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>

 

 

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beulahsunil movvaJohn R. GrahamBill Springercivisisus Recent comment authors
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beulah
Guest
beulah

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)

mark cuban
Guest
mark cuban

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

Leonard Kish
Guest

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… Read more »

sunil movva
Guest

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… Read more »

mark cuban
Guest
mark cuban

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… Read more »

sunil movva
Guest

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… Read more »

Allan
Guest
Allan

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… Read more »

Allan
Guest
Allan

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.

John R. Graham
Guest

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.

Allan
Guest
Allan

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… Read more »

John R. Graham
Guest

I am with you.

mark cuban
Guest
mark cuban

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

Saurabh Jha
Guest
Saurabh Jha

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… Read more »

Bill Springer
Guest
Bill Springer

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… Read more »

Saurabh Jha
Guest
Saurabh Jha

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

Agree.

Leonard Kish
Guest

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… Read more »

civisisus
Guest
civisisus

“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….

Saurabh Jha
Guest
Saurabh Jha

“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… Read more »

Allan
Guest
Allan

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… Read more »

Saurabh Jha
Guest
Saurabh Jha

“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.

Allan
Guest
Allan

“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… Read more »

Saurabh Jha
Guest
Saurabh Jha

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)

Allan
Guest
Allan

“ 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.

Matthew Holt
Editor

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… Read more »

Saurabh Jha
Guest
Saurabh Jha

“collectivism”

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

Allan
Guest
Allan

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.

mark cuban
Guest
mark cuban

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

mark cuban
Guest
mark cuban

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

Saurabh Jha
Guest
Saurabh Jha

“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.

mike
Guest
mike

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.