OP-ED

Radiologists vs. Mark Cuban on Don’t Ask / Don’t Tell

https://twitter.com/mcuban/status/583468799145349120

To his credit, Mark Cuban, engaged on Twitter in response to my post.

Mark, I’m sorry I had to leave Twitter abruptly. My wife threatened to kill me and then divorce me – in that order – if I didn’t get off Twitter instantly and get the groceries.

However, I caught the tail end of the Tweets. I’ll do my best to respond.

1. “Why is this contingency all radiologists?”

Mark wondered why everyone on a thread about overtesting were radiologists. It would be a great question if radiologists, who deal with testing, overtesting, limitations of testing, harms of testing, benefits of testing, appropriateness of testing, in other words the science of testing, would be offering advice on financial planning or offering the White House advice on their ISIS policy.

I can do no better than quote @jeffware.

“Exactly Mark – why are the Drs. who specialize in testing trying to explain the dangers of overtesting?”

That was a rhetorical question. But there are some entrepreneurial radiologists who are licking their lips at the epidemic of overtesting. I can hear them say “Mark and acolytes, bring it on.”

To wit, overtesting is better business for us. So our objection is not financially motivated. Let me make this even clearer. The more blood tests and genomic tests the “must prove that I’m healthy” brigade have, more $$$ for radiologists.

2. “Why if doctors fail so often do you want to limit patient interaction?”

Mark asks, given that doctors fail, why should we limit patient interaction? Given the context of the discussion, I’ll take patient interaction includes quarterly blood tests for everything.

If doctors promised 100 % certainty, immortality and never missing any diagnosis ever than we certainly have failed. We’ve failed to be honest. Medicine is not perfect. Information is imperfect.

When the healthy, remember we’re talking about the healthy, fish for disease that they could have but may well not have, they’re more likely to encounter a false than a true positive. That’s because many more people have that warning sign for early disease than actually have the disease the sign warns about.

Let’s say ten thousand Marks have quarterly blood tests to spot the earliest sign of a disease such as cancer. One sign of cancer is a low hemoglobin – this is one of many. Then one Mark, let’s call him Lucky Mark, will live longer because of vigilance. That Mark was destined to have cancer and the lower than baseline hemoglobin tipped him off that there could be cancer brewing. He then had a whole body scan which found a pancreatic cancer, which was nipped in the bud, and he lived happily ever after.

But there are many more Marks who have a slight fall in hemoglobin who don’t have pancreatic cancer or any cancer. The problem is we don’t know who the Lucky Mark is amongst them. They, too, will have whole body scans to look for a cancer because of the fall in hemoglobin.

There are some Marks, let’s call them Unlucky Marks, who have the whole body scan, which finds a lung nodule. This could be cancer but most probably is not. We don’t know. To confirm we biopsy. The biopsy is negative – that is no cancer. Unlucky Mark dies from a complication of the biopsy. Remember, biopsies are dangerous.

Think of Unlucky Mark. He was healthy. He would have lived happily ever after. But he wanted the medical system to prove that he was healthy. He wanted to make sure he was not Lucky Mark. Curiosity killed Unlucky Mark. Unlucky Mark died to save Lucky Mark. It’s like hanging an innocent man. Is this a fair trade?

Information is messy. This concept is hard even for doctors to grasp, so I don’t blame non-physicians for not getting it. Doctors have done a lousy job of explaining imperfect information. False positives are dangerous because we don’t know they’re false positives before a whole lot of intervening. We don’t know who the Lucky Mark is and who is the Unlucky Mark. If I knew I would be God, or at least a very rich man.

3. “So you believe don’t Ask/don’t Tell is a valid healthcare strategy to avoid overdiagnosis?

You’ve nailed it, Mark. For completeness let’s explore other strategies.

  1. Ask but not tell. Why ask in the first place?

  1. Ask and tell.

Once found, we don’t know it is overdiagnosis or not for sure. That’s the nature of information. Even if biopsied and biopsy says cancer it could very well be overdiagnosis. Cancer is not a single entity – there is mild badness and very bad badness.

The question is what do you want to do with that information? Let’s say it’s a tumor of the kidney that’s most likely overdiagnosis but you don’t know for sure. What next? May be surgery. Surgery has complications. Sooner or later someone will be harmed for a condition that never was destined to cause the person any problems. Is that a victory?

4. “The question for elective testing is how much data is the right amount.”

That’s an excellent question, Mark. Permit me to rephrase. How much data is necessary to prove that I’m healthy and not diseased?

This question has more philosophical than scientific implications, but it implies something. It implies that we must prove that we’re healthy not diseased, that the burden of proof is on those who say we don’t have disease. This has problems. Imagine if our legal system operated the same way and the burden of proof was on the defense to prove the innocence of the accused, rather than on the prosecution to prove the guilt of the accused. In fact it’s worse. Because we are talking about the healthy – they don’t have symptoms – they are not even the accused.

There’s no way to prove one doesn’t have disease with certainty. But it can get messy. The deadliest cancers are also the fastest growing. The only way to catch the fastest growing cancer is to scan the whole body regularly, at least faster than the cancer multiplies and invades. That means scans every two weeks or so. Since we don’t know which possible growth is the fast growing cancer we’ll be taking out tissue unnecessarily, although we’ll catch some fast growing cancers, sometimes. Soon Homo sapiens will be without any organs.

So on the scanner every 2 weeks and a biopsy every other month. Is that how you envisage the human race to spend their time, Mark?

Do you test the water for arsenic before drinking it? How do you know it has no arsenic for sure?

5. “There are no facts in an absence of data. Only educated guesses.”

Excellent point, Mark. I think every data-driven dullard should have this line tattooed on his forehead.

I’ll make a few points. Not all educated guesses are the same. I suspect the educated guess of the flying conditions made by an airline pilot is more valid than mine (that’s an educated guess). You get the drift here. I don’t call the pilot or air traffic controller paternalistic, even though once I was stranded in DFW because of a storm.

There never has been a controlled scientific study on the benefits of parachutes, or anti-venom for rattlesnake poisoning. Only an idiot would deny the use of either because of “lack of data.”

But testing in the healthy is not the same as jumping off a plane. If you don’t use a parachute you’ll die. If you don’t get tested you’ll likely live.

6. We need perfect information.

During the discussion futurists chimed in. Futurists are a combination of entrepreneurs and physicians who are distinguishable by certain traits. First, they use the term “disruptive innovation.” The term has created such a paradigm shift in me so that when I hear it I’m paralyzed with catatonic boredom. Second, they’re “solving” problems. It’s unclear exactly what is being solved and why. Third, they oppose status quo. But what’s on offer instead of status quo is never mentioned.

It’s like saying to car drivers “in the future we’ll have automatic flying cars fuelled by cow dung. Release your grip on status quo.”

Release my grip on status quo? Come again? Until the future car comes I’m going to have to do with my Honda Civic, which smells like cow dung.

Future promises that are not here yet can’t be a prescription for the present.

Like toddlers who haven’t controlled their sphincters, futurists wet themselves with excitement over what is patently embryonic.

May be in 2125 the human race will have perfect information. When one urinates, a computerized screen called Watson will detect subtle DNA changes in the urine which will alert a team of robotic surgeons called Da Vinci that there is an 8 mm cancer brewing in the sigmoid colon. Then a spaceship will hover over the lavatory, and internalize me and take me to hyperspace, and then, using minimally invasive cryogenic robotic surgery, the robots will take the cancer out in five minutes. Then a robot will give me a Press Gainey satisfaction survey to complete. Within an hour, I’ll be released and be able to visit the “Museum of Paternalistic Physicians” and read all about the crusade in medicine which brought about utopia.

Until then I have to make decisions with partial information.

About the Author

<em>Saurabh Jha is a radiologist and an armchair pontificator. The pontifications do not represent the views of his employer, spouse, fourth grade teacher, personal trainer or anyone remotely associated him. Follow him on Twitter @RogueRad</em>

 

 

Spread the love

Categories: OP-ED, THCB

Tagged as: ,

72 replies »

  1. Over the years I have had many patients that were symptomatic from hypothyroidism and didn’t know it until after they started on Synthroid. It was only then that they realized that they were better off with it than without it. I would say that is a positive outcome.
    We have to remember that TSH is not a of form of thyroxin rather a hormone that stimulates the thyroid gland when the body lacks thyroid. That makes it a very sensitive and useful test that is responding to the bodies own natural call for more thyroxin.
    thanku for sharing
    beulah (healthcareadmin.org)

  2. Thanks for your insight Mark. I’ve been a physician for over 40 years. I have watched dramatic technological changes in medicine but the social change of delivering care remains almost at a standstill or moving backwards. It is my opinion that but for technology medicine would be moving in the reverse direction.

    There is an undo amount of government intervention in the practice of medicine due to entitlements and the fact that tax deductions for health insurance revolve around an employer/ employee relationship and the employer not the patient is in control of those dollars. Thus the patient cannot fire the doctor/ insurer. He is not in control as no one cares about the patient because everyone is answering to someone other than the patient while placing additional burdens on the professionals to solve their own problems (not the problems of the patient).

    Among the many interesting comments you made your belief that we needed 3X the number of physicians than we have is central to the problems I see. When I first started practice overhead was about ¼ – ⅓ of receipts. At the end of my years of practice my overhead was about ⅔. The percentage of time spent with the patient was probably >er 4/5. The administrative time to meet insurer, Medicare and legal requirements dramatically increased over the years and today with government promoted EHR’s might have well exceeded two thirds of the time which strangely could account for your calculated need of 3X the number of doctors. (I am talking about things from the Internist’s vantage point, the primary care provider. I am also including unnecessary time spent with the patient that is done only to meet administrative requirements.)

    Formerly we were forced to spend enormous quantities of time evaluating physical symptoms and signs to make a tentative diagnosis. Today with the MRI etc. we are very frequently told what the disease is or is not. Yet, we seem to need even more time. Government’s intervention has been against doing tests, yet those are the things that speed up diagnosis and frequently make better diagnosis. The only reason government cares is because of cost, but the only reason they cost so much is that these tests are not in the free market place and have become political as so many people are feeding off the healthcare system. In a free system prices of MRI’s and the like would rapidly fall.

    Your view into the future went further than I was actually looking for. You were talking mostly about advances in medical technology which appear unlimited. I am looking at the divide between the scientific advances in medicine and the lack of development in changing the way care is delivered and who delivers that care (we need technology of a different source than is being forced down our throats). Hospitals are nothing more than brick and mortal malls with a lot of specialty stores inside. Physician offices are just mini malls. Technology if permitted to innovate (something government is intimidated by) in the present should have the ability to completely change the delivery system today. I can almost envision that in my head now just like you envision personalized medications, but yours is something for the future when my vision should have started to be realized years ago.

    Your point about the fears of doctors messing with people’s lives is justified on all sides, but frequently medicine is dictated by consensus while rapid forward movement is created by outliers. Rather than creating 3X the number of physicians which is costly I would rather create a better process reducing the need of physicians and create 3X as many scientists. Every physician is a potentially lost scientist and that might not be the best deal.

  3. There is no question that there will be Drs that offer data analytics support and get paid a premium for the service

    Which may be how you get less testing. Charge for analytics

  4. There’s sure seems to be a consistent trend toward anti-paternalism among our Direct Primary Care (DPC) physicians. It would be great to do a survey of attitudes between physicians in different models.

    Many, like Sunil, will support Mark’s side of this, including, I’d wager, Garrison Bliss, co-founder of Qliance, one of the real innovators in the field, highlighted in Time in December: See “Medicine Gets Personal” http://time.com/3643841/medicine-gets-personal/

    Isn’t it odd that those that are on the hook for seeing patients get better and lower costs are the ones that are more open-minded and less paternalistic about what works and what doesn’t, and even additional testing?

    Not really.

    As he says, “There are no insurance codes for ‘cure,’ In that world, more information does not automatically mean more treatment and more cost, it means better decisions.

    Mark, you may find part of an answer to your question in the 2nd to last paragraph of the TIME article,

    “When people say this is going to worsen the physician shortage (because docs can see fewer patients), Umbehr says, “No. The current system is worsening the physician shortage. The ship is already sinking. We probably talk to 10 doctors per week who are burned out, going bankrupt, ready to retire years before they ought to. And when they see they can take better care of their patients and never deal with insurance companies again, and earn $210,000, $220,000, $250,000 per year, you’re going to see physicians flocking.””

  5. I am an Internal Medicine Physician, a long time lurker and have a Direct Primary care practice. Wow !! a very lively discussion.

    @Saurabh: I am a big fan of your posts and have been meaning to contact you. I have to take an opposing stance here.
    @Mark : Mark , I am one of the few physicians that completely support your position and actually let my patients get tested as they need.

    Here is why:
    1. It is great that patients care about their health: Too often it is the opposite problem Diabetic patients that that don’t ever come back for testing or take their medications.
    2. It’s natural that people want to do something to improve their health: Whether it makes a difference or not , trying is quintessentially human and the essence of American dream. Restless, not happy with status quo, striving for something better.
    3. Cost of testing is trivial: Labs tests cost nothing to run. If they are expensive, the question should be why in this day that the entire genome can be sequence for a 100 bucks does it cost more to run a simple thyroid test.
    The cost of a thyroid test is the same as a cup of coffee. Even if it adds no medical value, why not? I want it, I pay for it, end of story.

    The problem lies not in the testing per se, but in what we do with the data. If the doctor recommends additional testing then that is not the fault of testing (which will inherently show false positives) but in the doctor’s risk tolerance. If the patient demands additional testing, then the doctor needs to explain the risks to the patient, including the risks of invasive procedures for testing. If the doctor cannot adequately explain that to the patient maybe there is an inadequate doctor patient relationship.

    If doctors do not take a lead in understanding this phenomenon and channelizing the patient desire for health information they will go a far worse source.

    Do you know how many patients, I get that talk about bio-identical hormone testing, salivary hormone levels etc.

    Paternalistic attitudes by physicians is what is bring about this quackery of complete micro-nutrient testing, whole body cleansing etc.

  6. I am an Internal Medicine Physician, a long time lurker and have a Direct Primary care practice. Wow !! a very lively discussion.

    @Saurabh: I am a big fan of your posts and have been meaning to contact you. I have to take an opposing stance here.
    @Mark : Mark , I am one of the few physicians that completely support your position and actually let my patients get tested as they need.

    Here is why:
    1. It is great that patients care about their health: Too often it is the opposite problem Diabetic patients that that don’t ever come back for testing or take their medications.
    2. It’s natural that people want to do something to improve their health: Whether it makes a difference or not , trying is quintessentially human and the essence of American dream. Restless, not happy with status quo, striving for something better.
    3. Cost of testing is trivial: Labs tests cost nothing to run. If they are expensive, the question should be why in this day that the entire genome can be sequence for a 100 bucks does it cost more to run a simple thyroid test.
    The cost of a thyroid test is the same as a cup of coffee. Even if it adds no medical value, why not? I want it, I pay for it, end of story.

    The problem lies not in the testing per se, but in what we do with the data. If the doctor recommends additional testing then that is not the fault of testing (which will inherently show false positives) but in the doctor’s risk tolerance. If the patient demands additional testing, then the doctor needs to explain the risks to the patient, including the risks of invasive procedures for testing. If the doctor cannot adequately explain that to the patient maybe there is an inadequate doctor patient relationship.

    If doctors do not take a lead in understanding this phenomenon and channelizing the patient desire for health information they will go a far worse source.

    Do you know how many patients, I get that talk about bio-identical hormone testing, salivary hormone levels etc.

    Paternalistic attitudes by physicians is what is bring about this quackery of complete micro-nutrient testing, whole body cleansing etc.

  7. The tech sector will leave people better off at a lower cost. Moores law will have its day. But we are 5 years off from minimal impact. 10 years off from Marginal Impact.

    In 20 years we will all look back and think 2015 was a barbaric year of discovery

    to give perspective. We pioneered the Streaming Industry TWENTY YEARS AGO. And now we are finally seeing streaming becoming mainstream as a technology but it still cant scale to handle mega live events

    HealthTech will continue to move forward quickly with lots of small wins. It will slow down when there is an inevitable recession in the next 20 years, then jump again afterwards.

    in 30 years our kids/grandkids will ask if its true that there were drugstores where we all bought the same medications , no personalization at all, and there were warnings that the buyer may be the one unlucky schmuck that dies from what used to be called over the counter medication.

    We will have to admit that while unfortunate it was true. Which is why “one dose fits all ” medications were outlawed in 2040 🙂

    By then hopefully we will have a far better grasp on this math equation we call our bodies.

    Of course it will be long before then that we make decisions based on optimizing health rather than trying to reduce risk

    The biggest challenge will be training health care professionals.

    Medicine today seems to be in that 1980s phase that tech went through where no one got fired for hiring IBM. So IBM got lots of business because it was the safe choice rather than the best choice.

    As best i can tell from my involvement in funding a single study on HGH for injury recovery (just getting started), becoming well versed on performance enhancing drugs and from the feedback on the blood capture and testing discussions, doctors are rightfully fearful of messing with people’s lives , so they make the IBM type decisions that “no one got fired for” or they dont get sued for. (again, just my observations).

    This may not be the best process for those who can invest in what they hope are the best minds. But its an understandable process when the funnel of people healthcare professionals have to see stays full continuously .

    Which is why I think part of the market and government response will be to increase the number of healthcare professionals

    We need 3x (or some multiple, this is a guess ) as many doctors as we have today so that the amount of time spent per patient can increase to better understand and use the dramatic increase in data we will see.

    Anyone have any good ideas on how to train 3x more doctors annually, with better quality at a lower cost ?

    IMHO, thats the holy grail

  8. I have one question to ask Mark Cuban. If the government weren’t so heavy handed, collectivist and controlling and litigation wasn’t such a dire threat does he believe our large technology sector could rapidly revise the healthcare sector in a market fashion that would leave all people better off at a lower cost? The bloat caused by excessive government intervention in the healthcare sector is astounding.

  9. John, I suppose a lot of people will state how horrible that is, but I see it as a way to lower prices and permit the individual to gain control over their own lives. Imagine real prices! It will also stop some of the other labs from jacking up prices when insurance doesn’t cover the bill. (In the somewhat distant past I saw bills jacked up 10-20 times what the insurer would have paid if filed with a different diagnosis.)

    What would happen if MRI’s (along with a lot of other things) were done in the same fashion, read in India with the results returned to the patient? Imagine all those patients that had back pains but were refused the MRI by their insurers. They could probably end up paying in the $200 range to find out that the MRI was normal and only go to the physician if needed. There would still be a big profit and the government and taxpayer could save billions.

    I know Mark Cuban’s technological know how could dramatically change the way healthcare is delivered permitting the patient to be the boss and moving government to the sidelines.

  10. Am I actually in a comment thread with Mark Cuban? OMG! But seriously, I think that yesterday’s signing of the Arizona law allowing tests without physician order tilts the playing field significantly towards Mr. Cuban. It was backed by Theranos.

  11. “testing data is quite useful is for self-management of chronic disease.”

    Agree.

  12. We can all choose a word to mean what we want it to mean when we want to mean as we want to mean. Vanilla can mean raspberry.

    So now I have a new meaning for paternalism.

    Paternalism: I don’t like that you don’t like what I like.

    Feel free to change the meaning.

    More a more scholarly discussion see Through the Looking Glass by Lewis Carroll.

    “When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’

    ’The question is,’ said Alice, ‘whether you can make words mean so many different things.’

    ’The question is,’ said Humpty Dumpty, ‘which is to be master — that’s all.”

  13. A benchmark of Paternalism- arguing about definitions in order to prove your position is correct

  14. A better definition of collectivism might be:

    Someone likes alcohol. A law is passed so that all taxpayers including those that do not drink have to pay for alcohol, but the collectivist specifies the alcohol has to be single malt.

    Willing buyer? No.
    Willing seller? No.

    Collectivism.

  15. As I read through the various statements from Mark Cuban, Saurabh Jha and the various commenters, one place where testing data is quite useful is for self-management of chronic disease. Who criticizes the insulin-dependent diabetic patient for regular or even continuous blood glucose monitoring, to help manage insulin intake safely? Granted, we have some distance to go before similar low-cost, reasonably accurate testing is available for all of the various chronic diseases where the magnitude and frequency of medical intervention is dictated by data. But there is a sizable potential population of chronic disease patients who would be helped by better and more frequent data about how well controlled their condtion is.

  16. “collectivism”

    If the tax payer is paying for your single malt regulatory agencies decide which brand you drink (collectivism)

  17. Today me and my entire family has the flu including copious vomiting (in our bed by the 3 yr old and 7 month old–at least the parents made it to the bathroom!). None of us drank single malt yesterday.

    On the other hand there has been the odd occasion when I drank way too much single malt and also vomited. I couldn’t find the bathroom, or for that matter the house.

    But today (for obvious reasons) I discovered the location and the instructions for how to use the washing machine.

    So there’s confounding and colinear impacts of single malt and flu–which makes me very confused

  18. “ You are talking baloney (paternalism)”

    You got anecdote right so now we have to work on paternalism. Just to let you know that non doctor, Mark Cuban, was the one that made the accusation of paternalism so take it up with him. I just agreed that a lot of your statements made in the past sounded as if they were in parallel with Mark Cuban’s thinking.

    In a way I liked your short remarks followed by a word related to those remarks because they are so you and revealing, but you left out the remark having to do with collectivism.

  19. “Sounds like you want to define symptomatic in your own way.”

    Not at all. I recognize that symptoms are often denied because the patient doesn’t recognize them or denies them. The note will read asymptomatic. There is an art in obtaining a revealing history and it doesn’t start with the collectivist approach.

    A person isn’t symptomatic until it is recognized that the person has symptoms and that sometimes only occurs after the fact.

  20. Anecdote vs. Evidence vs Advice vs Paternalism…

    Drinking single malt has stopped me from developing flu (anecdote)

    Fewer episodes of flu in those randomized to drinking single malt (evidence).

    Everyone should drink single malt. It stops flu (advice)

    You are talking baloney (paternalism)

    Government should pay for single malt (entitlement)

    We need evidence before third parties can pay for single malt (value-based healthcare)

    Everyone is entitled to opine what saves them from flu (freedom)

    We need science to determine efficacy of single malt (elitism)

    Burden of proof is on he who asserts the benefit of single malt (epistemology)

  21. “That’s why it’s called an anecdote.”

    No one labelled or at least not I labelled the Mark Cuban’s example as anything but an anecdote. However, there is scientific proof that many develop hypothyroidism without recognizing any symptoms.

    Mark Cuban, as a patient, was exactly correct in the way he personally assessed things though not necessarily correct in the medical aspects of the discussion. I like people who think out of the box and I like people that are independently minded. Frequently they are outliers, but they are the one’s that frequently can take big steps forward. As long as you do not advocate coercion with regard to my personal healthcare needs I have little problem with your desired goals in healthcare.

    Note: Great scientific advances frequently start with a single anecdote.

  22. “Mark Cuban might have developed hypothyroidism and not known it.”

    Correct.

    That’s why it’s called an anecdote.

    That’s why if we generalize it, we must run trials to account for those eventualities,

    This is the essence of hypothesis testing. Crux of science and evidence-based medicine.

    I think we, that is you, me and Mark, all agree with the definition of anecdote.

  23. ” disease states to normal fatigue, getting older or they simply deny their symptoms”

    Sounds like you want to define symptomatic in your own way.

    ok, symptomatic according to the rest of the world is asymptomatic according to allan. That’s ok. You suspected they might have hypothyroidism, treated them, they got better. Well done. That’s clinical medicine.

  24. Saurabh writes: “I have asked how might the outcome have been different without the testing.”

    Mark Cuban might have developed hypothyroidism and not known it. He might have blamed his fatigue on getting older or simply working too hard which a doctor might readily believe. The diagnosis may have been delayed for a considerable time period during which one of his many businesses may have suffered from the loss of his direction causing some people to lose their jobs.

    Anecdote Alert: When I was still a medical student decades ago I worked one summer at Brooklyn State mental institution. I had to do a lot of physicals and found a number of people who were hospitalized for decades that had undiscovered thyroid disease. I can’t say that was the cause of their hospitalization, but it was a potential explanation.

  25. That’s the whole crux. Individuals don’t need a hypotheses to collect data about themselves, but a physician needs a hypothesis to order a test.

    A patient can be curious. A physician can’t make a recommendation because of curiosity.

    Physicians are further down a decision tree, but that doesn’t mean satisfying curiosity is “useless”.

    Reminds me of all the big data vs. little data arguments about whether you need a hypothesis to gain insight. It turns out that sometimes you don’t need a structured experiment to see a pattern, you just need to open your eyes.

    Consider: perhaps we’d be able to see just how poor some tests are with more hypothesis-free testing.

  26. “Symptomatic vs. asymptomatic.”

    Obviously you are not a clinician dealing directly with the human element. Many people attribute disease states to normal fatigue, getting older or they simply deny their symptoms. Thus they are considered asymptomatic at the time of the testing. When the result is abnormal especially with hypothyroid disease they and their doctor still might not recognize any symptomatology until treatment is begun. You are a nit picker uninfluenced by context.

    Though not perfectly on target the disease apathetic hyperthyroidism might help you understand the context. For the lay person that is a form Grave’s disease (hyperthyroidism) seen mostly in elderly adults that do not appear to have the symptoms of hyperthyroidism.

  27. “First, they use the term “disruptive innovation.” The term has created such a paradigm shift in me so that when I hear it I’m paralyzed with catatonic boredom.”

    I came, I read, I laughed. Dr. Jha’s distinctive rhetorical style has at last intersected with the ideal complementary correspondent.

    Mr. Cuban, lay down your pen – you’ve met your match….

  28. “I am not affirming your point at all.”

    Symptomatic vs. asymptomatic. That was the point you affirmed.

    In the example below your patients had symptoms, then were treated for hypothyroid. That is they were SYMPTOMATIC.

    “Over the years I have had many patients that were SYMPTOMATIC from hypothyroidism and didn’t know it until after they started on Synthroid.

  29. “Symptomatic – gets treated – does better. ”

    I am not affirming your point at all. When the test was performed as a routine these patients did not know they were symptomatic and didn’t find out until after treatment was begun.

  30. “ the point was addressed to you…”

    I wanted to make sure you understood that Mark was not acting as a doctor. I gave you my answer which is documented scientifically. I demonstrated how outcomes might be better by doing a routine TSH.

    Not everything in clinical medicine revolves around pure science. Placebo’s work despite the fact that they contain no pharmaceutical benefit. My time in practice as an Internist was spent with human beings, not with computer images. I find there is far more in treating a patient than just science and reproducible data. That doesn’t mean that I don’t adhere to the scientific method, just that the variability faced in the treatment of various human beings seldom has complete scientific backing.

    “And cautioning that his anecdote is not generalized is not paternalism…”

    But to the recipient, Mark Cuban, it was paternalism and I expect he is correct because you promote coercion to get the healthcare system you desire. That is paternalism.

    Allan: “personal healthcare to everyone else”
    Saurabh “I’m sorry you feel this way about evidence-based medicine.”

    I don’t know how you tie these two statements together. There is little relationship between them that is important. I believe in evidence based medicine as much as possible, but the truth is that for much of internal medicine, especially when dealing with co-morbidity, there is little direct high level proof that what one is doing is correct. The evidence is inferred from a population that is generally on the younger side and has a singular disease.

    Today I worry even more because so many well intentioned physicians think that cost and a third party’s value of a particular life must be mixed with science to determine what is or is not acceptable evidence based medicine.

  31. “That is not what you have done”

    That is EXACTLY what I have done.

    I have asked how might the outcome have been different without the testing. Only a hypothesis-driven trial can answer that, though not with certainty.

    “I have said my situation is anectodal.”

    Then we have come to an agreement.

    The agreement is this:

    – your situation is anecdotal

    – you feel empowered by the collection of data (that no science can deny, and even a detractor like myself acknowledges)

    – you have a right to advise others based on your anecdote

    – to answer the value of quarterly testing we need science

    – that quarterly blood tests (+/- downstream tests) for the healthy should be paid out of pocket, not covered by insurance

    Where do we disagree?

    ” I think the risk of something bad happening from the process of extracting IA less than the reward of having the information available to me to use or not use with my doctor as we see fit”

    It was a good discussion, Mark. I think it should be recorded for posterity. Thanks for engaging.

    Best,

    Saurabh

  32. I have no problem being questioned. Ask away.

    That is not what you have done

    I have said my situation is anectodal

    I have not said having quarterly blood work accomplishes anything other than giving a personal baseline of information

    I agree it would be nice to have a study to prove the impact one way or another .

    Until then, I think the risk of something bad happening from the process of extracting IA less than the reward of having the onformation available to me to use or not use with my doctor as we see fit

  33. “Over the years I have had many patients that were symptomatic from hypothyroidism and didn’t know it until after they started on Synthroid. It was only then that they realized that they were better off with it than without it. I would say that is a positive outcome.”

    Symptomatic – gets treated – does better. Sounds like you practiced good clinical medicine on the symptomatic. You are affirming my point.

  34. “Mark is not acting as a doctor”

    But the point was addressed to you, not to Mark. I know you can act like a doctor.

    “Mark is not asking to be more than an anecdote.”

    And he has a right to. And cautioning that his anecdote is not generalized is not paternalism, it is acknowledging that it is an anecdote.

    “personal healthcare to everyone else”

    I’m sorry you feel this way about evidence-based medicine.

  35. “Mark can’t tell me the counterfactual. What if he did not measure the TSH? How would outcomes have been different?”

    Mark is not acting as a doctor so the words he uses mean different things to him than they they might mean to you. As physicians we have to learn what the patient is trying say. The best way to do that is to ask the patient and explain the subject matter.

    Over the years I have had many patients that were symptomatic from hypothyroidism and didn’t know it until after they started on Synthroid. It was only then that they realized that they were better off with it than without it. I would say that is a positive outcome.

    We have to remember that TSH is not a of form of thyroxin rather a hormone that stimulates the thyroid gland when the body lacks thyroid. That makes it a very sensitive and useful test that is responding to the bodies own natural call for more thyroxin.

    Mark is not asking to be more than an anecdote. He is asking to be treated ‘completely’ as defined by him. He is not forcing everyone to do things his way. He is simply stating what he as a layman thinks is best. Why do you wish to make Mark Cuban fit into everyone else’s mold (That is part of our own ongoing dispute where you wish to dictate personal healthcare to everyone else.)

  36. “promoting your suspicions as science suggests paternalism”

    What I asked you is precisely science. How do you know regular blood tests help.

    Answering with an n of 1, “in my experience”, is an anecdote.

    The burden of proof is on the person who states the benefit. That is it is on you that quarterly blood tests are helpful, not on me.

    Anecdotes have a place in society. Literature is rich because of anecdotes.

    But anecdotes are not science. And questioning anecdotes is not paternalism, it is the want of science.

  37. Saurabh Jha

    i have ever bit of faith in science. Just that my hope was that when people
    “wonder” they then ask/inquire rather than suspect.

    asking is science.
    promoting your suspicions as science suggests paternalism

    and Mike, we self insure, so i do pay for it and one of my companies does offer it. And it has not led to any surge in testing or stress

  38. Mark,

    If you feel so strongly about this issue, please pay for all of your employees that work for your various companies for which you have ownership of, to have quarterly blood tests and full body scans.

    Then pay for all of the treatment of ancillary tests which inevitable come from all of these screenings.

    And please do this all in Texas so the surge in demand doesn’t screw up my network of physicians.

  39. “test in the book which would include pregnancy testing that I am sure Mark wasn’t asking for.”

    How about CRP, zinc, selenium, ANA, p-ANCA, c-ANCA (to name but a few gender-neutral tests).

  40. I had the pleasure of having a simple test turn into an exam which turned into a camera being inserted into my urethra, which turned into a ultra sound, which turned into a CT scan which ended up being nothing.

    I would love to experience this on a quarterly basis.

  41. “Take note of what Mark told you: “You continually “suspect” and conclude Rather than just ask me.”

    Wondering is called science, allan.

    Mark can’t tell me the counterfactual. What if he did not measure the TSH? How would outcomes have been different?

    The only way of knowing, with reasonable certainty, the counterfactual is randomization, trials, control of confounder, hypothesis testing.

    That’s the difference between evidence and anecdote.

    ” ‘completely tested’ which is different.”

    Who determines what is “complete?” The patient or the physician? And on what basis? Whim, evidence or anecdote?

  42. But, some are requesting that all involuntarily pool their dollars making it financially impossible for them to be responsible for those things they prefer.

    It all gets down to coercion vs freedom of choice.

    ___

    In Marks case as a layman I don’t think he was asking to be tested for every blood test rather he was asking as a layman to be ‘completely tested’ which is different. Patients of mine asked me to test everything all the time and they didn’t mean every test in the book which would include pregnancy testing that I am sure Mark wasn’t asking for.

    That is the problem with not appropriately communicating with the patient and not knowing one’s patient well enough to understand what the patient is saying.

    Take note of what Mark told you: “You continually “suspect” and conclude Rather than just ask me.”

  43. Bird, I think NNT is still important for the individual.

    Taking the drastic case, only for illustration. Jumping off a plane with a parachute: NNT – 1.00000000000000000000001

    90 year old being screened for prostate cancer: NNT – trillion (quadrillion?).

    The population is not irrelevant in making personal decisions, even by die hard choiceists.

  44. Mark, thanks for continuing to engage. This is gracious of you, as you are in no obligation to discuss.

    We “wonder” because wondering is the essence of science.

    We “wonder” because we don’t have parallel universes where we can see whether your checking of cholesterol made more impact than simply checking your weight. This is an interesting question.

    This is science. If it disheartens you, imagine how I feel. I have to deal with it day in and day out.

    The “what if” is relevant. Because if 100, 000 people of your demographics are checking TSH regularly there will be a variation in experience. One person without symptoms might start the medication to combat the TSH. He would be treating the TSH not the symptoms. He would never have symptoms but would be on a treatment without benefit. He might even be harmed by the treatment, for no benefit. This is his choice, no doubt. Nevertheless, the choice does not mean he has not been overtreated.

    Blood tests induce other tests.

    “IMHO, once your blood is taken. TEST the blood for EVERYTHING possible.”

    Even without bringing imaging in to this, there are a lot of things that can be tested, and a lot of permutations and combinations.

    Anyway, I’m not going to zoom on to “everything.” The examples you have given me show that you feel empowered, in being tested. It still brings one to wonder, what if you weren’t tested. That’s science, not paternalism.

  45. if you are a c-suite person you want your personal healthcare to be about you and that means that you dont look at the number needed to treat stats because you are only interested not being the 1 in 1000, the corporations that you manage employ population health measures. That means that you dont look at the 1 in 1000 number the same way. You focus on not doing the test because you focus on the 999 that dont have the disease. not saying either side is right or wrong, just reality

  46. And I apologize for the typing mistakes. I’m rushed and on a phone and I dont see an edit function. If i wasn’t clear enough. Just ask any questions u may have

  47. Saurabh
    I’m sorry to say this but your approach is more than disheartening

    You continually “suspect” and conclude Rather than just ask me. It costs you nothing but a few key strokes and some time to get more info from me. I obviously have been willing to respond.

    Have I not been obvious enough .?

    As far as cholestoral, in my case when I say the word diet it is not some fad diet that I follow just to lose pounds.

    I gave up as much cheese and dairy as I reasonably could

    ( I dont ask restsurants to take the cheese or dairy out of recipes, I just try to avoid cheese and dairy based dish’s and products ”

    As far as my tsh , I started synthroid based exclusively on my blood test results. I had zero symptoms. Obviously that could have pre empted any symptoms .

    As far as an ultrasound, that has never been discussed. I didn’t even know that was an option and I have no reason to choose it

    As far as the threshold for taking synthroid, it was a discussion with my Dr. The fact that we knew I would be getting tested again meant we could try the least invasive option , synthroid, and see the impact gave me the choice to try it , or not. I knew I would be getting more data.

    And to paraphrase you ” I wonder if you only wonder and suspect or actually investigate and discuss ”

    And as far as “test everything ” it was obviously within the context of a blood test. You know better than I do the options available when you get your blood tested. IMHO, once your blood is taken. TEST the blood for EVERYTHING possible

    It was several your profession and a few of those who who write about healthcare that “wondered and suspected ” that what I tweeted in 420/characters was a proclamation for people to take as many tests as possible on a quarterly basis

    It was not
    I could not have been more clear about that.

  48. Since medicine is evolving all the time, there is no simple right or wrong. What we know today will change tomorrow. As far as my experience is concerned Mark points out two screening scenarios that I believe are strongly warranted in the general population, thyroid and lipids (cholesterol +). The frequency of course is debatable. I think Medicare denies payment for routine thyroid disease without symptoms, but I found elevated TSH’s in patients where the symptoms were hidden until the test made one focus entirely on thyroid disease. Why deny a screening test of that nature where a patient can essentially be cured and relieved of unknown symptoms with a relatively innocuous pill?

    Today, because of budgetary concerns, we have a tendency to beat ourselves to a pulp in an attempt to reduce testing. Is that a good thing? For many of the most common blood tests we are talking about pennies, nickels and dimes.

    Years back in order to save money Medicare demanded that many screening tests (such as the SMA-21) on hospitalized patients be excluded from admission testing on Medicare patients and an SMA -? (lesser number) be done instead . Since SMA-21 testing is batch testing (21 different blood tests) our hospital simply blacked out the testing that wasn’t supposed to be included. What was found was that the minimalist testing in some cases required more tests after further evaluation. That meant the entire SMA-21 and perhaps other tests had to be performed. This meant time lost, added days to hospitalization and markedly increased costs. Medicare abandoned the program.

    What should or should not be done should be left to the patient. The paternalism I see from some in my profession is sickening. Paternalism by itself can cause patients anxiety and can deter them from speaking their mind and thus getting the treatment they need. Of course we should not do all tests as screening tests because we don’t know what to do with the results and therefore might cause more harm than good, but for many of these tests we are not talking about harm, rather cost that has been involuntarily pooled.

    My answer is full disclosure to the patient and whomever the patient relies upon in a way that minimizes anxiety but permits the patient adequate information and guidance to help the patient make the best decision for his own needs and not the needs of a bureaucrat in Washington. I favor Marks position though I would temper it with additional knowledge so that he could make the appropriate choice. He isn’t asking anyone else to pay his bills.

  49. I was going to try to write something original to add, but Spencer and Matthew pretty much have it.

    Docs are struggling to realize that self-directed self testing is in a different decision domain than clinical testing, and likely much more accommodating of noisy data.

    As others have said, it’s not the data, it’s how you choose to act on it.

    20 years ago, doing a photo (or 10) of yourself every day would have seemed extravagant and expensive. Today, commonplace.

    I think we’ll see the medical selfie arise as a thing as costs plummet. We’re innately wired to find ways to measure and compare ourselves. Let’s be ready.

    Let’s focus on collecting, protecting, understanding and aligning this background data. Both sides seem to agree, problems arise when we’re misaligned, and opportunities arise for data to be used against the individuals from whom it came (incl over treatment, jobs, credit, privacy and many other ways).

  50. Your comment “But if you can afford the time and cost” has one major problem. The cost is not a burden to the patient. As a physician that deals with thyroid issues daily we will take the tsh level as an example. Every tired overweight patient wants me to check the tsh. Even though it has been checked numerous times in the past they still demand it checked. They demand it because they know they dont have to pay for it. Its like when my college daughter is at school and goes out to eat with her friends and has to pay for it with her own money she orders a water, no appetizer and the small flat iron steak. But when she is home for the weekend and says dad can i have the credit card to go out and eat with my friends I always tend to see a coke, an appetizer and the filet.

  51. I have been following this conversation on Twitter and various other sites for some time now. As one who intends to be involved in medical research, I find Mr. Cuban’s position worthy of consideration. I have thus far abstained from commenting because I felt that my observations were mostly self-evident, but it appears that this is not the case. Please, correct me if I am wrong; I am not asserting any point here, just making an observation from a layman’s viewpoint.

    First, I believe that Radiologists are the ones who are most vehemently against Mr. Cuban’s idea of quarterly testing due to the way in which Radiologists have to treat their testing results. There is a great deal of stress on Radiologists to find something wrong when observing the results of an X-ray, MRI, CAT scan, etc.; and there is also legal implications if they “miss” a red flag in the results.

    From that viewpoint, it is understandable that Radiologist would be against testing without substantial clinical grounds for such a test.

    Second, I do not believe that Mr. Cuban is proposing that the quarterly tests be observed with the same scrutiny that a Physician-ordered test would receive. I believe that Mr. Cuban is simply proposing that the quantified results be added to an ongoing log of data for reference when accompanied by symptomatic evidence. Data is only as good as its model, and a model is only as good as it is relevant to the data (e.g. for a young girl in southeast Asia, the historical baselines for older caucasian males in America would be arguably less relevant than a model that better represents women in southeast Asia).

    If Mr. Cuban, or others, undergoes regular testing, then that data can be used to more accurately reflect both Mr. Cuban’s ‘normal, healthy,’ baseline, as well as any benign “irregularities” (in quotation marks because, as many have pointed out, ‘irregularities’ are actually quite common).

    Third,

    Mr. Cuban has been explicit in stating that he does not believe that his proposal applies for the greater population, so any rejection of his proposal on terms of the capabilities of the healthcare system, or of the inherent costs of implementing such a program, are invalid.

    Fourth,

    There have been only two valid arguments against Mr. Cuban’s proposal. Either

    A) The assumption that his quarterly tests will be used as grounds for invasive preventative procedures that are not medically indicated otherwise, or

    B) The belief that there is no value in quarterly testing in absence of disease.

    For (B), this viewpoint seems to be split amongst healthcare professionals. In lieu of conflicting medical advise, it is my belief that the individual (or patient) should have the final decision (e.g. one Dr. proposes surgery for a condition, while another believes it is unnecessary; it is the patient’s decision whether to undergo the procedure or not). So, under Mr. Cuban’s conditions/beliefs, this argument, too, is invalid.

    Which leaves (A), the belief that doctors (or patients) will use the data to validate further procedures in the absence of other evidence. Correct me if I am wrong, but this seems to be the chief point amongst the dissenters of quarterly testing? This argument, while having some validity, also seems to be flawed.

    The problem is that there is a belief that more data is “bad,” because it could lead to further harm of an otherwise healthy patient. The flaw in this logic is that it IS NOT the data which is the cause of harm, but rather the subsequent use of that data which is to blame. In a scenario such as this, it is too easy to say that “over testing” is to blame. I believe this is a huge cop-out by the medical community; and also reflects the (invalid) position of applying Mr. Cuban’s position to the greater healthcare system. While it is true that there are instances of non-indicated medical procedures causing harm to healthy patients, there are also instances of non-indicated medical procedure cause *no harm* to patients (*aside from the implicit harm endured by the procedures themselves).

    As pointed out above, we are now at a point where technology is improving to make certain tests both cheaper, and more precise. Due to this, certain tests have become more common over time (e.g. I have had multiple MRIs for ortho-related sports injuries, whereas having an MRI every time one got injured in a high school or college sports competition would have been unthinkable just a short while ago). With an increase in testing, there will be an increase in data, and we will often find that the ‘normal’ ranges are not quite what we previously believed them to be. As more data becomes available, the model adjusts to create a ‘better,’ more accurate fit (i.e. the law of large numbers).

    Mr. Cuban’s idea involves providing additional, personal data of better quality to improve the model that is used to interpret further results. The position that “over testing is inherently bad,” is also a flawed argument to make AGAINST THE POSITION PROPOSED BY MR. CUBAN. While the value of quarterly blood tests is an interesting argument to consider, it does more to encourage quarterly blood tests than it does to dissuade against them. With more data, we may find that certain trends are more/less correlated with disease, we may find that there is greater/lesser variability amongst the general population, and we may find that the baseline of the general population is moving in certain directions, with or without harm.

    If there is one thing that I have learned from this ongoing conversation, it is that, surprisingly, the field of healthcare is lagging behind recent technological innovations and their capabilities. I am not a futurist, but I am young and wish to “stand on the shoulders of giants,” so to speak; and continue to advance the practice of medicine for further generations. It seems to me that the healthcare field could benefit from a shifting of the paradigm; to relieve the burden of Radiologists and lab technicians by creating a clear distinction between clinically indicated diagnostic testing, and regular, aggregate testing.

    For a large portion of medical professionals to dissent to a single, financially secure individual undergoing quarterly blood testing, and his subsequent endorsement for those who are in a similar position, seems to me that there is an unfortunate rigidity in current medical practices.

    For those of you who took the time to read this in its entirety; thank you. As I said, I am young and I know that I have much to learn. I hope that those of you who are older and more experienced do not dismiss my comments as misguided or uninformed. Rather, I hope that you take it as an opportunity to consider the issue from a new point of view.

    I look forward to any and all insight into this matter.

    Spencer

  52. “At some point if we’re going to get to accurate personalized medicine”

    Matthew, that will require substrates beyond what we presently have.

    Even the much villified cholesterol seems not to give a straight answer.

  53. First, it is evident that this information is empowering you, which tells me more about you, good things, than the tool which is used to empower. I would hazard a guess that you would be similarly empowered if you measured your weight, rather than cholesterol. But doctors have made “cholesterol” sound more scientific than weight.

    For that matter, since getting a Fitbit I haven’t suddenly started running 10 miles a day. But when I get serious about training for the marathon, the device will be handy. That is I will be empowered when I wish to be.

    Secondly, the rising TSH is indeed intriguing. I wonder how you chose the cut off. I also wonder how your symptoms matched the TSH, and whether the treatment was sooner or later because of the measuring, and whether the timing of treatment affected the control of symptoms, and whether the symptoms were relieved first or the TSH came down first.

    The value, or not, of measuring TSH can be shown scientifically. About 50,000 people should measure TSH quarterly, and another 50, 000 should not. We can see the general well being, use of medication and outcomes and see if any difference in the two groups.

    I suspect many with rising TSH will have a thyroid ultrasound. Some will have a questionable mass. Then some will have surgery for the mass. Then they will be hypothyroid. Self fulfilling prophecy.

    Medicine can be a Greek Tragedy, sometimes.

    Third, I think you really did not mean “test for everything” as you said in your Tweet.

  54. Mark Cuban is a billionaire doing his due diligence.
    If businessmen really want to enter healthcare, they should be mandated by law to take the Hippocratic Oath.

  55. I actually think Mark Cuban is onto something here, and not just because I want him or Mr Wonderful to buy 25%% of The Health Care Blog for $172,000 with my daughters future lemonade stand thrown in…

    …and I also think a bunch of smart people whom I respect are missing two things.

    Yes as a semi-trained health services researcher I know that we both over test in health care, and often over treat both false positives and real positives. But two things are changing fast.

    First — the cost of testing is plummeting. You can go to Walgreens and Theranos will do your blood panel for less than $20 (OK so you have to go to Phoenix or Palo Atlo but you get my drift)

    Second, data analytics are improving — from what I can gather about Mark’s story, he’s a proponent of watchful waiting. The main issue with excessive lab testing is that people are drawn to immediate interventions on limited data. My sense is that the more data we have, and the more we allow sophisticated analysis tools to review our accumulations of said data, the closer we will get to accurate diagnosis, and better treatment–which is much more likely to be no or little treatment, compared to traditional “lie down and I’ll operate”

    At some point if we’re going to get to accurate personalized medicine, while being judicial and conservative about treatments, we need better informed patients with better information about themselves. And Mark may be a harbinger of that, while everyone is treating him like someone demanding monthly PSA tests for all men over the age of 12.

  56. I had no symptoms of hypothyroidism until yrs after taking the blood tests. I didn’t develop any symptoms until after I went off synthroid to see if I could reduce my tsh using diet. This was 8 years after I had my first blood test I started synthroid before any symptoms because it was obvious my tsh was trending up over multiple years.

    As far as cholestoral , all my information came from my general blood tests over the 8 years. I had no reason to goal monitor my cholestoral . it was just one of the test results in my standard blood tests

    All of which are exactly what I recommended and why. Get your blood tested and learn about your body.

    Not as a means to search for a specific disease

    As far as comparing to a baseline, the deviations wash themselves out over time . usually. With tsh I talked to my doctor. We looked at the data. He suggested synthroid so I tried it.

    Had I not had the data I’m not saying something dramatic would have happened . but it certainly allowed me to modify behavior and positively impact my health . before any symptoms

  57. “And I feel far more confident that if and when I get sick, having those numbers will make me and my doctor smarter in our decision making process.”

    Mark, thanks for sharing your personal examples.

    Goal-directed monitoring of cholesterol is very different to the broad brush of your original Tweets.

    The merits of creating a baseline when healthy to guide when sick depends on what you intend to do if there is a clash between the clinical picture and the labs and what you consider a deviation from baseline to be.

    You mentioned the creeping TSH. But you had no symptoms in the beginning, right? But when you developed symptoms you started medication.

    It seems from your description that, at least in the case of hypothyroidism, your treatment decision was guided by symptoms.

    And being tested and treated when symptomatic is the right thing to do.

  58. Saurabh, your “abdominal circumference “? You mean your waist ?

    I have blood tests going back years. My choice. Not a single one was in response to an illness. , nor was any looking for a specific illness or a menu of diseases.

    It purely is to have a baseline. When I got my first blood test in 2007 prior to having a hip replaced it was a surprise when we reviewed my results and my doctor compared those numbers to a range of results for men of my age. I asked my doctors how this could be of much value unless any of the data was an outlier.

    He said that’s the way it was done. We didn’t have other choices. Again this was 2007

    I chose then to keep all the data so I could track my own baseline. In the event I got Ill or had a need I wanted to know what my numbers were in addition to what was readily available. Thats how it started

    Over time my tsh elevated and my cholestoral got higher as I gained weight . so I changed my diet up and increased my frequency of tests. I wanted to know if what I was doing was having an impact. It definitely did on some, not on others

    At no time was I ill ( other than kidney stones). At no time was I symptomatic of any illness.

    Of course for some vsriables , the results of the tests bounced around. I kearned how my diet, allergies,, even a couoke drinks affected me. In most cases the next test returned to normal ranges

    To no ones surprise there was a direct correlation between my diet and weight and my cholestoral . I adjusted my diet. Saw rhe impact and avoided medication.

    These tests also allowed me to watch my tsh creep up over time. No symptoms. No additional tests. Just climbing up

    Of course hypothyroidism is not the worst thing to have . it is what it is. But the ranges at which medication is necessary is very much under debate

    I started synthroid. Next test saw the positive impact. But there was still commentary that while levels were elevated, medications were not needed

    Because I was still asymptomatic and had a sense of my numbers and a baseline comparison range, I felt confident to tale the initiative to try to go off the synthroid and use diet to push my tsh down

    I knew I would be testing in the near future. So why not

    Didn’t work. Tsh next test skyrocketed to past 11 and for the first time I exhibited symptoms . (watch EPs of shark tank shot in sept and u can See it in my face and i gained a bunch of weight .) I’m back on synthroid.

    I know that some would say that I could do all of this with an annual check up or less, but I know what works for me for my cholestoral and more. I dont have any reason to believe I’m preventing specific diseases. My crap shoot of life is just as random as anyone else’s

    What I do know is that I’m in firmer control of my day to day health

    there is value when I review my results annually with my doctor , having the last 3 results to compare to. Now that I have a history of data looking at the results isnt stressful. Its the opposite. Its comforting.

    And I feel far more confident that if and when I get sick, having those numbers will make me and my doctor smarter in our decision making process.

  59. Cuban probably invested in some lab companies and wants to drive up profits by encouraging mass testing

  60. Mark, thanks for replying.

    I responded to your questions on Twitter. The 10, 000 Marks was to illustrate the True Positive and the False Positive harmed by treatment. People understand real people better than numbers.

    I wrote in response to what you Tweeted.

    “if you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health.”

    “a big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics.”

    These are your words, not mine (emphasis, mine)

    “‘blood tested for EVERYTHING available.”

    When you say “a big failing of medicine = we wait till we are sick to have our blood tested” how can I not think you’re talking about preventing disease and/ or catching early disease before symptoms?

    Goal-directed measurements are fine. I used to measure my abdominal circumference. I have stopped now because it ruins my day.

    But there is a difference between measuring resting heart rate and white blood cell count or PSA.

    Exactly how you would establish your own baseline without the uncertainty that what was being measured was truly your baseline, is beyond me. But I’m all ears.

  61. Also I really doubt that whoever is posting on Twitter is actually Mark Cuban. I always thought that you had better business acumen than this.

  62. I read your entire post. This is what I gleaned from it:

    “…At no point have I said the tests were to look for a specific disease”
    “…the value of having a series of data to reduce false positives and unnecessary follow ups.”
    “… I have seen the value of comparing a data series to environment and making life modifications . its not about did we find a disease or not. Its about learning about factors that impact my health”
    “..that an anomaly in the bloodtest can be compared to the most recent data and there is no reason to rush to judgement if there is an anomaly because another test is imminent and qualitative information can be accessed across the series as well”

    These are your own words. You want to shotgun test yourself to look for factors that “impact your health.” Point by point (which by the way I addressed already in my post):

    1) Tests that don’t look for a specific disease are useless in healthy people.
    2) A series of data in one patient has nothing to do with the false positive rate of a test.
    3) Your TSH is a test that is clinically necessary (assuming you are hypothyroid) because its value depends on how much thyroid replacement therapy you are getting or might need. That is one example.
    4) You can’t find all the factors that impact your health from a blood test.
    5) You don’t need to have a series of blood tests to identify anomalies in your health.

    There is absolutely no need for a healthy individual to have a series of data of any kind unless you are treating or looking for a particular condition. What it sounds like you really want is a bunch of numbers and bar graphs to help you sleep better at night.

    I have news for you: every doctor that you, Mark Cuban, will ever go to will gladly order every test under the sun because they want your money and first row ticket to the next Mavericks game. We have a word for this: VIP medicine. You get worse healthcare and lose more money. Now if it were just your money, I could care less. But it won’t be if everyone gets quarterly blood tests.

  63. To add, the points I raised are completely separate from the idea of overtreatment, to say nothing of false-positive or false-negative results. An often used example is that of prostate specific antigen. Let’s say I measure your PSA and it comes back at 7. You have no symptoms. Do you

    a) do nothing
    b) come back in a year and re-test
    c) get a different test which might be confirmatory
    d) get a prostate biopsy

    There’s no correct answer. Let’s say that you come back a year and re-test. Your PSA is now 7.5. You now choose to get a prostate biopsy. The biopsy comes back as Gleason 6, low volume cancer. Do you

    a) do nothing
    b) come back next year for a PSA and repeat biopsy
    c) consider definitive therapy for the cancer

    Let’s say you choose definitive therapy. Do you

    a) have robotic assisted vs. open surgery
    b) have radiation

    Let’s say you have robotic assisted surgery. The risks of surgery are primarily: incontinence, impotence, bleeding, risk of cancer recurrence, and so forth. You are lucky and manage to be completely continent after 6 months. Unfortunately, your surgeon saw a lesion on the prostate MRI (which they threw in for a modest fee before surgery) that was close to some nerves by the prostate, so now your erectile function is impaired. The good news is that the lesion on MRI turned out to be benign! Your final pathology is Gleason 6 low-volume cancer. You spend the rest of your life cancer-free, but with erectile dysfunction.

    This pathway, with huge expenses, consumption of resources, and most importantly anxiety to the patient, and quantifiable harms (erectile dysfunction) is seriously what thousands of patients go through. We can address overtreatment at any number of the branch points of the decision tree, even going as far back as the initial decision to get a PSA (urologists may disagree). And all for Gleason 6 cancer, which is very, very low risk. The odds are overwhelmingly that if you had never gotten that prostate test, you would have never known that you ever had cancer, and it would never have impacted your quality of life or longevity. So the question remains: Which population do we test? What tests do we use? How do we use them judiciously? What do the results mean?

    Who gets to decide?

  64. Mr. Cuban:

    The problem with your position is that longitudinal laboratory data obtained by blood testing is only useful in very specific scenarios.

    Blood testing gives you a snapshot of a few test results (how would these tests be selected?) which by themselves are neither 100% sensitive or accurate, in one tissue of the body (the blood), which are compared to reference values derived from a general population (which does not reflect disease states.)

    These metrics differ significantly from those derived from, for example, the stock market, because in the latter the data is granular, can be accessed in its totality, and can be modeled with high fidelity. We want nothing more than for patients as well as providers to be able to extract all the relevant data from their bodies, but at present this is unrealistic and unnecessary.

    Take for example your hematocrit. This is measured in the complete blood count and reflects your red blood cell mass. Let’s say you get tested every quarter and your hematocrit is 42. You continue getting tested for the next 10 years, and your hematocrit varies by 1-3 points. On the first quarter of the 11th year, you notice that your hematocrit is now 30. Two points: 1) you could have saved some money by only getting tested every year or every two years, and 2) a significant drop in hematocrit would be accompanied by symptoms: fatigue, elevated heart rate, etc., due to some medical cause (perhaps bleeding) which could then be addressed. It is silly and wasteful to include tests such as this in a regular battery. And the kicker is, you didn’t actually need a baseline hematocrit to know something was abnormal here.

    Where regular testing makes sense is defined completely by clinical context. Suppose I have a patient who had colon cancer which was removed surgically. Colon cancer secretes a marker called CEA, but this is secreted by other tissues in the body and not unique to colon cancer. It would be futile to test for CEA in healthy people (the test is nonspecific and the prevalence of colon cancer is not high enough to justify the cost, as compared to a colonoscopy), but in a person who is known to have colon cancer, measuring the CEA serially is invaluable in determining whether the cancer has recurred. This is your idea of a baseline in a nutshell, and it is primarily in these contexts which it is valuable. Another example would be TSH. In patients who are hypothyroid, we measure this to help decision-making in thyroid hormone replacement therapy.

    Hospitalized patients have blood testing done regularly because (presumably) they are in the hospital due to illness, and may have some derangements in their lab values. There are good arguments to be made against excessive testing in these patients as well. Healthy patients can choose to have certain tests performed (such as a lipid panel, etc.) at defined time points if those tests can change their clinical management.

    We obtain healthcare data, after all, primarily for decision making. Where data does not alter the conclusions we come to in a clinical scenario, it’s a useless expense.

    You might argue that these points only apply to blood testing, and that blood testing is harmless. However, lab tests are not cheap and take time to perform. Diagnostic labs do have backlogs. And blood does not convey all the information you need. There have been countless patients with stone-cold normal lab values who had cancers lurking.

    The idea of resource consumption is especially true for medical imaging. Apart from the cost of imaging itself, it is time-consuming to interpret and analyze. There is only a finite number of radiologists and they are already overworked. Going back to your quarterly testing example, let’s say you get an abdominal CT scan every quarter, with the following abbreviated results:

    Year 1: normal, context: healthy adult male
    Year 2: normal, context: healthy adult male

    Year 10: inflammation of the appendix, context: right lower quadrant abdominal pain

    Even if you took 100% of the data generated by the CT scans from Years 1-9, you wouldn’t be able to generate a model that could have predicted your development of appendicitis in Year 10. Hence the difference between health care data and other metrics. What could have helped in this case? Clinical context.

    Your focus is understandably on preventative health, which means you are interested ultimately in screening for disease before it begins. But your solution cannot reasonably be “shotgun test everything and hope that what’s wrong will be found by the tests I select.” Instead, the question should be “are there particular populations of patients in which a test might be valuable in detecting disease, how do we define such populations, and is it cost-effective to the patient and to society to screen for these disease?” This is a debate that is lively within the medical community, and if you would like to make a difference in this regard, there are plenty of researchers in preventative and population health that would love to benefit from your advocacy.

    There is also a philosophical argument here: can you predict illness vs. being well from the sum total of a patient’s data? I think that maybe eventually, with significantly more advances in technology, you might be able to get an approximation that would still need to be confirmed by a health care provider. Many others would say that goal is impossible. After all, being sick vs. being well are human conditions, which you might never be able to quantify.

  65. The one recurring theme in every blogged response is that the author poses the questions and the answers.

    Its a paternal “look at me tell him where his thinking is wrong”. Despite not knowing what he is thinking

    Then there are the strawmen and headline porn elements in some
    At no point have I said the tests were to look for a specific disease . But creating the 1 lucky mark who finds cancer serves not only as a straw man but is a great headline as well

    And for some reason beyond me, the radiologists who have replied seem completely ignorant of the value of having a series of data to reduce false positives and unnecessary follow ups. For some reason, and maybe I’m just missing something , every test has to be a game of chicken little. Let’s see if the sky is falling . this despite my ongoing explanations that this is meant to be a data series .

    While I realize this is anecdotal, I have seen the value of comparing a data series to environment and making life modifications . its not about did we find a disease or not. Its about learning about factors that impact my health. For me personally, its my TSH values.

    I’m not suggesting that everyone do it. But if you can afford the time and cost , and have a doctor that understands (unlike some commenting on twitter ) that an anomaly in the bloodtest can be compared to the most recent data and there is no reason to rush to judgement if there is an anomaly because another test is imminent and qualitative information can be accessed across the series as well,Worst case it allows the individual ( not patient) to make smarter decisions when talking to a doctor

  66. The general public doesn’t understand that data divorced from clinical context is utterly meaningless. To be fair, though, even some physicians don’t understand this.

Leave a Reply

Your email address will not be published. Required fields are marked *