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TV doctors say annual checkups save lives – real doctors call bullshit (2016) (vox.com)
254 points by paulpauper on May 27, 2023 | hide | past | favorite | 449 comments



Just had a recent physical - I got a low value for a test and it kicked off more tests, a visit to a specialist, more tests and no conclusion besides 'let's wait and see' which I could have done without draining my HSA. If the price of care was reasonable, sure, let's be proactive but because PCPs don't really seem to do anything but refer you to a specialist and any visit to a specialist + tests will immediately trigger thousands of dollars in bills, even if you're insured you're going be paying your deductible plus like 10-30% after that.

I got a random lab bill for like $650 (discounted from $2500) and in the follow up visit everyone agreed that was high but no could explain why it was that expensive - medicare's fee schedule has the same code costing $90. Until we stop this madness of providers basically charging whatever opaque negotiated random amount they want to insurers who then pass that down to charge payers after collecting a % the prices are just going to continue to go up and the broken medical system will stay fucked - with the consequence that the economics aren't going to make sense to seek proactive care.


The issue isn't really that they're expensive - they are, they shouldn't be. Proactive access to care is good.

The article kind of hints at this, but it comes down to Bayes theorem [1]. The general population has a relatively low incidence of disease, so even tests that are fairly reliable in a population with a high incidence of disease become super inaccurate when applied to the general population.

Worse, false positives generally - especially in the US, due to high financial liability risk - end up involving expensive, invasive medical follow-up tests, and the probability of a false positive multiplied by the risk of the exploratory procedures outweighs a later diagnosis.

No wonder annual physicals don't do much good.

High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives. However testing otherwise-healthy people for things they probably don't have isn't likely to yield good results no matter how good the test. It's just math.

[1] https://en.wikipedia.org/wiki/Bayes%27_theorem


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.

--

Concern trolls claim more testing begets false negatives, begetting unnecessary treatment, which has its own risks.

Fine. Change healthcare from transactional to relational. Change from our current fee-for-service to continuity-of-care (or capitation, prevention, whatever we end up calling it).

Like u/JumpCrisscross says elsethread, only treat anomalous results per new symptoms.

I believe periodic baselines with regular checkups would reduce testing and unnecessary treatments, overall.

--

[1] Monitoring, logging, anomaly detection, and RCA... Starting to sound suspiciously like engineering and operations. Of course, some orgs treat each incident as unforeseen one-offs, aka The Condi Rice Defense™. But high functioning teams plan ahead.


> 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.

[0] https://thennt.com/nnt/statins-for-heart-disease-prevention-...


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?

YMMV.


> 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.


I appreciate your compliment.

> 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.


getting the vaccine again, 6 months after covid, is what fixed it for me.


What were your symptoms?

(asking for info, not doubting anything!)


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.


What was different in the blood work?


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


How is that helpful? I guess for making a disability claim?


> How is that helpful?

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.


> Some doctors are test happy. Most are not.

In my family we detected lung cancer in stage 2b instead of stage 1 because we spent months fighting a doctor that didn't want to do tests.

If we 'listened to the experts' my family member would be dead.


Were there symptoms in stage 1?


Yes, thats why we went to see the docyor in the first place. Instead our concerns were dismissed


Was your vitamin D deficiency and allergy related to long COVID?


> Was your vitamin D deficiency and allergy related to long COVID

Nope. Indoor lifestyle and and a proclivity for cold weather. And, like, allergies.


The person that you responded to was not the one who made the covid claim.

I think it was a bit jarring to have that comment on the covid chain since their experiences are not related.


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.


For comparing current results to historical to look for anomalous changes.


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.


Bloodwork isn't part of a routine annual physical with a PCP.


That’s basically all my annual physical is with my PCP. Short chat, referral for lab work, 2 minute phone call when they get the results.


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.


Mine's just weight, blood pressure/pulse, and a chat.


Huh, weird, mine always has a basic blood panel - cholesterol, etc. But it hasn’t yet led to expensive follow-ups.


> High-risk people should get periodic tests for the things they're at risk of, and people should be in a position to report issues they discover in the course of their lives.

How do you know if you’re at high risk for something? This assumes a medically literate and motivated person will seek care based on … what? Realizing that grandpa, great-grandpa and dad all didn’t live past their 60’s? High cholesterol and hypertension can be “silent killers” - how do you know to check for them?


For what it's worth hypertension is a good example of a bad test - or a routinely poorly executed one, anyways.

According to the AHA, blood pressure is supposed to be taken with feet flat on the floor, relaxed, and quiet for five whole minutes before, on an empty bladder, without caffeine and not having exercised within 30 minutes. I can count on zero hands the number of times I've had my blood pressure measured in accordance with this procedure in a doctor's office during a check-up. [1] It's a highly variable thing that can spike instantaneously and take a long period of time to return to normal without issue.

Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical.

The optimal way to make a hypertension determination is a 24-hour continuous blood pressure monitoring cuff. You should take your blood pressure at home, on your own time, in a relaxed environment and if you see a consistently elevated reading, only then reach out to your doctor and set up an appointment to confirm with a 24h test.

[1] https://www.heart.org/-/media/files/health-topics/high-blood...


It is not worthless. After getting a series of higher test results my doctor suggested a 24h test snd only then diagnosed mild hypertension.

Baseline blood measurements can also be invaluable. When getting sick you don‘t want to go down rabbit holes.

The US has a comparatively high hurdle to access to doctors. When doctors see patients they need to assume it is bad (liability another factor) driving costs up. Also people are not used to reach out to doctors letting them hesitate when they should not - regular contact can help here.

Every year major bloodwork and investigations may not be worth it but seeing your doctor regularly, being able to communicate effectively, doctor having a baseline of you as a person and some bloodwork too makes other countries a lot more efficient in providing health care.


> seeing your doctor regularly, being able to communicate effectively

In other words, building a relationship. Continuity of care improves health outcomes.


I addition to the not-waiting-five-minutes part not being observed, I’ve heard from medical assistants that automated blood pressure cuffs always read high and that “good” doctors don’t trust them. In fact, when I go to the cardiologist, they seem to always use the non-automated method. However, every ER, urgent care, PCP, etc. seems to use the automated method.


Weird because the automated one I have at home reads normal but my PCP's always shows high. The difference is that I do mine after being still and quiet for 5 minutes while they rush me into the office, ask me a ton of questions and immediately read my blood pressure while I sit on that bed thing with no back support


White coat hypertension is also a potential contributor.

https://www.mayoclinic.org/diseases-conditions/high-blood-pr...


I highly doubt that, the situation in which it's measured (no back or foot support while talking) is literally against the AHA and other guidelines for BP measurement. When I replicate it at home, it's the same and higher but if I wait and use a proper chair and don't talk then it's fine


I’m not disagreeing with your (accurate) description of proper technique at all, or that incorrect technique can result in falsely elevated office BP (due to expected physiologic responses).

I just meant it may also be a factor in elevated office BP measurements even if done properly, hence “potential contributor”.

If you have multiple documented normotensive measurements on your home BP monitor that’s more reliable than even proper technique in a medical setting to be honest.

The hierarchy of BP measurement accuracy is:

24 hour ambulatory measurement > multiple home patient measurements > in-office automated BP cuff (with proper technique) > in-office BP measurement with auscultation (not sure why this was suggested as more accurate to the commenter you replied to).

Automated cuffs are great and reproducible.


I bring all my home gear in with me, to compare the measurements.

FWIW, my cheap OMRON blood pressure thing has agreed with the pro results, thus far.


Yea, I also have an OMRON and I'm sure it would agree in the same setting but I actually check my BP according to guidelines at home


> Which is probably part of why 30% of people who get their blood pressure taken in a doctor's office will register a higher than normal blood pressure principally only in the doctor's office. This is called 'white-coat hypertension' and doctors and researchers are pretty split on whether or not this represents an actual problem. With that in mind, it makes this a pretty worthless test in the context of an annual physical.

My favorite conspiracy theory is that this is why we always have to wait so long after we're in the exam room but before the nurse comes in to take BP. My BP monitor's instructions say to sit calmly for 15 minutes for an accurate reading and I think that's what they're doing.

Meanwhile, since the kids are so hyper it's not even worth trying the delay tactic so the pediatricians come in much faster.


That's impressive excus-making for doctor-priority scheduling density.

It's not "calm" to be on edge for 15minutes wondering when the provider will appear.

Also my office takes my BP as soon as my appointment time starts and then we sit waiting for doctor.


No physician should (and I expect would) diagnose hypertension on a single office-based blood pressure measurement. We suspect it based on the office measurement and then confirm.

I last worked in primary care back in 2016 but even back then we would either do multiple visits or ask the patient to check multiple times at a pharmacy (or at home if they could afford a cuff).

24 hour ABPM is the preferred method for diagnosis as you stated but has limited (albeit growing) availability today.

Fortunately consumer health-tech advancements has resulted in cheaper accurate BP cuffs but this is a recent-ish phenomenon.


Is there a form of passive blood pressure wearable? I am trying to find a way for my mom to track her BP throughout the day after meals etc. she does this with a libre for blood sugar


What's your position on wearable health monitors?

For stats like blood glucose, heart rate, blood pressure, etc.


The general consensus from MDs that I’ve heard is that the non-FDA approved ones have way too much variance to be useful. They just aren’t very accurate.


I suppose considering your family history or having your DNA analyzed is one way. But the more direct way is to consider your own medical history. Chronic diseases may coincide with risk for other ailments and you get regular checkups for those. If you had a heart attack, you have a yearly visit with a cardiologist. Etc.


This isn't an article claiming you should never have gone to a doctor. It's about annual checkups.


This is better known as the base rate fallacy.

https://en.wikipedia.org/wiki/Base_rate_fallacy


This is a more specific version of the base rate fallacy, called the false-positive paradox. It's illustrated by a simple example.

Suppose you have a test looking for an extremely rare genetic condition (say, 1 in 1 billion people have it). That means that the test needs to be extremely accurate (in this case, accuracy of .999999999) to avoid having so many false positives that it's worse than a coin flip about whether you have the condition or not. Therefore, in most cases you would be better off making a fake test that just says "no" every time.


While what you’re saying is true there are other options besides giving up, like having people who test positive take another test or two to confirm.


It's true that there are other options. However, in the real world that might not help, because sometimes the erroneous circumstances which cause the test to be inaccurate will continue to persist.

For example, genetic parental tests are very accurate... unless the parent being tested has chimerism, in which case you'll get the very confusing result that the child isn't your own, even under repeated testing.


> people should be in a position to report issues they discover in the course of their lives

What does this mean? Which issues? How many thousands of diseases are there?

I have a friend who has low level of energy, everyone was calling him lazy his entire life. He thought thats just how life is. He cannot compare how it feel to be him with how it feel to be someone else.

I convinced him to see a doctor about this at the age of 25. First doctor didnt take him seriously, didnt want to do any tests. The complains are very non-spesific. maybe you are lazy, maybe you are depressed.

After weeks of fighting the medical system he discovered that he had a digestive issue, which led to low level of iron and low level of enegy. His entire life he was suffering from an easily treatable problem.

Imagine he treated this at the age of 12, how many sports did he miss out on, how much academic achievement was missed, maybe his career and life trajectory would be different.

A friend of mine struggled with back pain for 3 years. He coupst find the cause. It got so bad, he thought he'd become disabled. He left UK and went back to Romania to have support of his family. Suffenly in Romania he started getting better. Turned out it was vitamin D defficiency.

I started taking Vitamin D agressively, 2,000 units daily, 5 times the recommended amount by the NHS. After taking it for 6 months I went private and did a first vitamin D test in my life - my level is 1/3 of normal.

So how doea one know what is normal, if most people gp their entire life without ever doing a full blood test


Surely the issue is the broken healthcare system in the US?

Proactive care is good. Testing is good.

However the insurance / healthcare cartel behaviour that's fuelled as a result is devastatingly expensive.


> Testing is good.

Not always. It depends on the performance characteristics of the test, i.e. the sensitivity and specificity. Tests with high sensitivity and low specificity often reveal indeterminate results that, in an effort to gain more certainty, expose the patient to significant procedural risk.


Bayes' theorem is not enough, I think you have to weight how expensive is the test, what are the consequences of false positives and true positives.

For example a low price test with almost zero both false positive and negative rate whose associate treatment has low cost and risk and that can save life of patients seems to me a test that should be applied to anyone at risk.


Bayes incorporates the false positive rate. In fact, using the posterior is exactly the point. It's just noting that the diagnostic power of many tests is not very high if the prior probability of the disease is low. All the points you make don't change that.


From a practical point of view, if the prior probability of the disease is low but the disease is mortal and there is a $0.1 test and $0.2 pill that cure the disease without having negative effects, I think that you should take the test and if positive take the pill. Knowing the posterior probability is not enough to decide what to do, you have to know what are the tools and trade-offs.


Wouldn't you just give everyone the pill in this scenario?


This is how non-prescription supplements work.


You make a good point. IIRC, the USA has a far higher rate of unnecessary MRIs "just to be sure"/to minimise liability.


Overuse of MRIs are due to accounting and financing, not standards of care.


Ok, but then I'd like to see Bayes theorem being actually applied for different cases, instead of just hand-waving the issue away for all cases. Also, for some false positives there is no problem, e.g. vitamin D deficiency, where you can just take extra vitamins without much risk.


This is quite the weird take. Maybe you meant to say that acceptable sensibility levels should be different depending on population sizes?


*sensitivity


Also relevant is the "Information Bias"


I'm not sure how they can be cheaper. The bill for a checkup pays the nurse and the doctor for their time. Claims about some greedy capitalist coming in and taking massive profit margins can be discarded by pointing out that non-profit hospitals do not charge substantially different rates for identical checkup services.

The way to make a checkup cost less is to pay doctors and nurses less. There are no pharmaceuticals, no surgeries, no complicated specialist medical equipment, and no expensive labwork involved in the price.

Society generally doesn't agree with the notion that doctors and nurses should be paid less. Therefore, checkups are more or less priced appropriately. Paying high skilled labor for their advice simply costs a lot of money. Ask any dev contractor here on HN.


The Direct Primary Care model shows that the overheads for healthcare are definitely a very large contributing factor to high costs and poor patient experiences. Cutting out the insurance company and related overheads from the medical practice, lab tests, and pharmacy creates an incredible experience for the patient at a very reasonable cost. I was and continue to be baffled at the attention I receive under a DPC physician, as well as how low the associated non-subscription costs are (effectively zero with the elimination of urgent care and expensive tests). The doctors and staff at the DPC practice are all happy and stress-free. Our system is definitely broken.


There is a lot more to it than that. At a bare minimum, you are also paying for the office rent, the administrative cost of billing through insurance, the administrative cost of the insurer, malpractice insurance, and the price of the doctor’s education.

All of these factors (except maybe rent) are higher or even unique to healthcare in the US. Capitalism isn’t even to blame for most of these. A free market would have price transparency, and would incentivize direct billing over billing through insurance due to lower overhead. Just because it’s the USA doesn’t mean it’s capitalism. That said, nationalized healthcare also seems to be able to solve some these problems through collective bargaining on drug prices, and reducing the billing overhead.


Complete nonsense. If you get a bad result run the test a few more times to confirm before getting expensive exploratory surgery or something.

Your attitude is actively harmful, real people suffer with uncaught diseases because we don’t routinely test “”healthy”” people.


I would urge you to do some more research. Over testing is well known to cause higher rates of unnecessary medical procedures. There are many ways it can break down. For instance, the test may false positive consistently if an individual has some other factor such as mediation, virus, or bacteria that confound the test. Tests are also only validated under certain criteria. For instance if the clinical trial only tested people who presented with certain symptoms, the efficacy of the test may be completely different on the general public.


Well then all that says is you need better standards for tests.

Just because some tests might have alarmingly high false positive rates doesn’t mean all, or even most do.


Running the tests again only works if the false positive rate is just due to noise. I.e. if the occurrence of a false positive is uncorrelated between re-tests. I guess most real false positives aren't due to noise, but due to the test triggering on something unrelated and rare. In that case re-testing will yield the same result.


This isn't what happens. A huge volume of the people that come in to US hospitals are chronically ill people with no money and very commonly no regard for their own health. Quite often they are also disrespectful and combative to hospital staff. The system pays for their extended care and the healthy majority pays huge premiums to subsidize their care. The vast majority will be paying premiums vastly out of proportion to what they will use.


This sounds like a delusionally extreme take, as if there is no in-between or nuance. You're either a victimized superhuman who never gets ill or a chronically ill scumbag with no regard for your health? Hardly realistic at all.


>> medicare's fee schedule has the same code costing $90.

People would be upset if the gas stations charged different prices after they review your auto insurance policy. With healthcare, they look at our policy and make up price numbers.

Maybe this violates anti-trust laws. The State attorney generals don't seem interested in pursuing such discriminatory pricing.

https://legal.thomsonreuters.com/blog/robinson-patman-act-an...


> Until we stop this madness

How? You were given a result that was concerning, and rightly wanted it investigated. You needed the test and the test cost money. How do you opt out?

I live in a country with a better (though still troubled) system. I can’t see how you fix the US system, even in hand waving terms.


Price transparency is the obvious start. Before agreeing to non-emergency care, you should be told what it'll cost. At least a range.


Medical tourism. Give the money to the airline industry instead, who have a more competitive market in terms of price.


That’s actually crazy.

Who can manage an international trip each time they need medical help?

Not everyone can afford the delay, the time, the money or the inconvenience.

If you paid me and made it immediately available I still wouldn’t want to travel internationally for medical care.


> Who can manage an international trip each time they need medical help?

> Not everyone can afford the delay, the time, the money or the inconvenience.

If you have no symptoms and it's follow up for a routine screening test, you can probably afford the delay. The time is certainly an issue, although if you can get any needed subsequent tests and care immediately internationally, it might be less time overall. The money could work out in favor of international travel, depending on the details; almost certainly less all things included, but not necessarily less if you're only counting money that comes directly out of your pocket.

The real question is when does it become legal for insurers to send you overseas for care, and when does it become legal for medicare and medicaid to do it.


Driving to Mexico isn't so bad from lots of the country- and in the North you could drive to Canada.


Private medical care is in most circumstances illegal in Canada and they have large enough wait lists that people are dying in large numbers waiting for medical care. Medical tourism to Canada is a non-starter for Yanks.

> “Canada is the only country in the world where it is illegal to obtain private health insurance when there are long wait-lists. That surely says something,” said Dr. Brian Day, medical director of Cambie Surgery Centre in Vancouver and past president of the Canadian Medical Association (CMA).

> He launched a legal challenge to the B.C. Medicare Protection Act, saying wait times in the public health system are too long and stopping patients from paying for those services outside the public system violates their rights.

> In July, the B.C. Court of Appeal dismissed the Vancouver surgeon’s challenge.

> However, in their ruling, the judges accepted that the act’s provisions “deprived some patients’ right to security of the person by preventing them from accessing private care when the public system had failed to provide timely medical treatment.”

https://globalnews.ca/news/9099696/canada-private-health-car...


> Private medical care is in most circumstances illegal in Canada and they have large enough wait lists that people are dying in large numbers waiting for medical care. Medical tourism to Canada is a non-starter for Yanks.

Can you cite a source for people dying in "large" numbers waiting for medical care in Canada?


Canadians live longer, and they spend about half as much on healthcare per person.

If Canadians are dying in large numbers waiting for care, something pretty grim is going on south of the border to make the stats worse in the US.

The bottom link is to commentary on the Supreme Court’s recent ruling in the case, and the criticism of a more privatised system is interesting.

“The entire premise underlying the Canada Health Act is that people ought to be able to access health-care services based on need, rather than ability to pay…

It's pretty clear that having physician's practice both in and outside of the public system, if anything, results in longer wait times for patients in the public system, not the other way around…

The people most likely to need urgent surgery are often the least able to pay out of pocket.”

Notably, the legal action was brought by someone with very vested interests.

https://www.statista.com/statistics/274513/life-expectancy-i...

https://www.healthsystemtracker.org/chart-collection/health-...

https://www.cbc.ca/news/canada/british-columbia/analaysis-br...


There's no reason to assume that government care supply would rise to meet demand. If private pay is allowed, and medical school enrollment is not artificially constrained, supply can rise to meet demand at a low price.


> supply can rise to meet demand at a low price.

But would it? Those doing the training (eg surgeons) are benefitting from the high prices.


What is the reason for the wait times, though? If it's availability of doctors, I don't see how paying for private insurance magically makes doctors less busy and able to see you. And if that does work, then it just means that the mostly-unavailable doctors are prioritizing people who can pay them more, which isn't exactly a great outcome either. Or am I missing something?


This is how it happens in Spain: public doctors work from 8:00 to 15:00, with long queues. The same doctor has a private office from 16:00 to 20:00, where the queue is almost zero.

There are some doctors that works exclusively public or private.


> The same doctor has a private office from 16:00 to 20:00, where the queue is almost zero.

If there is a queue, the price is too low. Surely a good business optimises price such that there is no queue and maximum revenue?


It may be that the service provider (in this case, a doctor) realises that to price too many people out would be an optimisation that ignores that not all kinds of suffering are equal e.g. yes, optimise the pricing of Playstations and flight tickets and some people will miss out and feel bad, but the suffering of those priced out of a medical procedure is worse.

On the other hand, if we allowed a freer market in medicine (anywhere, no particular target country in mind), seeing doctors make more money treating something should spur on new trainees, thus more doctors in that specialism, and hence price drops and improvements in waiting times and possibly techniques, but that would require that freer market that so many seem against.


Doctors are a finite resource. Ultimately you have to ration that resource.

You can do it based on social status and wealth (America) or on medical necessity.

Obviously this is HN were people have money so they are upset if they are put on a waiting list. We don't hear much about the people from trailer parks getting million dollar cancer treatments thanks to the public healthcare system.


> Doctors are a finite resource

Partly because other professions, like banking, attract greater remuneration. It's also why you'll notice that many new doctors (in the US) choose the ROAD, for many reasons[1], but this one stands out:

> The amounts of money that can be made in dermatology and plastic surgery are a temptation that many people cannot resist

If you want more doctors, and more doctors in things like primary care, then offer incentives. Money is a good one. You may also ask if plastic surgery is still an expense that only a wealthy elite can access, as it was in the past, or if it's become quite commonplace, and then, since it has, why. Could it be that the usual processes that other capitalist goods follow also work in healthcare?

The other side of that is training enough doctors. I think it would be a good question to ask why so few are trained, and I wouldn't be surprised if one of the reasons is that the guild itself, as all guilds do, limits the number of new entrants. That's speculation on my part.

> Obviously this is HN were people have money so they are upset if they are put on a waiting list.

I thought that everybody gets upset if they're put on a (long) waiting list so I'm not sure what need the ad hominem in your comment serves.

[1] https://medicine.yale.edu/news/yale-medicine-magazine/articl...


> that would require that freer market that so many seem against.

I’m not sure that medicine could ever be a poster child for the free market. It’s tightly regulated for good reason. Is there anywhere that has free market medicine? I’d like to read about it, but wouldn’t want to use such a system.


You think the kind of regulations that are being discussed in this thread are good things? They don’t seem to benefit anyone but insurance companies. Tell me, why shouldn’t you be able to walk into a doctor’s office and they be able to tell you how much a test costs? I wonder what regulation makes that impossible and what intended good it is supposed to make possible.


> Tell me, why shouldn’t you be able to walk into a doctor’s office and they be able to tell you how much a test costs?

I can. I live in New Zealand. Medical practice here is plenty regulated and complying with these regulations is a meaningful percentage of my day job. Not all of it is worthwhile, lots is.


I'm glad to hear that, even if it's not particularly relevant to this thread, but still worthwhile hearing about.

It doesn't clear up why you think a free market and regulations are opposites.


A literal free market is one without regulation. If you want a regulated market, don't call it a free market.


No, that's anarchy. A free market is one where market forces are allowed to work. A market captured by monopolists and anti-competitive agreements is not free at all.

Take a small market store selling product A and product B. Whichever sells more at a given price wins more profit, great. Free market forces are at work. But then (anything goes, after all) the manufacture for A comes in and says to the store owner: if you sell product B we'll firebomb your market and kill your dog. So then the small market stops selling product B. Now, the small market only sells product A and at a huge markup.

Is product A actually better? Does the consumer win?

Regulations are necessary so the manufacture of A can't do that and make sure that the market is actually free.


That's a well-regulated market not a free market. I completely agree that regulation is needed, and better by the people than by the biggest bully in the market.


> Canada and they have large enough wait lists that people are dying in large numbers waiting for medical care.

Googling shows ~2000 Canadians died waiting for surgical care in 2020. Meanwhile in the US:

* Millions of people delay even starting care in the first place due to costs

* In the seven years from 2000 to 2006 an estimated 162,700 Americans died because of lack of health insurance

* Massively worse medical outcomes than Canada in virtually every metric

* Massively higher costs

* Systemic lying about waitlists and patients to cover up how bad they are [1]

[1] https://www.cnn.com/2014/04/23/health/veterans-dying-health-...


>Private medical care is in most circumstances illegal in Canada

That's not quite right.

As I understand it, private clinics themselves are fine: the very next sentence of your article explains that the doctor in question runs his own private clinic. Instead, the issue is how you pay for services rendered by those clinics since BC's Medicare Protection Act restricts insurance policies that would cover them.


More or less correct, healthcare in Canada is mostly “private” with a single public payer on a provincial level. One other difference is that hospitals are owned and run by the government (with slight variation between provinces) so they don’t bill the government and are instead given large annual budgets with some incentive based payments.

Imagine the US system with Medicare as a single payer setting rates and HHS owning all of the hospitals.

Physicians (for the most part) bill the government on a fee for service basis and most do so through a medical professional corporation that only physicians and certain family members are allowed to be shareholders in.

It is illegal to charge for services insured by the government. It is not illegal to charge for uninsured services (for example some knee arthritis injections) or those not insured (e.g. visiting Americans).

I knew Dr. Day professionally, he has run an ambulatory surgical center (different from a private clinic, all freestanding clinics are “private” in Canada) for several years now and the issue with his practice is they are providing insured services (like joint replacements) charged directly to the patients. Although technically illegal, the BC government has let this happen due to long wait times and lack of political will in their voter base but this recently gone to the legal system.


If our (US) medical system is so broken that your best option is to travel thousands of miles to a different medical system for care, that's a sign that things need serious change. Medical tourism is the equivalent of treating a symptom but leaving the root cause untreated.


I can think of a few ideas:

* you can't get paid by insurance unless you have payment authorization from the patient on an estimate that is within 30% of the actual price (exceptions for emergency care).

* a requirement that all provider participate in an digital marketplace where patents and providers can get immediate quotes for labs/procedures and you get a list of local options+prices.

* anti-trust break up of healthcare cartels

* some price cap like 200% of medicare negotiated rates as a backstop for these really crazy outlier bills.


Your test is consistent with condition A. Its prevalence in the general population is B/1000 people. We can do a follow-up test that involves B, C, D, will cost $E and in cases like yours confirm condition A in F% of cases. Or we can wait and see; we'll redo the test in G time out if you present with other signs and symptoms H, I, J. Other possible causes for the test result are K, L, M. How could you like to proceed?


I have a PhD in this stuff and I'm not sure I'd want to be making those sorts of decisions, especially for myself or a loved one.

In your example, suppose I do have A (or K, L, or M). If I wait, how will that affect the costs and prognosis? Or if I go ahead with the test, what are the possible side effects (e.g., for a biopsy) and what would managing them cost? Even if you're confident that you have—and understand—all the relevant information, you're also often making these decisions in an emotionally-charged situation.


remove pharmaceutical companies ability to set their own price.

remove the insurance ability to negotiate prices.

Ensure American's right to Healthcare.


> pharmaceutical companies

But it’s hospitals/labs which are as bad or much worse in this regard. “Greedy” pharmaceutical companies are just a boogeyman, insurance companies, hospital admin and doctors are just fine with charging “random”/arbitrary fees based on clients perceived ability to pay and not in anyway related to actual costs.


It’s both. Pharmaceuticals companies are not an innocent bystander. Everyone is happy to get this big piece of the pie, including drug companies.


Of course not. It just seems that they might actually be the most transparent segment of this entire system which makes more visible.

And well… from the society’s perspective high/very-high prices for new drugs for a decade or so (20 years seems too long though) might be a good deal if it results in very high investment into R&D.


These are all correct, but as an individual you’re pretty much limited to writing to your representative. You can’t opt out in any immediate sense.


See my nearby comment on Direct Primary Care. It is possible to partially opt out of the system, and fortunately it is the part of the system that you touch most often (or should be anyway).


[flagged]


Lol. You'll get better results if you stop smelling with your ears


> PCPs don't really seem to do anything but refer you to a specialist and any visit to a specialist

(Yet another, I live in the US, therefore everyone else does moment)

This is one of the things that surprised me the most in the US. Doctors seem afraid to draw any reasonable conclusion and are more like salesmen. I'm sure the fact that you can sue for pretty much everything plays a role in them not being more confident.

I hope that testing gets cheaper and more data gets public so we can eventually have AI doing the medical scoring and with it routing/prioritizing patients.


I live in the US and have run into both kinds of doctor. If you end up with one that does nothing and only refers you to specialists, it's worth trying other doctors. There are definitely nerdy doctors that know a lot more and are more willing to get their hands dirty.

Ultimately, even the nerd doctors will send you to a specialist if you need it.

I like my current doctor a lot. He runs his own independent practice and is just generally really cool.


> it's worth trying other doctors

In much of the US finding a PCP who is accepting new patients is hard. And the ones that are accepting new patients are unlikely to be one of the good noes.


Plus, new patient appointments are a 6-9 month wait where I am (suburban California) so it could take over 2 years to try 3 Primary care doctors.

We just got a doctor appointment now after scheduling in September. Went into the office and the receptionist explained “oh, sorry, Doctor X is busy and can’t make his appointment. Next available is in July.”

It’s always funny when people say “universal healthcare will have long wait times for doctors like in Europe!!” This is is currently happening in the USA.


> universal healthcare will have long wait times for doctors like in Europe!!

I don't know about that. The missus had a problem, had to see a specialist, they first said next slot is in 1.5 months, then she read her blood test over the phone and they scheduled her in like 3-4 days. TBH that wasn't funny at all, the 1.5 months appointment would have looked ... healthier.

Eastern Europe where the universal health care isn't considered great.

[Posting as throwaway because the missus can be identified by my HN nick]


Same experience with me in the Bay Area. Wait times where 2-3 months for anything reasonably close (within 45 minutes driving). Ended up paying for one medical.


Are there any walk-in doctor surgeries in the US? Or tele health? What do you do if you need a doctor today?


"Doctor's surgery" is what we'd call the doctor's office in the US, right?

In terms of walk-in, there's "urgent care" and similar things. And of course the emergency room if the need is severe. Telehealth was vastly expanded during the pandemic and has stuck around to a significant degree.


In addition to urgent care clinics, every doctor I've had holds a few appointment slots open for same-day or next-day visits. I just have to call them when they open.

Just checking my doctor's group, they have multiple appointments available for new or existing patients in all 7 of their locations around Austin as early as Tuesday - and that's probably only because Monday is a holiday. The only caveat is that you have to accept whichever doctor is available, rather than selecting you PCP.

I know it's a big country with a lot of variability of experience, but this has been the case everywhere I've lived.


Yea, we basically use urgent care for everything, since it seems very few in-network doctors want any more patients, and the ones who do have no availability for months. So we're in this weird position where we have no "primary care doctor".


Growing up in the sticks, I had a primary care doc who, in retrospect, tried to treat things he should have referred out to specialists. The result was at least one early death in my family, another close call, and avoidable permanent disability.


Is it really common to sue for testing or lab work? i mean, theranos being an obvious exception here.


It's not common to sue for anything really. Most people don't ever sue anyway, but a small amount of people sue a lot, backed up by the armies of attorneys that advertise on daytime tv and bill boards. My wife works in liability defense and it is common that most plaintiffs have been involved in other lawsuits. Car wrecks, slip and fall, wrongful terminations, plaintiffs will often have 2 or 3 ongoing cases. They are all generally bullshit but will settle out for between 20-40k after a year or two of depositions and back and forth.

One interesting thing though is that pain and suffering is typically calculated at 2x medical costs. So those crazy high bills work in your favor when you are suing someone.


You can likely get labs and imaging for significantly less by going to specific stand alone lab/imaging facilities.

Health care groups tend to refer you to onsite services and/or specific companies they have relationships with.

It is a pain though because you have to call around to get prices.

Generally, the places with the lowest cash prices will also be the places that are least expensive after you've reached your deductible, but it's good to confirm with your insurance.

Medicare's fee schedule is almost always lower than what you can get, even with all cash, because the US government can set the rates they pay to some degree. It's up to doctor's/medical groups if they'll accept that or just stop taking Medicare completely.


Specialists are great, but it would be so much better if healthcare systems did a better job at properly looping back in the patient's primary care / family doctor in on important health decisions. Primary care physicians, when not stifled by the system, have a remarkable ability to keep track of a patient's health over the course of several years and provide a balanced, realistic view of what might be needed. The way that PCP visitations have become shorter and shorter in a more overworked and hectic environment has done a great disservice to patients.


I think that's basically a fantasy. My experience with primary care physicians is that they barely remember who I am, and they frequently move on to other practices. It's not uncommon to see a new person each time.

On my latest attempt to make an appointment they said that I am no longer a patient because I didn't come in during COVID, and that I would have to wait to get back in.

I decided I'd just go without until something bad happens. So far so good.


Yep, this is what the system has created. There's little incentive to stay within that career path, and nobody is helped by the fact that healthcare administrators and staff shortages are forcing doctors into 3 minute visitations that establish little to no connection with patients. It leads to so many "my doctors are idiots who couldn't figure out my condition" situations that are rarely caused by lack of education (not that there aren't any closed-minded doctors), but by lack of cohesiveness of the entire system. Healthcare urgently needs to go back to being a continuous process, not a series of tech support tickets.


The behavior you're describing is clearly an effort to economize use of doctors time. Since there is a cartel controlling salaries hospitals are doing everything legally possible to maximize their usage and shift work to cheaper labor.


Lookup direct pay family doctor office in your area. I pay about 80 bucks a month for doctor I can call, text, spend 30 minutes of I visit. She have arrangement with testing lab with really tiny costs for tests, x-ray, etc. And because of direct relationship, she indeed can track my health over the years.

I still have high deductible insurance to cover something serious, but otherwise pay cash for routine stuff.


This is the way - the Direct Primary Care model. Find the smartest DPC doc that you can and you will be free from so much of our broken system.


Have you had experience with the system?


My obgyn didn’t remember me when I went in pregnant for the third time. I’d seen her at least 20 times in the previous 5 years.


It's like that for most employed physician practices and a large number of group practices but if you can find a solo practice (i.e. a practice with one doctor and maybe one or more NPs), odds are they will be pretty decent.


I had an abnormal value. Doctors kept telling me to ignore it. Despite me having a lot of issues.

2 years of battling to get tests done. End up having 3 uncommon conditions. One of which was going to kill me without urgent treatment. Drastic quality of life improvement from proper treatment.

Spent years being told I was a hypochondriac for insisting something wasn’t right. That everything I was experiencing was just anxiety.


Oh that's tough. I think the only diagnosis here is "suffering from American medical care"


That lab really gouged you and your insurance provider. I use CPL and I don’t recall ever paying more than 200 for custom bloodwork, not going through insurance either. My insurance prefers LabCorp but their assays are questionable at best.


Isn't this a problem with the economics precisely, rather than with the concept of proactive care?

For all their problems, Cuba achieves excellent health outcomes. Some of that may be because of the extensive primary and preventive care.


> any visit to a specialist + tests will immediately trigger thousands of dollars in bills, even if you're insured you're going be paying your deductible plus like 10-30% after that.

(In the US)


You wouldnt be writing like this if they did detect something.

I bet then you would be the apostle of periodic checks.


What % of that cost was the zero-value-added gatekeeper?

Here is a list of prices: https://dhhr.wv.gov/bms/FEES/Documents/Clinical%20Diagnostic...

Testosterone is $46.

Toxoplasmosis is a shockingly common and easily-curable brain disease: $12.

Imagine, an entire population held hostage to this racket.


Setting aside the cost, this is a good thing.


A half-lifetime of experiencing and observing modern medicine, in good faith, has taught me that participating in the medical system while not in need of emergency care is risking one's health and life.

Assuming that one doesn't engage in risky behavior, the smartest path is to avoid the medical system altogether. That doesn't mean "seek alternative medicine". It's just what I said.

The Medical system doesn't highlight its failures. It obscures them, and only speaks in bullshit PR terms. Its failures (premature suffering and death) are almost always attributed to causes other than the malpractice that caused them. Even families are hoodwinked.

Laugh at anyone quoting "evidence" without citing it for critique. The medical profession hasn't had broadly-intact scientific integrity for decades.

Much of medicine is charlatanism for billing. Doctors know this though most won't admit it. The consequences range from annoyance, to minor malfunction, to catastrophic.


Having kids has shown me how much of medicine is about incentive alignment, rather than doing no harm. Every time one of my kids gets an ear infection, pinkeye, or a sore throat, my daycare requires a doctor’s note and antibiotics to be given before they are allowed back in daycare. The urgent care doctors always prescribe antibiotics, even though the most likely cause is viral and most bacterial infections resolve within 3-5 days with or without antibiotics. I had one case where the strep test was negative, and the doctor still prescribed antibiotics because it could be a false negative. And my kids are allowed back in daycare after 0-24 hours depending on the diagnosis, even though the medicine takes 3-5 days to work.

I was shocked to go through this the first time, after reading so much about the over-prescription of antibiotics. But doctors would rather write a prescription than explain the evidence to stressed parents and daycare providers. And daycares all copy each others’ policies, because nobody wants to admit that kids are just contagious snot-monsters and medicine can’t really help.

It’s pure theatre, at the expense of kids’ health (antibiotics do a number on the digestive system) and leads to antibiotic-resistant strains. But at least nobody ever had to stop and have a difficult conversation.


That's crazy. I have small kids and the doctors never give antibiotics. They just say it's something viral and to give Tylenol / Ibuprofen to treat discomfort. The daycare doesn't have any rule like that either they just check for fevers and they have to stay out until no fever for 24 hours. When one was really sick with croup they gave him some steroids but that's it. We have even switched doctors 3x and always been the case.


Yeah, my kids have had what feels like every illness under the sun, and I can count on one hand (maybe one finger?) the number of times we’ve been given antibiotics. They’re in public school, which may have something to do with it, but the rule has always been 24 hours sans fever with no antipyretics and you’re good to return. Sorry to hear that the parent poster has encountered such bizarre rules, that’s pretty lame.


Wow, I’m shocked (and heartened) to hear that your experience has been so different. Maybe it’s just the area I’m in or my healthcare provider. I always expect to be told “it’s a common cold, get the kid some rest and leave urgent care to the real illnesses” but I’ve literally never had that happen.


Definitely varies by country. In Czechia, they give antibiotics only after three days of fever or symptoms that strongly hint at bacterial infection. And they usually do at least a CRP test, often a cultivation.

The daycare rules here vary place by place, though. Some of them just check for fever, some don't like running noses.


I am on the west coast in the US, and my kids’ pediatric group almost never gives antibiotics. They typically tell me over the phone not to bother coming unless it has been a very high fever or multiple days of worsening symptoms.

Only antibiotics we have had were after they looked in ear and said the redness and pus indicated bacterial as well as the color and consistency of conjunctivitis discharge.

And around here, daycares do not require any doctors’ note. They just tell you not to bring your kid in if they have fever or vomiting or diarrhea within the last 24 hours.


Same for my family here in a midwestern state. I'm curious where OP is living...


I go to Palo Alto Medical Foundation in the Bay Area, literally down the street from Stanford. If there were any region I would expect to follow evidence-based practices I would expect it to be them.


I'm guessing they are more into doing the feel good thing to avoid angry parents.


My experience with doctors and daycare is similar to Hattmall. Keep them home for 24hrs if fever. No doctors note. I’m in Minnesota.


This varies country by country. In Switzerland you need to beg for antibiotics if you think you need them.


There is damn good reason for that. Wife is a doctor, although not a pediatrician. There are some long term stats that if kid receives antibiotics before age of 1, the risk of getting diabetes later in life jumps by at least 30%.

We have tons of doctors as friends, most work in biggest hospital in Switzerland (HUG in Geneve), and all with small kids adhere to this and try to steer away from atbs as much as possible. Its not some quack unproven theory.

Thats just 1 specific situation, you can deduct that atbs do quite a mess in those little bodies and it doesnt stop with age of 1.

If you meant even adult people dont get atbs automatically, thats also is great approach especially longterm. Most infections dont need them, they do more harm than good in the body. But uneducated folks that suffer seek literally anything that can help them, some basic medical facts be damned, so doctors sometimes give up and give atbs to obnoxious patients. Then there are of course those bacterial infections where they help, but they are rather small % and usually not the most severe ones.


Meanwhile here in Vietnam (and I guess for most of the developing world) I can walk into a pharmacy and ask for any medication they have available, including antibiotics, and they'll hand it over, no prescription needed.

I've heard this is slowly changing in the big cities but I'm not holding my breath.


Same in Sweden


I got antibiotics in Sweden when I had mononucleosis (a viral infection). It definitely varies.


Individual organisations / groups' practices vary dramatically.

From a friend who was involved in health care analytics decades ago, they'd frequently find that specific norms of healthcare practice depended highly on senior medical personal (e.g., a head physician within a department), and that you'd find major differences in standards both at different-but-comparable groups and at the same group following a major personnel change (retirement, moving elsewhere).

Another friend doing roving-doctor work at a number of smaller clinics and facilities described wildly different standards amongst physicians specifically regarding antibiotic prescriptions (my friend resisted prescribing them without specific indication, other doctors offered them as a default).

As with many other aspects of the world, what we observe directly is very much through a drinking straw (if you can find one of those any more): it's a very narrow view. This doesn't mean your experience is invalid or even infrequent. It does mean that it's likely not especially generalisable.

That said, what seems to change overall behaviours most is standards and norms being applied through policy, whether institutional (think Kaiser in California) or at the governmental level (government-offered services, etc.). Thought comes to mind that much of the US is now experiencing the negative aspects of that last, as with many tools, it can cut both ways.


Must be specific your region. Not my experience around Atlanta.

Around here common illness kids can come back after 24 hours of symptom free (daycares dont ask how they became symptom free). Super contagious like pinkeye requires doctors note that it's not pink eye, or put on a treatment plan.


> bacterial infections resolve within 3-5 days with or without antibiotics.

Citation needed

I do worry about overuse of antibiotics but I know a lot of times it just doesn't "go away without", or the viral infection ends up evolving to a bacterial one

Though what the doctors should do is give the prescription but say just to take it if the situation doesn't improve. This way you save a return to the doctor if it doesn't get better.


I don’t have any citation, but if you google bacterial ear infection or strep throat you’ll see that it’s true. And my pediatrician agrees with me, even if the urgent care docs don’t mention it.


The risks of Strep Throat include Rheumatic Fever, Kidney disease https://www.cdc.gov/groupastrep/diseases-public/strep-throat...

and https://www.cdc.gov/groupastrep/surveillance.html

and in some cases even death https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6474463/

Thanks, I'd rather not risk it (though I will wait a couple of days to see if it gets better)


Yes, but even your link says that complications are uncommon. I’m not advocating waiting until you’re on death’s door, but isolating and waiting 2-3 days to see if you’re getting better is fine.


> The urgent care doctors always prescribe antibiotics, even though the most likely cause is viral

This is irresponsible, tackling AMR is a WHO priority and local guidance (e.g. NICE, I don't know about the states - is it ICER? the CDC?) should reflect this and steer away from "just in case" antibiotic prescriptions.


This is so skewed towards the US. Eg here in Europe people go to their GP much more often because those visits are free, and hard data says we live longer than in the the US. So the problem isn't "doctors" or "medicine", the problem is the US medical system.


Please. I've been through medical systems in several European countries, and the GP system is frustratingly bad. GPs will at best prescribe you some medication, but will otherwise act as entitled gatekeepers to the rest of the system. Unless you're bleeding on their table, they'll do their best to avoid sending you to a specialist. They'll engage in the same charlatanism that GP is talking about.

Healthcare in Europe is not free. You're taxed for it quite highly.

Calling this system "healthcare" is too generous. It only exists to keep people from complaining, and healthy enough so they can be productive enough to be taxed. There is no care.


What? I have never seen these alleged "entitled gatekeepers". I have been passed to specialists with no issue. The public sector healthcare is excellent and the same medical standard as is received in the private sector.

Let's talk about that price. So how does healthcare work out for you in the US system if you cannot pay for insurance? In a public sector system you still get healthcare just the same if your income is zero. The total tax cost for middle (or even higher) earners in European countries is often less than equivalent private insurance premiums paid in the US. In private sector systems you still ending up paying out of pocket even when you are "covered" with those deductibles. So your overall cost is even higher. Don't forget in the US you still pay taxes for healthcare for schemes like Medicare so don't forget to add that on when doing comparisons. What does the typical private insurance policy say about pre-existing conditions and congenital disorders? You're fully covered in public sector healthcare. What if you suffer from an expensive illness? You may find your insurance premiums increase. Your taxes don't increase in public sector healthcare regardless of what illness you have.


It's just americabrain. You can hardly blame them as this is the only system they know and were socialized in. I've talked to otherwise intelligent and well adjusted people who came up with the most spectacular mental gymnastics defending the US health system and coming up with the weirdest reason why public health care in the developed world isn't actually better (you have to pay taxes!!:(), it's absolutely mindboggling and I just laugh at them now. It really sucks for the families who have their lived destroyed due to unnecessary and massive medical bills.


The irony of the comment you’re responding to is that Americans also pay a lot for healthcare in taxes and we don’t even get decent healthcare in return.


> What? I have never seen these alleged "entitled gatekeepers". I have been passed to specialists with no issue. The public sector healthcare is excellent and the same medical standard as is received in the private sector.

I saw it and "suffered" it in the UK. GP visits are terrible there: You only had 15 minutes and GPs seem to always be in a hurry. I've always had IBS and had to go through several GP appointments until they refereed me to a gastroenterologist. Once I was referred, it was pure joy and incredibly good, and I din't pay A DIME.

I also experienced it in Germany. Although it was a bit better than in the UK. My GP in Germany referred me to a specialist Gastro pretty quickly.

I am talking coming from Mexico and the Mexican system. Here we are very used to two systems: A nefarious public one which is just terrible. And a private one which is quite good and at great price. Also, for private care, you can go directly to specialists.


> GP visits are terrible there: You only had 15 minutes and GPs seem to always be in a hurry.

This is how standard care in the US is, even with good insurance. I've always assumed a doctor's time is so valuable it makes sense to carve it into ever smaller pieces.


What we have in much of Europe is mostly a dream compared to clusterfuck that US healthcare is. US has by far the highest costs globally, unavoidable even if insured. People here never think 'should I go to doctor, can I afford treatment'. Thats 3rd world country stuff.

Yes we pay for it, much less than US, but its not part of our net salary so nobody actually cares, this topic is simply not discussed by commin folks, and you can easily see how much stress it causes even to wealthy US folks.

We treat people in same way regardless of their origin, wealth, status, even homeless get top notch care if they dont run away from it.

Something in your words tell me you are not a standard patient.


That's not my (UK) experience.

I can get a telephone consultation with a GP within 24 hours; if I need to see my own designated GP, I can get a face appointment within a week, usually. If consultants are appropriate, I'm referred to a consultant.

There are some specialisms where it's hard to get a referral; podiatry is an example. As far as I can tell, NHS podiatry is mainly reserved for people with diabetes. I had to hire a private podiatrist, £50 per session, 6 sessions. I gather there are long queues for mental treatment (although GPs enthusiatically diagnose depression, and hand out antidepressants like jellybeans).

I don't like taking antibiotics; I don't want to nuke my gut biome, if I can avoid it. I can't remember the last time I was prescribed antibiotics prophylactically.


When was the last time you tried that? In the past month there have been a number of newspaper headlines about difficulties in accessing GP services.

Eg: https://inews.co.uk/news/health/gp-receptionists-care-naviga...


> When was the last time you tried that?

Last summer.

There's been a wave of strikes in the NHS since Christmas; I've only used the surgery recently to renew prescriptions over the phone, and I was able to get through with a 5-minute wait. I haven't had a proper appointment for 2 years.


Your anecdotes aren’t data.

And the data is pretty clear.

Also, GPs should act as gatekeepers to the far more expensive, and far more risky, specialists. That’s what will keep costs down and reduce risks.


They are gatekeepers. That is literally their job. Doctors are a scarce resource that you're not paying for. You think all the taxes you pay in a lifetime is enough to cover even a week in a ICU?


> GPs will at best prescribe you some medication, but will otherwise act as entitled gatekeepers to the rest of the system

I feel that's more on the UK/Irish medical system

On the continent specialists will happily take you without a referral, though usually private only (which to be honest, the "GP as gatekeeper" method is stupid - thanks I know which doctor to go for a skin disease, I'm not from the sticks)


> I feel that's more on the UK/Irish medical system

I've had no issues getting a referral in the UK system, though I appreciate some people do struggle. Hell, I've had to actively turn down the offer of a referral when I felt like the problem would be better dealt with in primary care.


> Healthcare in Europe is not free. You're taxed for it quite highly.

Healthcare isn't free, but the visits to your GP are free, which is what I said.


You are often also charged fees at the doctors office or even emergency care. And places like Sweden have private health insurance so you domt have to stay in the “free” broken system with years of waiting before getting to a specialist. I always cringe when nordics make fun of the US healthcare system. Ours is just as expensive and horribly broken. You may not get a 20k dollar bill for immediate care. You are instead set on a 5-14 year (not a typo ) waiting list.

Sweden is a capitalist country with socialist taxes.


There are waitlists but not for urgent care, this data suggest the US actually has the highest waitlists:

https://worldpopulationreview.com/country-rankings/health-ca...

But maybe if you are rich you can buy a place faster. Not sure if that should be celebrated.


The real hack is having friends and family in the medical field. You can skip the chicanery of medical “intake” and diagnosis outside highly specialized conditions, get advice without extortionate bills or misaligned incentivizes, and they can help you get appointments with specialists/tell you who’s the best to see, even write you rx’s directly.

I recently had an infection that, due to being geographically isolated from my typical medical network of friends and family, resulted in $1k of bills after insurance for something that was essentially routine and which I would have been able to treat myself if I had the ability to get medicine without an rx.

The general public who don’t have the scientific/medical literacy to self-serve and lack the network to get treatment without going through the formal process are getting fleeced.


Friends and family need to be off the clock too, be respectful if anyone chooses to do this.


The flip side is that they sometimes genuinely want to help. As you say, be respectful.

My elderly neighbour (who I saw maybe twice in a decade) had her daughter visiting, and the daughter came by and suggested I might like to change the dressings on her mother’s ulcers because I’m “used to looking at gross stuff.”

I’m a radiographer. I’m pretty much useless in every situation unless someone has a a high field magnets and wants pictures.


Right, I am speaking more about close relationships where they’d offer help without you even having to ask, not some long-lost friend that you only ever bother when you need their medical opinion.


The medical field will soon be over-ran by software and AI specialists applying and graduating from medical school in order to build the modern individualized medicine augmentation systems of the future. Think about the specialization required to build a reliable, trusted and tested GPT-for-medicine, and then give it to all citizens for free, because, hey, it's going to be a huge boon for our country.


Is “rx” an abbreviation of “prescription”?


Yup.

> Rx (sometimes written ℞) is a common abbreviation for medical prescriptions derived from the Latin word for recipe, recipere.

https://en.wikipedia.org/wiki/Rx


> A half-lifetime of experiencing and observing modern medicine, in good faith, has taught me that participating in the medical system while not in need of emergency care is risking one's health and life.

This is rather hyperbolic. And furthermore, your clearly don't have chronic but non-emergency conditions which require regular care if you care to have a reasonable life (3 going on 4 for me).


So you advocate avoiding doctors and prescriptions unless you break a leg? Good luck when you get one of the many things modern medicine does treat pretty well.

Your criticism of it may have some truth to it, possibly particularly when applied to the US, but the conclusions you draw from them are foolish.

And you'll drop them like they're nothing when you get a bacterial infection your body can't deal with, the likelihood of which will increase in the second half of your life. Or maybe you won't, and die much earlier than necessary. We just had this discussion on a societal level.


The worst experience for me has been dentists in the US. To me it’s a massive fraud industry.


Thank you for your comment. Now I don't need to write the same thing.


I think this is a reasonable response to the terrible atrocity that is medical care (in the US*). The way forward is likely going to be the medical form of 'self-hosted': home medical devices for self diagnosis.

There will be many that flock to this comment to make claims about home devices and how they're 'inaccurate' or other nonsense, but the truth is that it is very possible and in many situations already the case that home devices are FDA approved, and often better accuracy than what you may receive in the clinic. Obviously, this is for a subset of diagnostic tests, and certainly nothing dealing with radiation potential, but the opportunity for expansion is certainly there and I think will continue to expand and fill this enormous hole the US has.


You obviously have no clue how this stuff actually works. Most major medical insurers already have programs to distribute connected smart devices for monitoring vital signs to patients that have been diagnosed with chronic diseases such as heart failure or type-2 diabetes. But those devices are largely useless for diagnosis. You can't really get a home HbA1c blood test.


Demonstrably untrue. CVS sells a kit to do hba1c for $50

https://www.cvs.com/shop/cvs-health-at-home-a1c-test-kit-pro...

Other tests can also be done with a lab. You just have to ask.


Yeah, it's a whole cottage thing: https://www.everlywell.com/


Time in range is arguably a better metric to control anyway, and that’s really easy to track now with a CGM and one of the myriad diabetes apps.


Chronically ill person here, cannot help but agree. "The doctor committed neither malpractice nor acted abusive" is the best outcome you can get out of the average healthcare professional.

It's a profession where practitioners are treated like saints, while having zero incentive to actually do their job- there's no other field in which telling every client "it's all in your head" after running some meaninglessly basic and unlikely to be wrong diagnostics until they give up and go home keeps you employed and paid.


How many people have ever heard the term iatrogenic harm? Basically no one. "Iatrogenesis refers to harm experienced by patients resulting from medical care"

Studies put iatrogenic harm at about 30%.

It is also estimated that the 14th leading cause of death in the world is iatrogenic harm


30% of what? What studies?


Yup. I cannot believe how much insurance providers bend over for actual fake bullshit like chiropractors, dentists or "naturopathic doctors" who use homeopathic remedies, and related quakery, but then try to screw people over on stuff that's actually scientifically more sound.


Are dentist really fake bullshit tho? Dental insurance is bullshit but like dentistry is a legitimate profession.

Insurance however is selling to the customer and the government, it's easy to cover the fake bullshit.


I mean dentists who peddle homeopathic remedies. This literally happened to me where a dental surgeon had me purchase some homeopathic thing to use before a surgery and gave me scare tactics about how much I needed to use it. I ended up forgetting to use it, and was freaked out. When they told me not to worry, I had a hunch, and sure enough when I got home, I saw "homeopathic" on it.

I ceased all service with this dental surgeon and filed complaints with my states dental board. They told me to pound sand, as I have to show that this stuff would hurt people. You could hear my eyes roll as I listened to the states dental investigator explain this crap to me.


> They told me to pound sand, as I have to show that this stuff would hurt people.

What total nonsense. What the dentist did is actually _worse_ than just stealing the same amount of money from your wallet. I guess the only reasonable approach is to try to ruin the dentist’s reputation publicly. Or I guess to just move on since that dentist is just one in a million professional charlatans in modern American society.


CBC did a study went to 20 dentists each of them found a different number of fillings required


Out of curiosity, where are you from?

FWIW, I agree with you, although I experienced the medical system only as a patient / outsider. I live in a former communist country in Eastern Europe.


At this point I'd rather die in my house. So much of it is obviously crap and it's so inconvenient and expensive I'd rather avoid doctors altogether.


If you’re on hospice, you can die at home while still making use of the US medical system.


Nah I don't want them involved.


Hospice’s amount of involvement is largely up to you. Also hospice doesn’t only help you, but also your family. That said, it is of course your own choice. I would personally want as as little involvement as possible from people outside the family.


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?


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.


> 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.

That or it's yet another example of selection bias. There have been so so many things like this where the epidemiological data shows a correlation with health, but there isn't actually a causal link. For example, annual checkups might correlate with better health because it's a more common behavior among people who can afford to do it, and wealthier people tend to be healthier.


Here's a local study that try to provide some data - although I'm a little uncertain about the control with respect to yearly checkup (would you do yearly checkup on the control, then do nothing if you found cancer?).

https://uit.no/research/tromsostudy


> exploring virtual care options as a better alternative

s/better/cheaper/


Your industry exists only by taking in more in premiums than you give out in care, correct?


Maybe I’m saying the most obvious thing ever, but with that last paragraph, you really make it sound like the American healthcare regimen is decided upon by the for-profit insurance companies.


On the contrary, preventative services such as annual checkups are mandated to be covered 100% by the Affordable Care Act:

https://www.hhs.gov/healthcare/about-the-aca/preventive-care...


Thanks for the link! That’s quite refreshing to hear. I didn’t realize the Affordable Care Act did so much more than ensuring availability of coverage and whatnot.


The ACA got a lot of headlines for a lot of BS but some of the really great things it did were very basic, under the radar items.

For example, a lot of the research that we are reading (including possibly the article we’re responding to) is the result of funding created by the ACA.

My favorite aspect of it is the massive push to digitization which means handwritten prescriptions have pretty much been eliminated removing an entire class of death and disease causing errors (from pharmacists misreading doctors’s handwriting).


While there are some regulations, it's basically a tug of war between business interests (insurance, hospitals, pharma, device manufacturers, testing companies, revolving door government agencies) that buy politicians and scam the government* and patients. No one would plan a health system this way, but planned economies (for the interests of regular people, not private equity) are "socialism" so we get to be the victims of life-or-death extortion rackets.

Anyway, our government continues to denounce as "authoritarian and oppressive" the tiny socialist island nation of Cuba that built an incredibly impressive health system that exports doctors (such as to Italy at the start of the ongoing pandemic) when they can't even get metal for syringes b/c of U.S. sanctions.

* For a striking example, Rick Scott was Gov. of Florida, now Senator. He was able to do this because he was rich. He got rich by scamming the hell out of Medicare. https://www.newsweek.com/rick-scotts-connection-massive-medi...


[flagged]


Generate profit by reducing cost via better health of the population? I'm surprised you didn't make that connection?


Not OP, but I think the underlying meaning is that the focus on profit is primary. As in when it aligns with better patient outcomes it’s going to happen and that’s great.

But probably there are a ton of scenarios where profit is anti-aligned with patient outcomes and the decisions are made still to maximize profit.

I can believe that. Not because people are wicked, but collective behaviors behind the system favoring profits more than patient outcomes. The system is extremely complex and even small biases somewhere deep can possibly have a big swing in the outcomes.


> Not OP, but I think the underlying meaning is that the focus on profit is primary. As in when it aligns with better patient outcomes it’s going to happen and that’s great.

> But probably there are a ton of scenarios where profit is anti-aligned with patient outcomes and the decisions are made still to maximize profit.

It may align in their financial interests for most of these required preventive services[0] but there are some that very obviously don't like lung cancer (it would be cheaper to let smokers die quickly than to put them on immunotherapy + SBRT) and others with weak evidence, I doubt a good cost-benefit analysis has been performed for weight counseling.

Point being is that insurers are not the final say in a lot of this, the ACA did add a lot of requirements for them. But I concede there are times they don't, OP is just being overly harsh here and "improving health outcomes" isn't an insurance-specific PR line it has been used in academia and the government for a while now, even in public health systems.

[0] https://www.healthcare.gov/preventive-care-adults/


Even so, they are insurers. They focus on profit by cutting costs or increasing revenue. Annual checkups must be believed to do one of those things.


But that’s how the system is supposed to work! The goal of the insurance company is to reduce costs. The govt and the healthcare system are the parts of the system that advocate for the patient.


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.


> People working in healthcare generally do care about improving health outcomes.

If you knew the first thing about capitalism, you would know that what one "cares about" has only the most contingent relation to the end product of their labor. In other words, what the workers care about is effectively meaningless because the workers are not in charge; the profit is.


What profit in public systems and with non-profit insurers is driving increased screening?

Nihilism aside you seem to have a deep misunderstanding of evidence based medicine. While cost is a consideration in population-level screening programmes you seem to be ignoring that it is balanced with benefit and is not decided by insurers but rather the USPSTF.

> what the workers care about is effectively meaningless because the workers are not in charge

The agency in charge of screening (USPSTF) takes the work-product of physicians and other health professionals (workers) researching and building evidence on health outcomes (what they care about) which establishes the standard of care that is then forced down by the government onto insurers.

On an individual level I can also advocate as a physician by recommend screening regimens to patients who's care I am involved in and force the insurer to pay, which is what we did for breast screening before the USPSTF caught up.

Sure if you want to take a reductionist view I am using profit (specifically the fear of liability) as a tool to force the insurer but that does not mean what I care about (reducing breast cancer deaths) is effectively meaningless.


> If you knew the first thing about capitalism

There's no need for this tone (and similarly in your previous comment). From HN guidelines:

> When disagreeing, please reply to the argument instead of calling names. "That is idiotic; 1 + 1 is 2, not 3" can be shortened to "1 + 1 is 2, not 3."

https://news.ycombinator.com/newsguidelines.html


> 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.

In the case of annual checkups, I believe insurance companies are required to cover them 100% by the Affordable Care Act:

https://www.hhs.gov/healthcare/about-the-aca/preventive-care...


The ACA doesn't require insurers to cover annual check ups at 100%. Only certain preventative measures are covered that way.


An annual checkup is one of the certain preventive measures and the Aca does require it to be covered with no cost sharing.


But the second you mention some new issue that’s cropped up, it no longer coded as an annual checkup and you will be paying.

The only way to guarantee a free annual checkup is to go in, say nothing about your state of health, let the dr take your vitals and leave.


Is this universal?

In previous annual checkups with my primary care doctor, I have mentioned symptoms as varied as:

- recent depression

- trouble breathing

- irregular heartbeat

several of which resulted in follow-up appointments / lab work, but all of which were still covered 100% as annual checkups.


Do you have an ACA plan or employer provided insurance??

If you can find a doctor that takes your ACA plan then anything other than checking for a pulse is likely to result in some sort of bill.


Employer subsidized plans are also mostly compliant with ACA. Based on the trends in figure 13.3, I might even say less than 10% of Americans with employer subsidized health insurance are in non ACA compliant plans.

https://www.kff.org/report-section/2018-employer-health-bene...

And I have never had a doctor not accept an ACA compliant plan, which have been in the BCBS network for me.

This website seems to have a decent summary of coverage rules:

https://www.verywellhealth.com/aca-compliant-health-insuranc...

https://www.verywellhealth.com/preventive-care-whats-free-wh...


I don't mean ACA compliant. I mean actually purchased through the exchange, a.k.a Obamacare.

If your employer provided insurance it's good insurance, that's the perk of working there and part of your compensation.

If your employer doesn't provide it you have to buy during open enrollment through the exchange and the plans are terrible and expensive.


Of course, billing is by procedure done.

If you bring up a complaint, it's no longer a preventative check-up, it's addressing a complaint, which has a different billing code and different reimbursement.


Nope. The ACA doesn't classify annual checkups as preventative measures for adults.

https://www.healthcare.gov/preventive-care-adults/


I thought #4/5/15 effectively make it an annual check up.


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.


> 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.

They tried to bill me for that in the past at practices I was a patient of. There's a fine line between preventative care and E/M. You can generally walk the "preventative care" line by presenting your concerns as an observed change to be documented rather than a problem to be solved.

If they do charge you, call the office to appeal the billing and they generally drop it as long as you can push the point that you weren't seeking a specific treatment but rather were just informing the doctor of a change in your health or conditions since the last visit.


Oh yea just call and talk to someone its easy and its not like you are going to be put through the ringer talking to 10 different people over several weeks inexplicably over several continents.


I've not found that to be an issue with smaller practices. Most of the times small practices just have one person other than the doctor who deals with billing. Sure they often outsource past that but if you can get either the doc or that person, they'll often just change the codes because even if they can technically bill you, it's probably not worth the time or effort for them.

But yeah at big practices good luck. They are a living nightmare to deal with and I feel for anyone who can't get access to a smaller (ideally solo) practice.


Because they get paid more when people are diagnosed with conditions.

https://www.nytimes.com/2022/10/08/upshot/medicare-advantage...


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.


> 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...


Major medical insurers are not naive about this stuff. They employ expert actuaries and data scientists who understand statistics and causality.


Sure, they understand the problem... But is there anything they can do about it?

I'm not aware of insurance companies being too keen on getting into medical experiments like 'people with a birthday on a Thursday don't get the free annual checkup'.


I suspect that part of it is that some huge percentage of Americans are obese, and obesity-related health complications are a driving cost center.

If even 10% of those who get an annual checkup succeed in losing weight when the doctor recommends they do so, it's a win.


There was a case here in New Zealand where the "not for profit" insurance company "Southern Cross" was owned by a group of doctors.

You can see how something that might not be in the insurance company's best interest could be in owners best interest, particularly if they own the hospital too.


My work offers free annual check ups and it’s mostly DIY. Prick of a finger, punch in weight, height and blood pressure into web app. Eventually once the results on the blood return, you get feedback on cholesterol etc. I get $500 from it and it is psychological to an extent - it helps encourage healthier habits


Insurance companies don't care if you're healthy - they just want to save money.

Sure, they could prefer healthy customers, or they could select for lower risk populations. The latter is easier.

So instruction following and hoop jumping are the sorts of test that won't improve health incomes, but will select for good customers.


That's simply not how the medical insurance business works. Since the Affordable Care Act, insurers have almost no ability to pick and choose their customers. And since profit margins are capped there is like little incentive to "save" money by reducing medical expenses.


That's not true because they can pick and choose where and what to offer based on geographic areas through the ACA plans. But even more selectively they can offer group plans to employers that incentivize maintaining a healthy workforce. Most unhealthy people don't work good jobs that provide insurance.


Your country is the bizarre case.


> Sure, they could prefer healthy customers, or they could select for lower risk populations. The latter is easier.

how are insurance companies (in the US) supposed to achieve this, when it is generally acquired through an employer?


Under the ACA, insurance companies have a profit cap as a percentage of expenditures, so they need to drive expenses to increase total profit (but still have to be competitive price-wise so it isn't unlimited).


Around here the insurance companies created a billing code that is just for annual checkups, with discussion of ongoing care turning it into a different type of visit (that isn't necessarily free).


They only looked at death, and only two causes of death - cardiovascular and cancer over 10 years. That makes for a pretty stupid study if you ask me..

There are tons of other problems that won't cause death but nonetheless will bother you or subtly impact QOL without you even knowing. Thyroid issues are one. It won't save your life but it will make it a lot more enjoyable and maybe make you more productive too. There are other causes of death too.. so the conclusions they are trying to draw seem completely invalid to me. The study showed equal mortality from 2 sources, it did not show that checkups are pointless..

A lot of the complaints about unnecessary follow-up etc. are down to cost not inconvenience. In most cases, the only follow up is a blood test which is quick and easy. Even a ultrasound/CT is like 1hr. It only becomes a problem when you have to pay $1000s for it.

Whole article is just a gross misrepresentation.


Apropos to a submission about Vitamin D that was a couple of links above this article is the fact that it ignores quality of life.

Sometimes it seems that medical researchers don't actually care about health, they only care about numbers, because numbers are easy.

During an annual checkup a couple of years back I mentioned that I had "been feeling down and sluggish quite a bit lately" and my doctor said "hmmm, might be vitamin d, we'll see with your bloodwork".

Wonder of wonders my vitamin d was low, I started supplementing it, and once my levels got back to normal I unquestionably, irrefutably, CAUSATIONALLY, felt better. My quality of life improved.

I didn't know Vitamin D was tied to energy and mental health issues. Sure there are at-home tests now, but there weren't any back then and I wouldn't have known to take one anyways.

How many people are living shitty lives because of something simple that could be caught during an annual blood test?

Researchers: "We don't care, those numbers are hard to get. Deaths are easy to count."


> People walked out of their appointments having been told they had a condition they might not have known about before. But those additional diagnoses didn’t seem to save lives. Knowing about a particular condition didn’t, in these studies, correlate with better health outcomes.

Duh... I am guessing a lot of these diagnoses require lifestyle changes (instead of med) that the patients wont do, e.g. pre-diabetes, high cholesterol, obesity etc

But it would be wrong to say that these visits are a waste.

> Annual physical exams can “do more harm than good”

Key word being "can", one can say this for literally for anything. They chose one bizarre case that led to expensive follow-ups and a bleeding during the procedure. Most annuals likely dont lead to any follow-ups at all. Let alone follow-ups for a possible aortic aneurysm.

> “I'm not sure you need an annual visit to the physician. You're very unlikely to have any serious diseases that haven't shown symptoms.”

A disease does not have to be life threatening to show symptoms and even life threatening diseases (e.g. certain cancers in women) can have no symptoms until you are beyond the point of no return.

Sometime a person has "symptoms" that they think is a part of life and would never go to the doctor for if not for an annual physical. e.g. I personally know people who have had serious vitamin deficiencies found out through annual tests which they got after many years. Their "symptoms" were lack of energy, focus, hair loss, mood swings, sadness etc. Something most people probably wont go to the doctor for. A few months on high potency supplements and their quality of life changed considerably. Would this be classified as a "serious disease"?


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.


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.


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.


Morbidity is not mortality, it means "suffering from disease". The dictionary definition is "the condition of suffering from a disease or medical condition". So being on dialysis would not be "no decrease in morbidity", no.


Wouldn't the checkup crowd be on dialysis from age 60-80 while the no checkup crowd from 75-80?


Isn't that a tautology? Of course knowing you have a disease doesn't prevent you from having the disease.

The point is that knowing you have a disease allows you to treat the disease, which one would hope would reduce your chances of dying or becoming disabled.


> one would hope would reduce your chances of dying or becoming disabled.

The point of the comment you're replying to is to explain that didn't happen.


Maybe I'm missing something, but is this basically saying treating disease doesn't improve outcomes?


What about relative health while you’re still alive?


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.


> 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/documen...

[2] https://www.ahajournals.org/doi/full/10.1161/HYP.00000000000...


"This is just boldly incorrect and a VERY dangerous statement to make."

I couldn't agree more. I worry that individuals will read things like the grandparents uninformed take on hypertension and conclude "I guess I don't need to worry about my blood pressure". Be careful what medical knowledge you take away from HN. Imagine forming opinions about software engineering practices by reading a forum filled with medical doctors.


That was my worry as well, especially with how misrepresented the cited evidence was.

I’m very supportive of the intellectually curious looking at evidence for themselves, but directly evaluating primary medical research is challenging even for a trained academic physician. Like in all fields, a lot of the papers published (even in reputable journals like NEJM and JAMA) are biased/flawed.

As one example, there was a landmark trial 40 years ago that claimed screening mammography doesn’t improve outcomes which was discordant with other smaller trials and mostly ignored by the medical community. That study was recently exposed as borderline fraudulent[0][1]. Had we stopped screening undoubtedly many women would have died of breast cancer. Those of us involved in colorectal cancer screening/diagnosis are well aware of the Nordic trial, but it is not practice changing.

For the curious HN reader wondering why we do some of the things we do in medicine, my strong recommendation is to refer to the USPSTF or Google “society guideline on [disease/intervention]” where you will always find an excellent summary of the evidence, strength of recommendation, rationale and limitations written by domain experts in that specific area rather than risk misinterpreting a single study, it’s how physicians practice too.

[0] https://academic.oup.com/jbi/article/4/2/108/6555324?login=f...

[1] https://academic.oup.com/jbi/article/4/2/135/6555326?login=f...


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.


Let's not kid ourselves: Americans are terrible about looking out for their health. If an annual physical is what it takes for PCPs to effectively route people to the necessary screenings, so be it. That saves lives.


Under most insurance plans you also can't see a specialist unless your primary care doctor writes you a referral. If nothing else the Free Annual Checkup is a way to get a referral without incurring additional primary care copays. (If you have a PPO, that's not a problem, but you're paying higher premiums to compensate.)


See figure E, HMO and the old style plans are far in the minority in terms of population covered.

https://files.kff.org/attachment/Summary-of-Findings-Employe...

I would bet most insureds in the US can see a specialist without seeing their primary care doctor (if they even have one).


But if they're not done at the physical, the physical is where the doctor asks whether you've been screen/checked for things and when, and then schedules them.

If I didn't go in for an annual physical, I'd never get tested or screened for a single thing. I'd never have blood work done. Because when else do I go to a doctor? How else would I know?

That's what baffles me here. Your annual physical is the launching point for everything preventative. It's the only time you ever see your doctor if you're otherwise healthy. Saying no to annual physicals means saying no to literally all screening, or am I missing something?


That's just completely wrong. You can get preventative care including screening tests without an annual physical.

https://www.healthcare.gov/coverage/preventive-care-benefits...


Of course you can but that requires knowing what you need and when.

I certainly don't. The person who knows is my doctor. And the time they're going to tell me is my annual checkup.


Sample size of one, but I don't get any tests or exams of any kind. This thread makes me suspect that I should. Not really sure where to start.


If you can find a primary care physician near you and ask for a standard "just checking to make sure everything's good" blood test, they'll probably order you something called a Complete Blood Count panel and maybe another that measures blood glucose. The CBC panel isn't used to diagnose anything particular, it's more of a general snapshot that gives you insight into all kinds of potential issues (or, more likely, tells you everything is fine). Mine always come back saying that I'm a bit anemic, but iron supplements don't agree with me so I just live with it.

Another benefit of semi-regular blood testing (and I'm talking once every year or two) is that it provides a good baseline for what your body is like. Then if you ever start having specific medical issues that warrant more tests, you know what your Healthy Levels are and can compare accordingly. For example, my MCH tends to dip just slightly below normal thanks to the anemia, so I know not to take that as an ill omen in itself. Conversely, I've never had abnormal blood glucose levels, so if that starts wavering I'll know something's up.


Thank you. I actually have a primary care physician, although I just don't remember ever seeing him. I'm pretty sure I did at least once though.


A lot of health providers just email or call about the preventative screenings these days.


The standard physical is where your GP teaches you about those things and has you schedule them as needed based on your age and the things they notice during the annual physical.


If that is what the annual is, then it's probably no wonder why they aren't helpful.


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.)


That's different from an annual checkup.


Regular checkups give your doctor the opportunity to encourage you to seek relevant services (like OPs doctor did).


Yep. I will say that the doctor's visit that spurred the colonoscopy talk wasn't an annual checkup, per se, but it was almost as benign—initially went in to complain about a hemorrhoid and mild tummy problems, walked away several weeks later with a pretty serious (but treatable) diagnosis.


Those things are checked and screened for even in places where yearly checkups are unheard of.


...when?

If you're otherwise healthy you're not visiting the doctor at all. So where are these checking and screenings happening for adults?


Here's a review of annual physicals by Cochrane Collaboration, where they looked at 15 studies involving 250,000 people and found no effect: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353639/


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.


I'll agree with this... I had one dumb/obstinate nurse who mis-measured my height 4 inches below my real height... claimed it was that I'd gotten shorter... 2h previous a seperate facility measured me at the real height.

that height is showing up again on my charts. Last 2 visits they measured my height and said, huh chart is wrong, I told story, they were like "we'll fix it". Still not fixed.

She also wanted to put me down in the system as a smoker as I had been in smoking resturants.


At one point someone mis-entered my height as about 4 feet. This obviously caused my BMI to trigger all sorts of alarms! That impact is probably why it got fixed pretty quickly.


Good point


Having lived in three countries with universal health care, annual checkups is a bit foreign concept. I mean you could ask to get tests whenever you want to, but it is not something doctors will recommend. Most people go to the doctor when they experience symptoms.

I don't know how to compare these systems, but I guess if we look at life expectancy, similar European countries are doing pretty well.


I think life expectancy is distorted by Americans being fat, driving more, and drug deaths. Probably violence factors in too, but I'm not sure if that's big enough to meaningfully change things.


The US health care system fails on many metrics. Life expectancy might be distorted, but all these other metrics paint a pretty clear story of the failure of the US health care system to provide health care to the general population.

https://news.ycombinator.com/item?id=35516775


Healthcare or lack there of is something that kills you when you're 50 or 60. Drugs, suicide, homicide, auto accidents are the kind of things that kill you when you're 20.

People dying their 20's skews life expectancy way more then people in the 50's or 60's.


Some of these metrics take that into account, for example Life expectancy at age 60 in years is still lower in the USA then most other comparable countries. This metric eliminates the potential bias you described by not counting anyone who died before the age of 60.

But the point of having a variety of metrics is that other potential biases might be present in some of them, but across all of them, the most likely explanation is a health care system (or health care norms) that work worse compared to health care system in other countries.

To summarize, there may be a cultural reason for some of the metrics (say higher drug usage among pregnant people causes higher infant mortality rate), but if you have higher number of preventable deaths, higher treatable mortality rate, uniquely a negative trend in maternal mortality, higher deaths from suicide, etc. etc. than the evidence that this is the fault of health care system instead of culture starts to become overwhelming.


A lot of Europe smokes like a chimney too. Smoking in the US has been dying out very rapidly.


It's purely a cost issue. Even in those countries, if you're important enough you will have at least an annual check-up.


This is black-and-white thinking. The metric was, saving lives from cardiovascular or cancer causes. Nothing to do with quality-of-life.

I often don't see my doctor but once a year for that annual visit. We cover lots of ground, make adjustments, give me heads-up on what I can expect as I age, and so on. You know, what a GP is for. An expert collaborator on my health decisions.

For god's sake, visit your doctor sometime. Maybe not as often as you visit your dentist or hell, your auto mechanic. But maybe your body is worth some care and maintenance visits? Think about it.


I have a doctor that was essentially assigned to me by the fact that they were the only local doctor accepting my insurance and new patients. It takes two months to get an appointment and my annual check ups are with random physician assistants - not actually with the doctor, whom I have never met.

As an American, I look forward to retiring in some other country with a functional healthcare system.


I don't use an HMO, I have a regular doctor with regular doctor offices and hours and so on. That's an important part of it - somebody I know who knows me, asks about my activities, about my family, who's doing well, how are my brother's kids getting along and so on. A family GP.


Exactly! This headline/article is harmful in my opinion. We need people to get checked more not less!!!


My annual checkup uncovered that I was a raging type II diabetic with an A1c of 8.7 (higher is worse, 4-6 is normal). I changed my diet. Cost to my insurer over the last eleven years? ~$600.

My friend Leroy Nova didn't find out he had diabetes (no annual checkup) until he passed out on a BART (Bay Area Rapid Transport) platform. He spent a month in the hospital in a coma. At $10k/night (typical), it cost $300k.


Yes, but you're ignoring the population aspect.

Let's say an insurance company has 1M members, so if you screen everyone for diabetes each year, it 1M * $100 = $100M.

Or you don't screen everyone, but just pay the costs when they get so sick they are admitted. So it's 1M * 0.01% (diabetes that results in 30 days of hospitalization) * $300K = $30M

You just saved $70M by not screening everyone.

And it's not just private insurance companies that do this, government paid healthcare systems do too. It's just basic health economics. Of course, the goal is to include all costs, lost work, etc.

It's an entire field of study.

The thing is - when you look at how best to allocate healthcare dollars, what's great at a population level can suck at the individual level because you're just one patient out of millions.


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.


This sounds like you've missed the point entirely.

> 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.

The point of the movement as I understand it is that this is actually a pretty significant problem. Extra checks due to "possible problems" aren't free - it's always paid for by somebody, and even if that isn't your wallet directly, it still take up time, inconvenience, and usually physical discomfort. Some have pretty significant risk of complications. Often, nothing is found or what was suspected to have been an issue wouldn't have affected the patient's quality of life. Exactly where the line should be drawn is debatable, but the point is it's not necessarily a good thing to aggressively find and investigate all "possible problems".


Most tests have a high enough false positive rate that it can cause real issues with real false diagnoses too.


People really think annual physicals ought to help, for all the reasons you listed. But they've been studied extensively in empirical trials, and they just don't; not everything that seems like it ought to work actually does. (Just like how the Earth feels solid, flat, and stationary, but of course we know now that it's a spinning sphere.) Here's a review by Cochrane Collaboration, where they looked at 15 studies involving 250,000 people and found no effect:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353639/


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


> Physical manipulation is cheaper than a scan tho!

This relies on the assumption that the physical examination has useful sensitivity or specificity as a screening tool which is untrue.

As an aside, MRI screening is not supported by evidence with the exception of select patients for breast cancer and people with hereditary cancer syndromes.


Checkups save lives.

It's a bit ridiculous to speak of needing evidence for that.

Catching cancer early is of great importance. Hence the yearly breast control checks.

The question is one of cost benefit in this regard and wether the annual checkups proposed can be more efficient regarding types of tests and demographics


> Checkups save lives. It's a bit ridiculous to speak of needing evidence for that.

This is a silly attitude. Maybe you should do some salutations to the sun god Ra if evidence isn't significant.

> Catching cancer early is of great importance. Hence the yearly breast control checks.

Breast cancer screening isn't annual (in women or men).


Many people really do want a form of shamanism still with their medical care.

The shaman does their useless ritual once a year and people are satisfied they are protected from black magic until the next annual checkup.


Large scale meta studies dont provide any form of substantial evidence, they point to vague correlations, from which you can look for causation.

Feel free to do salutation to the false god of large scale metastudies :).

Here you already know causation. Early diagnosis is proven of great benefit for many diseases. It's more effective to specially study different groups of people and see what does and doesn't work.

Btw here breast cancer is biannual indeed, annual if you had it. Might differ per country.


It's not as simple as you're suggesting. Take cancer screening for example. Doing more investigations and more procedures for things that weren't going to become problematic puts people at risk for the complications of those procedures.

Screening programmes need to be carefully thought out, not only from a cost-benefit, but from an actual risks vs benefits perspective.


Which is why in other countries, such as the UK, the NHS will look at the potential for preventing disease/extending QALY based on peer-reviewed evidence, the risks of harm and overall cost-effectiveness before then coming up with a model for the whole population when it comes to screening which targets patient demographics most likely to benefit. The following conditions are pro-actively screened in this way:

- Abdominal aortic aneurysm

- Bowel cancer

- Breast cancer

- Cervical cancer

- Diabetic eye screening

Patients with early symptoms of e.g. skin cancer can get moles checked out free of charge, and the yearly dental & vision check will screen for conditions like oral cancer and glaucoma.

The harm of something like a yearly colonoscopy in the general asymptomatic population would far exceed the potential benefits.


Yes, and the screening committee publish their methodology and evidence. https://www.gov.uk/government/organisations/uk-national-scre...


Wasn't that my point?


> Screening programmes need to be carefully thought out, not only from a cost-benefit, but from an actual risks vs benefits perspective.

vs.

> It's a bit ridiculous to speak of needing evidence for that.

So from my perspective, you were saying the opposite, and using an argument I've heard before about the power of prayer.


> Catching cancer early is of great importance

Is it? There's lots of stuff (including lots of cancers) where finding it early doesn't have much impact on all cause mortality.


I live in a country where annual checkups are mandatory (companies are fined by the government a lot of money for each employee who does not get it done). I've been told a couple times now that something is a bit off, not too concerning by itself, but it requires more tests to rule out suspects from a list. had a lot of blood tests done, nothing unusual came up, still being regularly told to keep doing tests in between checkups. I can say perhaps one of the upsides is I get nudged by the doctors to keep a healthy lifestyle.


This is very goofy.

I had no idea I had high cholesterol or high blood pressure. I have a healthy diet and exercise, but it just runs in my family. A checkup found that very early and now I'm on medication that controls it.

I believe they didn't find a change in 10 year mortality, because none of this was going to kill me in 10 years, nor would finding out about it 10 years before my death help very much. But finding out now while I'm relatively on the younger side has a real chance to move the needle.


Most of my medical issues I caught were do to me being proactive. Even HMO is very lax in actually taking care of people.


> 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.


Most people probably do not need an annual checkup:

https://nutritionfacts.org/2021/04/20/is-it-worth-getting-an...

> many health authorities “have all agreed that routine annual checkups for healthy adults should be abandoned”


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.


Not really surprising. The biggest giveaway should be for Americans to look at other countries. Annual checkups really are not at all the norm in most places. In the UK for example, the last time I saw a doctor was about 16 years ago when I broke my wrist.


Korea and Japan have high quality cheap health care and people there visit all the time.

https://www.statista.com/statistics/236589/number-of-doctor-...


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...


As a layman (not a medical professional), I've never heard the term "periodic health maintenance visit" before reading this comment.

I've definitely heard "annual physical" and "annual checkup" before though. And that's what my insurance pays for once a year for free, in my understanding.

It seems like "periodic health maintenance" is necessarily a part of an "annual physical/checkup", just the same as a quick physical inspection is part of your annual as well.

But that Vox is ignoring the "periodic health maintenance" part?

Why? Out of ignorance or is there an agenda here?


> I've definitely heard "annual physical" and "annual checkup" before though.

"periodic health maintenance visit" or just "periodic health check-up" is more of the newer academic/formal medical term (for example on UpToDate which is a very strong authority in clinical practice) but in real practice (when I used to do this) we also used annual checkup or physical. This was both with patients and other health professionals, it's just easier and it doesn't make a practical difference to you or me but in the context this article they're mostly referring the actual old annual physical exam.

> It seems like "periodic health maintenance" is necessarily a part of an "annual physical/checkup", just the same as a quick physical inspection is part of your annual as well.

> But that Vox is ignoring the "periodic health maintenance" part?

Keep in mind this article was written in 2016. This is from the article (emphasis added):

>"Almost nothing in the complete annual physical examination is based on evidence"

I was in residency around then and it was in the early days of screening evidence and tests becoming available and cheap. This was before even all the fancy new colon cancer stool tests came out and it wasn't that long before this article came out. We were even routinely ordering unnecessary labs like screening liver function tests and checking urine (which still happens sadly) on 30 year olds once a year who are in completely good health.

I think when this was written the annual physical actually meant an annual physical with a laundry list of unnecessary labs, but it was transitioning to the period where we use those words to mean a visit primarily aimed at evidence-based primary/secondary prevention and during peak "Choosing Wisely" campaign to reduce unnecessary investigation. I think the authors agenda is positive but seems misleading in the context of 2023.

Honestly, in my opinion if you're palpating an aortic aneurysm these days you're practically a nutjob but people (and myself) were absolutely doing this circa 2016. This is what that looks like[0], so even if you have someone skinny enough that you can feel this through their abdomen (the aorta is in front of the spine) we're pretending this is anything more than voodoo when we have cheap ultrasound (if appropriate).

[0]https://i0.wp.com/medicine-opera.com/wp-content/uploads/2016...


Thing is, however, that statistics don't deal with the individual outcomes. Just because statistically the health checks are claimed not to make a significant difference, it doesn't mean that they couldn't save your life at some point.


Unless you have some pre-existing medical condition or are over 45 years old ... I don't see the purpose of annual visits. I'm in my late 30s and haven't gotten a physical in a decade. Why would I? I'm heathy, exercise, sleep enough, have a good diet, etc. All they do is weigh you, make you answer 1000 questions, engage in some impersonal small talk, and push unnecessary inoculations on you (oh, and suggest expensive blood/lab work). I feel fairly attuned with my body so if something is wrong, I can go to a doctor, but "preventive" medicine, just seems like a money making scheme.


I feel like an annual blood test, done at a cheapo outpatient facility, would be far more useful than a typical physical.


About a year ago I went in for a regular checkup after my wife reminded me I had not had one. I thought, I’m 25 don’t really need one. Turns out my blood cell count was slightly elevated. 2 months later I do another test, it’s off the charts. Turns out I randomly developed leukemia. 11 months of chemo later, and I’m in remission. Not sure what would have happened if we had not caught it so early.


So what's the alternative? Just wait until something bad happens to come in? Seems a lot more unproductive.


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.


But I would never get screened or do blood work if it weren't for 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.


In most cases, you’re far more likely to get a false positive than a real positive with those tests - unless you feel or notice something wrong already.

That is what is being pointed out.


So if this article is not against regular blood checkups then what...?


"“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?""


At the turn of the century in the early 1900s we were nuking babies' thyroids cause the only corpses they could find had diseased thyroids and the healthy babies had them. So obviously something must be wrong.

There's always value in the counter example to see where our processes breakdown and fail.

What we learn tomorrow in how abnormal our bodies are from another?


So bloodwork yes but no touch...?


If it ain't broke, don't fix it. Most diagnostic tests have good sensitivity (they pick up most cases of real disease) but relatively poor specificity (they pick up lots of false positives). Actively looking for asymptomatic disease does identify some diseases earlier and improve outcomes for those patients, but it also subjects a large number of patients to expensive, inconvenient, painful and risky tests and treatment. The benefits to the former group are matched almost exactly by the harms to the latter group, so (with very few exceptions) just waiting for symptoms to emerge gives you the same net benefits at significantly lower cost.


> So what's the alternative? Just wait until something bad happens to come in? Seems a lot more unproductive.

Maybe it does seem less productive, but really it’s just a reminder that surprising results that contradict are intuition need not be wrong.


Make a list of which screening do appear to be beneficial, and setup doctor visits based on the recommended schedules for those screenings instead of annually.


Does this list exist anywhere? I would have assumed so, but I'm struggling to find it.


Or maybe it's exactly the same?


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!


> "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.

The American Medical Association is not a research institution, it is a lobbying group and price-fixing cartel. I would not trust any doctor that is an AMA member.


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.


What does proactive medicine look like? Or do you just mean eating healthy and exercising? Everyone knows you should be doing that.


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.


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/recomme...

[1] https://www.uspreventiveservicestaskforce.org/uspstf/recomme...


Proactive medicine.

You wake up in the morning and have a piss. Your piss is measured for various chemicals from simple ions to proteins. It detects you have too much sodium so it communicates to your food dispenser and your bacon ration is reduced. (Yes that's from The Island.) You then get dressed in front of a camera which counts your moles and freckles. It sees a new one so you get a notification that your Touch Grass(TM) session is shortened.

When you get to work your workstation monitors your alertness to ensure you sleep enough. It detects your attention drifting 5% more than tolerated so another notification comes in letting you know Lights Out(R) is now 15 minutes earlier.

You attend a social gathering after work but your purchase of an alcoholic beverage is denied because a blood test last week showed a liver enzyme was elevated 1% out of the baseline range.


You posit these interventions like any of them have a shred of evidence to suggest they're effective (or that we actually have reference ranges and test accuracy for what you're suggesting) and conveniently ignore civil liberties.

"liver enzyme was elevated 1% out of the baseline range" is medically meaningless but let's pretend the patient is cirrhotic so your hypothetical is valid, this individual has a constitutionally protected right to be an idiot and continue drinking themselves into death.


You do not have a right to damage government property. You must live so that you can pay taxes. The government will ensure this. When you are no longer productive you will be prescribed MAID.


It’s data driven.

You get tested every few years and adjust diet/supplements/exercise based on the findings.


Random screening are more harmful than useful. Overdiagnosis[0] is a thing.

[0]: https://en.wikipedia.org/wiki/Overdiagnosis


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.


I’m not a care provider, but I’ve worked in healthcare for a long time. The real answer is: there is no consensus among doctors about this. Opinions vary widely. The article alludes to this. One thing I do know: tests are not the reliable gold standard they’re believed to be, and even when ‘accurate’, interpretations of results vary and evolve over time.


The Cochrane review referenced was updated in 2019 and if anything the conclusions are stronger now: https://www.cochrane.org/CD009009/EPOC_general-health-checks...


American healthcare system is for profit. That's why you should always be suspicious when they say something. You're dealing with a used car salesman.

In the Netherlands doctors are not concerned with renumeration- only science and statistics. Efficiency and productivity are necessary for a public healthcare system.


This is really a bad article, one that can actually have a net negative effect on the world. Vox is trash.


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…


> 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?


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.


Even assuming a nonzero risk of death via annual checkup (however close to zero that may approach), I'd still be hard-pressed to believe that that causes anywhere near as many deaths as it prevents. For every person who contracts pneumonia in the waiting room and dies(?) there have to be at least two people who get a hypertension diagnosis and go on meds that prevent an early heart attack. Probably a lot more than two.


Hypertension isn’t a fast killer.

So it’s not that people should never go to the doctor, just that going every single year doesn’t have any benefit for young healthy people over going every 3 years.

And again don’t discount the impact of regular visits reducing the odds someone goes to the doctor with new symptoms. This rash is converting but I’ve got a visit scheduled in a few weeks so I might as well wait etc.


> For every person who contracts pneumonia in the waiting room and dies(?) there have to be at least two people who get a hypertension diagnosis and go on meds that prevent an early heart attack. Probably a lot more than two.

Do you have any evidence for this claim?


Do you have any evidence that primary care visits are killing people, let alone at a higher rate than preventable diseases do? How is that not the far more outrageous claim here?


> Do you have any evidence that primary care visits are killing people, let alone at a higher rate than preventable diseases do? How is that not the far more outrageous claim here?

Shall I take this response to mean that you, in fact, have no evidence for your claims?

Instead of being defensive you might consider researching the basis for your beliefs? Besides the defensiveness is unwarranted. I never said or even implied that your beliefs are wrong. I only implied that without evidence, you might consider that scenario.


I'm not normally a fan of the r/atheism style of debate where people invoke the names of various logical fallacies to make themselves feel smart, but this does seem like a good time to revisit that little concept called the "burden of proof."

The initial commenter I responded to made a decidedly outrageous claim that primary care visits kill more people than they help. And I'm starting to think that even acknowledging that claim was a waste of my time, because now I'm being asked to seriously prove that doctors are not recklessly slaughtering patients by asking them to turn and cough once a year.


I am following actual research, as mentioned in the article. It’s not difficult to test the outcome of annual doctors visits, and shockingly they don’t save lives.

You’re seemingly basing your opinion on gut feelings or something.


The article says:

> They found that “although general health checks increase the number of new diagnoses, they do not decrease total, cardiovascular-related, or cancer-related morbidity or mortality.”

And then gives a single anecdotal example of a biopsy gone wrong that almost (but didn't) result in a patient's death.

You made a completely orthogonal claim that annual exams *"cost as many lives as they save," which is extremely dubious on the face of it and not supported by the very research you're claiming to cite.


> cost as many lives as they save

That’s literally what failing to reduce total mortality means. You can’t statistically separate saving 0 lives and costing 0 lives with saving 5 lives and costing 5 lives.


No it does not lol. Failing to reduce mortality is not remotely the same thing as actually increasing mortality.

"Cost as many lives as they save" means the physician visits are actively driving deaths that would otherwise would not occur if those people had not visited their doctor (which is also what you said, like, two comments ago).

"Failing to reduce total mortality" means that physician visits did not save people who already had medical conditions that were going to kill them.


> "Cost as many lives as they save" means the physician visits are actively driving deaths that would otherwise would not occur if those people had not visited their doctor (which is also what you said, like, two comments ago).

Unless there is spare capacity, a bunch of young, healthy people going to a the doctor means that older, unhealthy people are unable to. Is it really that hard to imagine a scenario in which more people visiting the physician could lead to more deaths occurring?


Ahh, taking a moment to bask in the ignorance. If nothing else car accidents are going to kill some of them.

You’re arguing that billions of doctors visits for hundreds of millions of people save save exactly 0 lives and cost exactly 0 lives. That seems unlikely, but even still 0 = 0.


Okay so I guess both the poster you responded to as well as you are making unfounded claims? Okay I won’t argue against that. I’m sure this comment thread has had hundred of unfounded claims made supporting various positions. In any case, I guess you are confirming that you in fact don’t have support for the claims you’ve made.

> because now I'm being asked to seriously prove that doctors are not recklessly slaughtering patients by asking them to turn and cough once a year.

I never said you claimed this. If you would like to bring in debate terminology, you seem to be engaging in a straw man.


"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.


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.


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.


Yes they do need one and the article is trash because it makes it look like includes all med exams. Colonoscopies, blood exams,blood pressure exams etc are absolutely necessary. It's just plain silly to think they are bad for you. Really dangerous.


You gotta say why they’re wrong so we can evaluate it.


Because the article talks about med exams like it includes everything. It will make people skip their annual breast exams, colonoscopies, blood exams and so many other things that should be done annual and they said lives. Thus, the article is indirectly killing people. Yes the author. From his ignorance.


On the other hand, because this article exists, I read these comments. And I have concluded that there are probably some tests that I should do, although I'm not sure exactly what yet. But I'm going to get some kind of test. As opposed to none, like before. Take heart.


Back in the day, there was a strong earthquake occurred in China. During that time, some experts brought up the idea of Triangle of Life, and claiming that "If you found the Triangle of Life of building that you currently at during an earthquake, you'll likely survive it's collapse".

Problem is, the Triangle of Life was "selected" by the building during the earthquake. That means whether or not you can "found it" is largely down to chance.

The same thing is true for medical checkups. Because there are so many things occurring inside that biomass, whether or not a checkup can discover abnormality is largely down to educated chance.

Here in our city, a full-body checkup in the city hospital costs around $2,000. It includes blood and urine test, MRI & X-Ray & B-Ultrasound scan for conditions that are common, cardio stuffs, endoscopy from both directions and a few others. But even that kind of test still has misses, so again, it's down to chance.

On the other hand, when done correctly, checkups do have it's benefits. There are stories that I've heard claiming medical checkups (some full-body, some just good old regular) saved their life. So I guess you just have to manage your expectations, change it from "This will definitely help me" to "I'm playing a Whack 'em All that comes with a few risk factors all by itself".

> Annual physical exams can “do more harm than good”

There is a fun story: I had an endoscopy a long while back. In the middle of the operation, the doctor in charge decides to hand me over to a med student (which is a common practice in China's state/city funded hospitals during graduation months) who I assumed should just be there doing observational study among the other classmates. Long story short, that dude, has blown too many air into my colon and it was painful. But still, I was not in a "bled to death" situation, the doctor was quick to correct it, and he also kindly told me to "just fart it out". I hope the student learned something that day.


My partner was trained in primary care and basically said the same. Obviously it’s not so black and white - there are patients with risk levels that warrant regular checkups, but most people do not need them and for them risk of false positives outweighs an undiagnosed positive. The regularity of checkups should be a call made by the medical team and patient, not something pushed by insurance.

Some people in the comments are complaining this article encourages the other extreme, never visiting your doctor, but I think most researchers and doctors would argue that the frequency of checkups should be based on their view of your health and risks. Too frequent or too rare check ups are both a problem.


If you read the financial plans of these direct primary care clinics you’ll see that they intentionally lose money on primary care with the strategy of making up for it in increased referrals business.

Healthcare is so greedy. Thanks for sharing this.


In the U.K. it is not normal to go for an annual examination at all. Here, once you hit 40, you get an examination every 5 years unless you have some specific health condition which would requires you to be seen more frequently.


Something I find interesting is that more and more single-service, tech enabled medication providers are popping up. Example - if I want ADHD medication, there's a service for that, and there's another service for hair loss medication, yet another for weight loss medication... How do PCPs feel about this? It has to represent a loss of control for them when their patients can basically go out and get what they want in such a low-friction way.


I'm not a PCP, but some of this self-service healthcare is very concerning from a public health perspective. One of the biggest problems in American healthcare is overtesting, overdiagnosis and overtreatment. Quick and convenient access is obviously very good for some patients, but there's a significant risk of harm if patients are given easy access to treatments that may be ineffective, unnecessary or actively harmful to them, based on commercial imperatives rather than medical need. The most tragic example is the proliferation of pill mills, which were one of the fundamental drivers of the opioid crisis.

I'm obviously opening myself to accusations of paternalism, but unnecessary healthcare causes real harms on a drastic scale. By some estimates, as much as a third of healthcare spending in the US is on treatments that offer no medical benefit; all of those unnecessary treatments carry some level of risk. The consequences of inappropriately prescribing ADHD medication might seem trivial if you once took a few ritalin or adderall to get through your exams and suffered no serious adverse consequences, but these drugs can cause devastating harm in patients at risk of mania - bipolar disorder and cyclothymia can look a lot like ADHD if you ask leading questions and don't take a thorough history.

The US healthcare system is obviously broken, but the proliferation of self-service healthcare offers at least as many risks as potential benefits.

https://www.choosingwisely.org/



Even the title is baffling to me. It has "TV doctors" in it. TV doctors!

I can't even begin to imagine all the possibilities, almost none of them good, of having such a thing in the first place. This has to be on the same level as tv shamans and what not.

[proceeds to the article, finds about they mean "tv show doctors", then realizes this changes nothing. literally nothing]


One thing that definitely makes sense is yearly eye checkups, including eye pressure. I had undiagnosed glaucoma for a year or two until my eyesight got bad enough to go to the Dr. No headaches or anything. Fortunately I still have enough vision left to read most normal sized text, but it was close. Get your eyes checked out, you can get glaucoma at any age.


Screening by mammography increases the incidence of breast cancer: https://twitter.com/daniel_corcos/status/1659854579993903106


I've started to use chatGPT4 as a major part of my routine healthcare. I can comfortably ask question I want at my pace to really probe each symptom and likely cause, tailored to me. Easily better than most general practitioners I've had.


(2016)


Think there's plenty of evidence that the countries in which the average person sees a doctor more often have higher life expectancy.


Perhaps because they can see a doctor when they need one?


And the link titles on hacker news are following the same trajectory that Reddit did about a decade ago. It's depressing.


There’s a website that can pass the test to become a doctor now. Why can’t I order my own diagnostics?


Just by the fact that they recommend 1 year which is just an arbitrary number of days picked(365) is a red flag. Every person should have different days, say you have family history then after age 50 visit more often even less than a year. They are just lazy to apply individualized care


Or just get yourself some chronic disease and be regularly checked monthly.


Incredible how much contrarianism flourishes on HN just for the sake of it


What contrarianism are you referring to? Are you saying that those who find the idea that recommending everyone get annual checkups might be suboptimal health policy are just being contrarian? Or is it because you are bothered by the idea that your preconceived notions on healthcare policy might be wrong?


Yes the idea is false and contrarian and the article puts under checkup everything undoing centuries of medical science. But OK, it's against the mainstream thinking bruh


Are you claiming that centuries of medical science have supported the idea of the annual physical?

Honestly I’m having trouble following your point. The article is pretty clear in its arguments. Which do you find so unreasonable? Could you quote to me a part of the article contradicted by centuries of science?


Just 2 simple things:a) the article under annual checkup is a Mashup pop science.b) annual exams and preemptive medicine are worth it, all medical science is based on either preempt and treat early or late.

Now if you think that doing annual exams is harmful and catching diseases early is harmful and everyone believes it OK, humanity believed earth is flat for a long time. Doctors believed covid is nothing, you can find videos of doctors saying that early etc. Skip doctor, go only when you have pain brother.


I asked you to quote something from the article that you disagree with. Given it’s apparently so bad, this should not be difficult.

Edit: Also maybe refrain from irrelevant nonsense like the following:

> Now if you think that doing annual exams is harmful and catching diseases early is harmful and everyone believes it OK, humanity believed earth is flat for a long time. Doctors believed covid is nothing, you can find videos of doctors saying that early etc. Skip doctor, go only when you have pain brother.


I'll be shallow and say this. Anyone that thinks that it's better to find cancer late than early or diabetes or blood pressure needs a head examination.


> I'll be shallow and say this. Anyone that thinks that it's better to find cancer late than early or diabetes or blood pressure needs a head examination.

I'll be shallow and say this: I don't think you remotely understand what the article is saying. Let's make it simple and only consider a single of the article's points: there are not enough primary care physicians to provide yearly checkups for everyone. In this scenario, providing yearly checkups to someone healthy in their thirties is done at the cost of _not_ doing it for someone else. If that person is at a higher risk for cancer or diabetes, then promoting annual checkups for everyone can easily make it _harder_ to find cancer early since we're not focusing on high risk people. Of course there are many more points to the article (e.g. unnecessary treatment), but that single point is enough to make it quite obvious that the article is not entirely without merit.

What I find incredible is that you keep repeating that the article is terrible yet even after repeated questioning you are unwilling (or unable) to actually quote any single aspect that you take issue with.


Yes the article is bs because your argument is that there aren't many physicians and maybe the insurance companies complain for costs and this is humongous vastly different than prevention and erly screening is bad. And the article doesn't differentiate. No more discussion, going to do my annual blood exam. You skip it.


> Yes the article is bs because your argument is that there aren't many physicians and maybe the insurance companies complain for costs and this is humongous vastly different than prevention and erly screening is bad. And the article doesn't differentiate. No more discussion, going to do my annual blood exam. You skip it.

This might be the most incoherent post you've made so far. Honestly, what are you even talking about? The article never once made an argument against screening. And the number of physicians and the cost of visiting them is extremely important for any analysis of the system.

But yes maybe you're right that there should be no more discussion. You have after all not actually pointed out a single paragraph or sentence from the article that you claim is wrong. You haven't even really made any sort of argument. You've just repeated that the article and the research are wrong without providing any supporting explanation.


This is insane and your ego too.

"The article never once made an argument against screening"

How do you start screening without an annual physical? You book doodle appointments from things you saw on Wikipedia? I just can't, stop. Calm.


> How do you start screening without an annual physical? You book doodle appointments from things you saw on Wikipedia? I just can't, stop. Calm.

So basically your point here is that you claim it is impossible to convey information about standard screening schedules without doing an annual physical? I mean you understand that's a ridiculous claim right? It could be done by a doctor over the phone, or a nurse, or another system.

Your point is totally illogical. Why does it need to be yearly? Why not every other year? Why not every 6 months. Even taking your ridiculous claim as fact, it doesn't imply anything about how often these physical exams need to occur.

> This is insane and your ego too.

My ego? You've claimed over and over how bad the article is, yet you haven't pointed out any reasoning supporting your statement. You are the one with an enormous ego. You seem totally incapable of accepting that maybe just maybe you could possibly be wrong. Learn a little humility.


Tell me a country you live and you can schedule screenings without actually having a physical even for the first time. Let's cut the bs and make a public bet with escrow. Only way to make people realize they talk bs.


The US?

https://www.honorhealth.com/healthy-living/time-colonoscopy-...

Hopefully we can now get passed the fact that you are unquestionably incorrect. I don't need your money, but if you'd like you could maybe take the public bet and send it to a public organization promoting colonoscopies.

Aside from that, you should maybe take a moment to reflect and ask yourself why you're so stubborn about this topic. Let's say that research showed that annual checkups are unnecessary and don't promote overall health, but for bureaucratic reasons you are required to see your primary care physician in order to schedule screenings like colonoscopies. Well then obviously the answer is to change the system so that that no longer is required right? Right? Why is it you can't see this? Do you think that it's literally impossible for patients to receive this information except by way of a physical exam? Like you actually can't imagine another possible approach for this information to possibly reach the patient?

edit: The more I think about it, the harder it is for me to wrap my head around your position. Your point is that basically that we need to get more people at risk for certain diseases to get certain medical screenings. You are (presumably aware) that the vast majority of those people are older. Your solution to this is to tell _everyone_ regardless of age or history to go to the doctor because that is the _only_ way to get people at risk this kind of information. You even stand by this position even though there is a clear shortage in many areas of primary care physicians meaning you are making it even harder for high risk people to go to the doctor by telling low risk people to do so. How can you not see that your position is ridiculous? How can you not see that overall this practice could possibly maybe just maybe not be a good idea?


We can't agree I bet we can't agree on many other things. I think the opposite of whatever you say in fact.


Annual PSA checkups absolutely save lives.


I don't know, in Japan they do a mandatory yearly checkup for every employee, obviously the doctors there believe it is good, they also live very long.




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