherapy and radiation.
I understand that statistics don’t relflect every individual. But I am here and healthy because my doctors treated ME, not the statistics.
Totally agree! I’m against medical professionals trolling in my body to find something to do to pay for the boat. Many of my friends choose to center their lives around visits to the doctor. It’s kind of a hobby that replaces working out at the gym. 😏
I just wanted to drop a line and thank the entire sensible medicine group for providing such great content. I am a 6th yr MD/PhD student and have been an avid podcast listener since you all started. I really appreciate the critical discussions and I love the Friday reflections. Keep up the good work, you all inspire me to work to be critical and thoughtful about medicine and research.
For many, the tests usually bring anxiety and a treatment that while it may reassure some, actually does not extend life or its quality significantly.
Statins are the most prescribed drug in America 96 MILLION people take them, yet heart disease is our number one killer.
That sounds like a painfully poor tradeoff!
Hello!!
People seem to enjoy living at a doctor’s office. That is not living to me.
I am a gastroenterologist who performs colonoscopies, mainly for screening and surveillance. I am starting to feel like a hypocrite bc I’m not really sure I’m helping anyone.
I have not had colon cancer screening myself at age 54. I literally don’t care. 5% lifetime risk of colon cancer is not worth all the rigmarole to me
I’m sure this will cause any GI on here to have a stroke.
People don't enjoy living at the doctor's office but sometimes the fear of a bad health outcome and unfair healthcare marketing can drive the ill-informed consumer to the clutches of a physician who is the hammer that sees all nails.
I'm also past the age of colon cancer screening as a physician and it's not because I don't care, in fact, I care a lot, which is why I haven't gotten screened yet.
I don't get the point of this article. If as a patient you keep looking, you will eventually find ... something ... no matter how clinically relevant or irrelevant. The horse is out of the barn. Every for-profit entity is pushing "preventative" "well-being" medicine as a commodity. So expect people to show up at the clinic with greater frequency with some "findings" from recurrent unregulated often unnecessary testing based on anecdotes to prevent death. No one wants to die. Iatrogenic harms be damned. However, it would be interesting to know how much the government pays out for medical misadventures driven by the for-profit sector.
Actual case reviews are one of the best teaching methods.
I was surprised not one of the hypothetical vignettes included a procedural or treatment complication. These are really the best case scenarios for erring on the side of being seen to be “doing something”.
While the absence of evidence of benefit is not the same as the evidence of absence of benefit, it also seems that the incontrovertible evidence of benefit in all these cases has only accrued to the treating physicians.
GJTL is correct. BUT it can teach the wrong thing. As physicians and economists know, there is no such thing as 100% or 0%. Advocates of a policy that research has shown hurt the majority of the population, can always find that person in the 1% of the population to tell their story to policy makers. As someone who advocates evidence-based policies, it is difficult for us to find the 99 people who benefit from the policy. So we use stories AND data.
If Bill has UnitedHealthcare, his new diagnosis of peripheral arterial disease will mean big bucks for his insurance company! They will be thrilled. UnitedHealth Care will get about $2,500 extra dollars from CMS. Save themselves the trouble of a home visit.
“The corporation views patients as entities that have money attached to their bodies,” said Michael Good, a retired physician who worked at a Connecticut practice where UnitedHealth tested older patients with the device, called QuantaFlo. “They want to use the clinicians to mine the money that lies within the bodies of the patient.”
The unnecessary screening may have served no purpose for Bill or his physician, but it sure helped UnitedHealth. So there's that.
For many, the tests usually bring anxiety and a treatment that while it may reassure some, actually does not extend life or its quality significantly.
Statins are the most prescribed drug in America 96 MILLION people take them, yet heart disease is our number one killer.
That sounds like a painfully poor tradeoff!
It's not quite the same thing as population-based screening, but it has always been quite surprising to me how few people get tested for Huntington's when they know they are at risk.
I could go on here and will try not to:
-my psychiatrist uncle once said the problem with screening is people live longer and with all the disease being treated along the way. Before screening, people got sick and died; we saved a lot of money pre-screening days.
-my mom was a DNR at one point in her life (PMH complicated for oral CA treated with radiation, post op back surgery staph infection with nonhealing wound due to malnutrition as a result of oral CA treatments that then resulted in osteomyelitis from a secondary infection into her neck at the are of radiation damage, AFib and CHF caused by a meniscectomy in which she was dehydrated due to lack of saliva (due to oral CA treatment) and water restrictions prior to surgery. So when the docs wanted to do cardiovascular studies (after she contracted Afib and CHF post op which both resolved with proer medical treatment), I asked her if they find something did she want surgery? And since she had many years of battling to live after her oral CA treatments, she said no. She strangely and beautifully died of a heart attack 6 months later. It was quick, she did not suffer. Thank God because she had 17 years of suffering after oral CA diagnosis and treatment. I am not sure if she knew the amount her life would be negatively and irreparably impacted by oral CA treatment that she would have had treatment. I think she would have smoked herself to death and traveled the world until she died.
-93 yo friend whose PMH was significant for colon cancer 20+ years ago, diabetes controlled with insulin, gets all the screenings, carotid arteries, skin cancer etc; her PCP wants her to get bone mass density test and also cardiac screening because her voice is weak and thinks she needs a pacemaker (based on what information I have no idea). I scratch my head because at 93 what would you do if you now found she had osteoporosis? Maybe her voice is weak because she has had silent reflux burning her vocal cords for many years (she is 83!), or because she is losing height and sits a lot and slouches so her voice is weak due to her diaphragm and core being compromised? And at what point do we say some of this is normal at 93? And this 93 yo woman also worries about her credit rating! I am not sure what she needs a credit rating for since she isn't planning on buying anything that would require credit beyond $1000. So I guess the fears get embedded early and we take them with us as we age.
-and then there is the person who gets osteoporosis treatment and ends up with bone degradation to the point of nonhealing fractures and a fracture that was spontaneous; maybe this person would have benefitted from a gut consult, proper dietary changes, weight bearing exercise, sunshine and fresh air because now her bones are fracturing while being post-op nonweight bearing! And the fracture is above and away from the surgery redo for the fixation of the non-healing fracture. And this probably is the segment of the population that says thank goodness I took those osteoporosis meds, imagine if I hadn't!
exactly right. At 93 y/o, the less you interact with the medical system and stay in good balance on your own, the better you are. Not a time for "screening"
Couldn't agree more I can't tell you how many times I had 90 yo + patients show up for screening mammography, some for the first time. I would send them out the door without the study withe advice that the next time they had the urge to have a screening mammogram, go have an ice cream sundae instead! For heaven's sake if you get to over 90 without consulting us, for goodness sake, don't start now. There's no question we can do a lot of harm.
But when is a good time for screening? Sounds like "Never." . . . When one sees blood in one's urine and goes to the doctor, I don't think we call that "screening."
Screening makes sense at certain ages, when the condition is common enough, life left to live is reasonably long enough (most screening recs suggest "10 years"), and we have an appropriate test. very late 80s and 90s is not a time for "screening" - and frail elderly bodies are high risk for adverse events and side effects. The more they stay independent and have good quality of life on their own, per their own habits, serves them best.
And you are correct - evaluating symptoms is an entirely different issue and is not considered "screening"> there is no age limit to evaluating symptoms (though treatment options not appropriate for everyone).
There are some standard screening tests that I think people within those age parameters should consider and discuss with their doctors (I certainly recommend screening!)
Often, the silent harm is there, but the patients (who survive the treatment) think they had great care, and that they owe their survival to what was probably unnecessary treatment.
Well said.
These cases are great for showing the nuances of medical management. The data generated by medical studies will always be at a population level. The art is in applying it to the patient in front of you, i.e., discussing risks vs. benefits and patient values before ordering additional tests.
Cancer screening is especially fraught due to the high chance of morbidity and mortality. This invokes emotional responses, and we often don't factor in the best available evidence, leading to impaired judgment. I have many people in my practice who have been treated for "cancer" that was likely overdiagnosed. These patients feel that the oncologist/surgeon saved their life—and in a small fraction of cases, this is probably true. However, many of them are now living with side effects of treatment such as neuropathy or incontinence.
Additionally, quality metrics force providers to perform screenings without having a risk-benefit discussion, leading to overdiagnosis and overtreatment. This becomes the new norm and changes patient expectations (like the last patient mentioned). In turn, this makes the doctor's job much harder as it takes longer to make nuanced decisions during an office visit. Busy providers then fall back on ordering tests as they meet quality metrics, take less time, lower the risk of medico-legal liability, and reduce the chance of losing the patient. This vicious cycle continues.
Another challenge is that we call our profession "healthcare." It should be called "medical care," as we are good at treating illness. Health begins "where you live, work, and play." I wrote about this in my first article, "From Doctors to Social Workers" https://www.pcplens.com/p/doctors-to-social-workers?r=5c1wm.
As humans we seem to put a lot of faith in the anecdote. I am non-clinical and work in a national bowel screening program. I’ve read the literature and have the data from the program, and it seems at a population level useless and a very poor investment.
I like your comment that calls for calling it medical not healthcare. Health is avoiding medical care until nessecary. Unless I have known factors or suspicions - as I age I’m choosing to skip screening.
That was a well laid out showing of what medical advice can do. It works in reverse too. I've had to tell families that their loved one has weeks to live not months and years as the doctor said. Those were the cases where MDs were uncomfortable telling the truth and passed the buck. As for me? I don't want to know, I want no tests, leave me alone. Now should I be in the throes of extensive s/s of a disease, then test me, let me know what it is, and let me go on living my life till I can't.
I think you summed up how I feel about screening/testing at this point in my life.
I am a case that makes one scratch their head and rethink all of these. I’m 61. About a year ago I had a screening mammogram and they called me back to recheck a suspicious area. I thought “oh great, another radiology revenue enhancement opportunity.” It was actually a 1.8 cm invasive ductal carcinoma. My breast surgeon heard my concern for my daughter, whose father’s family has very concerningly high rates of breast and ovarian cancer and ordered genetic testing, even though I meet zero criteria for the testing ( my paternal grandmother had breast cancer in her 60’s, but that’s it). I have a BRCA2 mutation. Fortunately, because my tumor was found early, my disease has been managed by surgeries both for treatment and prevention and aromatase inhibitors, but no chemotherapy or radiation. My 26-year old daughter was recently tested and diagnosed with the same BRCA2 mutation, inherited from my father, a healthy 90-year old. Yesterday, she saw a physician who specializes in management of heritable cancers and hopefully, with the guidance that provides, will avoid cancer diagnoses in her future.
Yesterday, I also read a JAMA paper from September 2023 that posits that sentinel lymph node biopsy did not provide benefit in women who have small (<2 cm) breast tumors and no lymph node mets obvious on ultrasound. My tumor was 2 cm and no mets were seen on ultrasound of the regional lymph nodes. At surgery my breast surgeon did do a sentinel lymph node biopsy and one of 3 nodes taken had a 0.5cm metastasis. In a subsequent surgery, 13 more nodes were taken with no more tumor cells found. Again, I have avoided both chemotherapy and radiation.
I understand that statistics don’t relflect every individual. But I am here and healthy because my doctors treated ME, not the statistics.
ETA: so there’s no confusion, the breast mass was 1.8cm. I mistyped the second refermce.
Totally agree! I’m against medical professionals trolling in my body to find something to do to pay for the boat. Many of my friends choose to center their lives around visits to the doctor. It’s kind of a hobby that replaces working out at the gym. 😏