I had a similar mindset as you describe here - but I no longer agree after experiencing long covid. My experience with long covid was made easier because of historical lab data from bloodwork tests that were taken pre-covid when I was a healthy 30 y/o white male. After suffering for months from (what I now know was) long covid, I went in for a checkup for some help.
The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.
Periodic baseline tests are The Correct Answer™. To establish individual patient normals.
Can't manage what we don't measure.
Attention should focus on what's changed. Instead of playing 20 Questions for each new problem. [1]
High LDL? Well, it's always been high, and stable. We don't have to treat it.
Bone spurs (on spine)? Well, most everyone has them and they're not bothering you.
Oh, new sciatica symptoms? Hmmm, looks like you've got a new bone spur which may be impinging. Let's try some PT, get you a standup desk for work, and reassess in 6 months.
Etc.
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Concern trolls claim more testing begets false negatives, begetting unnecessary treatment, which has its own risks.
Fine. Change healthcare from transactional to relational. Change from our current fee-for-service to continuity-of-care (or capitation, prevention, whatever we end up calling it).
Like u/JumpCrisscross says elsethread, only treat anomalous results per new symptoms.
I believe periodic baselines with regular checkups would reduce testing and unnecessary treatments, overall.
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[1] Monitoring, logging, anomaly detection, and RCA... Starting to sound suspiciously like engineering and operations. Of course, some orgs treat each incident as unforeseen one-offs, aka The Condi Rice Defense™. But high functioning teams plan ahead.
> High LDL? Well, it's always been high, and stable. We don't have to treat it.
Only if you particularly want to die of a major adverse cardiovascular event[0], then we don’t have to treat it. Note that treatment begins with lifestyle interventions and not necessarily pharmaceuticals.
We have reference ranges with lab tests for a reason. There is no such thing as a “normal” high LDL and there is growing evidence that statin therapy is beneficial even in those without other cardiovascular risk factors.
Again keeping in mind that lifestyle interventions are the first step. Dismissing dyslipidemia as “stable” is flatly incorrect.
N.B. This evidence synthesis is outdated now but presents the risks in an accessible format, interval evidence is even more supportive of intervention.
Number Needed to Treat (NNT) seems like a great idea. Will learn more. Thanks.
The risk of cherry picking examples is they'd distract from my thesis. So I used two from my own life. I am fail. (Also, I have mo medical training and cannot advise others.)
As for LDL, mine is borderline, I'm very worried, it's unchanged by statins or diet, and I guess the plan is to monitor it. Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux. I'm currently eating buckets of fiber (oatmeal, beans, etc) and misc fish & krill oil, and recently added cocoa butter. Next I'll prob try that Fire In a Bottle stuff (some kind of tea extract).
I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?). And they'd know best, right?
> Number Needed to Treat (NNT) seems like a great idea. Will learn more. Thanks.
No problem, NNT and NNH are the most important measures we look at when deciding on interventions on a population level and easily understandable. "https://thennt.com" is a high quality resource intended for physicians but is fairly accessible to an educated reader and covers many common interventions one may face.
A lot of proposals have sounded great during my medical practice until the numbers come back with a NNT of 100,000 and NNH of 1000.
> Further, the more I read about cholesterol, the more confused I get. It seems to be a topic in a state of flux.
We used to have "LDL target < 2" when I was in training but my understanding is the general consensus amongst experts (and some recent evidence, but not enough to make a general recommendation) points to a stochastic relationship rather than a deterministic one/specific threshold with continued benefit scaling to 0 (found looking at hunter-gatherer indigenous populations).
> I think statins make sense for most patients. A cardiologist friend says everyone in their practice start statins preventatively by age 40 (?).
This is beyond my scope of practice (i.e. don't take this as medical advice) but anecdotally I also recently asked a cardiologist I greatly respect about a family member and his response was similar to what you were told, he started statins himself in his late 30s as male with "normal" cholesterol and no risk factors although the evidence is not yet there to support such liberal use and the guidelines don't recommend this (yet).
Beyond cholesterol reduction statins coincidentally also have plaque stabilizing effects that reduce the risk of MACE.
Given that there is next to zero harm with statin therapy and they're cheap, it seems like a reasonable intervention en masse in my non-domain expert opinion. The diabetes risk was overstated in earlier literature but we have better data now that their use is so widespread, myopathy is a self-limiting nothingburger that goes away when you stop/switch agents.
Personally, I'm planning start a statin soon as well regardless of my LDL levels (typical disclaimer of this is not evidence-based and a personal decision, discuss with your physician etc).
> And they'd know best, right?
Either endocrinology or cardiology would be good experts to ask as they live in this world. I would/did trust a cardiologist when I needed expert opinion on this personally.
> The risk of cherry picking examples is they'd distract from my thesis.
I mostly wanted to address the LDL as that has a strong body of evidence behind it.
The issue with your thesis otherwise is that most tests have no relevance without appropriate clinical context and if they won't change management what's the point?
Consider radiology which is the land of meaningless incidentals, the issue we often face is "oh great, there's an incidental adrenal adenoma on this appendicitis scan that's probably nothing but could theoretically be an adrenal cancer what the hell do we do now?".
A single baseline would often be nice in the sense of if a patient did develop a non-adrenal cancer I could look back and say "oh this was there before, it's not metastatic" but there isn't enough evidence to support this statement considering the potentially life-threatening harms from over-investigating benign findings with biopsies/surgery. This has been the main criticism of whole-body screening MRI but the literature is just starting to come out.
Thanks again. I'll consult my primary about restarting statins.
I forgot to mention a huge reason I support regular baselines of some sort: eldercare.
In the case of our mom, now 85yo, it would have been really useful to have done cognitive assessments and bone density and maybe image likely arthritic joints when she was 65.
Divining when, which, and how much brain pills to give her has been pure guesswork.
And deciphering her chronic back pain has also gone poorly. Resulting in a lot of trial and error. With no real improvement. IMHO. (Experiencing chronic pain myself, I know it's wicked hard to treat.)
Ditto the 3 other elders us siblings have been responsible for. We were just guessing how to best care for them. We didn't know their rate of decline, so weighing risk/benefit was just guesswork. So maddening and wasteful. It really felt cruel and inhumane.
Maybe having better medical history, perhaps in the form of baseline assessments, would have helped.
Hopefully the research you mentioned will help future care givers make better decisions.
Thanks for the informative, thoughtful replies. Peace.
Having baselines is fine, but they don't have to be annual and they certainly don't need to trigger a barrage of tests which are unnecessary at best and potentially harmful at worst.
In somewhere this is where authority fallacy comes into play
People need to push back and ask questions not just accept everything the doctor says at face value..
If I take my car in for routine maintenance and the mechanic comes back with 1000 things they want to do I am not prone to just say "sure do what ever you think is best, you are the expert"
Except physicians don’t practice independently like a mechanic and we answer to several authorities (licensing boards, specialty colleges, hospital M&M and MAC). We follow evidence-based guidelines that have looked at various outcome measures.
It would be malpractice and I would be sanctioned if I were to willfully ignore validated guidelines without strong medical evidence to support me.
It’s a good thing to ask questions but “pushback” suggests an adversarial approach. If you feel like your physician is attempting to fleece you find a different one, in my experience most of us aren’t like that. Physician-patient trust is critical.
If you’re unsure of where to look a good starting point is an academic-affiliated practice which will have more oversight and reimbursement structures that don’t align with over billing.
You point to "several authorities" as meaning the relationship between doctor and consumer should be less adversarial as the doctor then to the mechanic and consumer. as the doctor would have sanctions if they go against that authority, that orthodoxy
to me however that means my personal care is not the only concern, with the mechanic the motives and incentives are clear. With the Doctor they hidden with a split set of masters and at the end of the day the patient is not the primary concern or factor, the Licensing board is, the insurance company is, the government regulators are, but not the patient.
These over lapping authorities you think make the system less adversarial to me makes it more adversarial, as now I have to ensure the motives of your decision making is about me, the patient, and not the government authority that told you what you have to do... not the licensing board, not the insurance company, etc.
See COVID response as a recent example of this, but history is fraught with other examples where patient care suffered under the weight of authority.
this is with out going into the pure corruption that influence many health policies from diet to drugs... Making it less "evidence-based" then I think you are asserting.
I mentioned these as you said “do whatever you think is best” and to contrast with the workflow of a mechanic. I’m not doing whatever I think is best I’m doing what the body of evidence thinks is best, adjusting to specific patient circumstances.
As an aside the “agenda” of these authorities is to ensure we practice safely (i.e. evidence based medicine) in the interest of patient care and not based off our own personal gain or thoughts (as you posited with the mechanic analogy). An example of a sanctionable offense is performing an unnecessary procedure because it pays well, like in your mechanic example.
Where there is no compelling evidence, or when there are unique patient circumstances, I practice with more latitude (e.g. I commonly biopsy lesions that don’t need one when it’s causing patient anxiety and the risks are low, despite not adhering to guidelines, and have no fear of being sanctioned as it is justifiable as reducing anxiety/for the patient’s mental wellness. What I can’t do and will be sanctioned is if I unnecessarily biopsy a benign incidental lesion for the $90).
With respects to insurance and pharmaceuticals I couldn’t care less what their interests are. As part of my job I fight with them routinely and we take industry funded evidence with a grain of salt.
The primary guiding interest in any patient encounter is unequivocally the patient’s health. We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
COVID is a perfect example of why science-based medicine doesn’t work as the response was not evidence based at all, largely because it’s impossible to acquire evidence during a pandemic.
As someone who was critical of the response, you’re right that the authorities limited us (not that I practice primary care) but that period of time was the medical equivalent of martial law. This has been the only period in my lifetime where medical practice was dictated by an authority to such a degree.
Mistakes will happen in exceptional circumstances, most medical encounters are not exceptional. We are also all human.
Pointing out rare exceptions doesn’t disprove the validity of evidence-based medicine or provide evidence of its corruption.
FWIW, I think you're coming from a position of good faith and you do want to see doctors do all they can for the patient's health.
That being said, the structure of medical practice in the US leads to mediocre and expensive outcomes for patients because no one cares to address systemic issues because no one is incentivized to.
> We are explicitly instructed (and obligated) to disregard systems-level issues and concerns in patient encounters.
That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
Another anecdote: my uncle was a doctor in South America and he is appalled whenever he sees doctors in the US. Doctors in the US do not care to learn anything about you beyond your symptoms, vital signs, and blood work. They see you like a car engine and follow a cause and effect flow-chart to decide on a treatment. In South America, he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc. to understand if the patient's self-identified symptoms are consistent with other patients with similar backgrounds. Seeing each patient took more time, but he and his patients were much more satisfied with the exchange than in the US. The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
I think there is a very important distinction to be made. An individual doctor-patient relationship may not be concerned with systemic issues, but that doesn’t mean the overall healthcare system ignores systemic issues. If a patient goes in for care, they deserve to have their symptoms and underlying disease treated, irrespective of the physicians ability to make systemic change.
However, I will say some healthcare systems do try to get to the root causes. Once upon a time, I worked for a healthcare system in a “process engineer” role, for a lack of a better term. There was a team of us, and the whole point was to take a systemic look at healthcare outcomes so we could mitigate root causes that led to less than optimal patient outcomes/quality of care.
> because no one cares to address systemic issues because no one is incentivized to.
I'm not sure that's true having practiced both in the US and Canada which are both very similar. Speaking to my own specialty (radiology) there are several academics working to build evidence to reduce unnecessary and expensive follow-ups that seem to have low clinical utility.
I'll give you an example, current follow-up regimens for pancreatic cysts are unnecessarily long and expensive with very high probability although all societal guidelines (US and international, with the US version actually the shortest) have very long and expensive follow-up recommendations based on limited evidence from Japan and expert opinions.
When I report a pancreatic MRI although I don't personally want to I still recommend "follow-up in one year per ACR guidelines" as that is currently the standard of care and in the chance that I'm wrong (no compelling evidence on either side at this point but the status quo is to follow-up) the outcome (pancreatic cancer) is devastating.
Simultaneously, several groups (including myself) are looking at long-term evolution of these cysts so we can one day stop doing these probably unnecessary studies with confidence. This is despite the fact that I can bill $130 for a "stable pancreatic cyst" MRI that takes me 2 minutes to report.
Within my own specialty the same thing has been done for breast masses, liver lesions, ovarian masses and renal masses within recent memory and we have dramatically reduced investigations at financial cost to ourselves in the interest of patient care.
> That's a problem isn't it? Since we're on HackerNews, if I have an application that has a performance issue due to a slow disk, should I just throw my hands in the air and say "I have to disregard systems-level issues and focus on delivering features"? I hope I and my management can cut through the org chart to align on addressing the root cause which is getting a faster disk.
There's a time and place to fix systems-level issues (which are very hard to objectively evaluate and obtain evidence for fixes), during a specific patient encounter is not one of them.
Inertia in healthcare is real but we also have to remain cognizant that the consequences of mistakes/poor decisions are far more significant than in most other areas of life.
> Another anecdote...
Primary care is broken in the US and Canada (can't speak to elsewhere) due to several issues, the funding model being one of them which greatly limits how much time a GP can spend with a patient while still eating/being able to sustain a practice. Hospital-based specialty care is a lot better on average as we have more resources.
> he would spend time trying to understand the patient's living conditions, his occupation, stressors, hobbies, etc
For example we do this in oncology where I mostly reside professionally. Treatment decisions are influenced by these factors and every cancer center I've worked in has allied health professionals as part of the team to also help evaluate these factors.
> The lesson he learned there is that in the US there are too many invisible hands in the room guiding the doctor's hand, leading to an outcome where the patient's health is just as important as the insurance's health, the doctor's (financial) health's, the hospital's health, and the government's political health.
The issues you describe are most prominent in private practice environments which are very heterogeneous and there are definitely toxic physician groups that optimize billing, but I wouldn't say the system as a whole does not care. I suggested somewhere that patients try to find academic-affiliated practices (ironically my clinical work is private practice) if they are unhappy with their care as these groups have far less financial considerations and are generically speaking a better choice.
Overall I'd say the system is far from perfect and there are many inefficiencies but the majority of physicians I've worked with do in fact care about patients more than financial incentives. There is no easy fix for these very complex issues.
Thanks for the detailed reply, I sense then there are at least 3 kinds of health related interactions we’re talking about: 1) PCP visits which have wide variance in quality 2) non-hospitalized specialist visits where it’s unclear if the cost is justified 3) hospitalized care.
Most people don’t experience 3 until there is a serious enough problem, but when they do their care is far better than anywhere else in the world.
I don't know in which country you practice but here in Switzerland no board will ever give a decision of malpractice short of the doctor sticking a pitchfork in your eye. Theory is all nice but current practice makes this medical responsibility a joke.
Sounds like you're over it now, any idea what helped? I also developed long covid as a healthy 30 y/o white male, but haven't been able to kick it after 8 months.
Might be pure coincidence but my wife shook her long covid symptoms when the first vaccines appeared. They had diagnosed inflammation of the small passages of the lung and she had real shortness of breath. Inhalers of various kinds didn’t seem to help. Bad when things can be diagnosed by zoom or a phone call with good sound reproduction. Fortunately it’s not recurred.
brain fog, no smell, and reduced lung capacity. elevated liver enzymes in the bloodwork showed i wasnt crazy. oh, i should mention probiotics helped out too, along with the vaccine.
> asking for info, not doubting anything!
sure, just hesitant to answer because im not looking for a debate on this stuff anymore, got enough of that in my day-to-day while i was symptomatic. after the last 3 years i just want to put it all behind me and get everything back to normal.
Curious how blood tests helped you in this situation? I not only had extensive blood tests prior to getting sick but also had a sleep study and extensive psychological testing, none of which were consequential in my eventual long covid diagnosis
It helps eliminate benign anomalous results in emergencies. I have a low neutrophil count. It is totally uneventful. Having that baseline means if I’m sick and have the works run, doctors need not start treating my neutropenia—that wasn’t caused by whatever is going on.
More broadly, catching a vitamin D deficiency and allergy early probably saved some years of life and definitely improved my quality of life.
Some doctors are test happy. Most are not. Finding the right fit is part of being a human in the midst of modern healthcare.
Most medical diagnosis goes like this: you see a symptom, this could be caused by a dozen entirely different problems. A few of them can be easily ticked off by absence of some very clear flags in the lab result list. Others only have indicators that are much less clear, that are shared with a whole bunch of other outside-the-norm conditions, many of them perfectly fine. If you have a backlog, if instead of a list of current measurements you have a matrix of current and previous measurements, you can narrow it down much more.
Not really, very few diagnoses benefit from such historical data.
Any lab value flagged as abnormal is typically >95%ile meriting some form of further investigation (whether that’s continued follow up/repeat blood work or a different test depends on what we’re talking about).
The tests that could be physiologic for a patient outside of reference ranges (e.g. mild LFT elevations) will often just get repeated to establish stability as you propose. There isn’t a compelling argument to do this prospectively before symptoms start.
My wife's hemoglobin comes back high. It always comes back high. That's just her, it doesn't mean something's gone wrong. Some out-of-range values are meaningful (like cholesterol) by themselves, but in many cases if they're out of range but the patient is healthy it's simply something to note as normal for that patient.
Mid forties, my insurance only covers preventative blood work every 3 years or something like that. I guess that can be based on having a normal/good workup the previous time.
The blood test comparison of healthy me to sick me was invaluable, because the healthy tests established a baseline of my system at peak condition.