Loved this article team, thank you. Very well written and considerate, with plenty of "aha" moments. This part stood out to me:
"...a waiting period that can stretch for months or years before anyone can tell you what it was. One of the JAMA authors described how that process reorganizes your sense of yourself, so that you start living as a patient with a problem even when the finding eventually proves benign."
I am from NZ. We have universal public healthcare. We also have private healthcare insurance, so people who have the money can "skip the line" and get procedures, scans, etc done in much nicer clinics and in a much faster time frame. I am not one of those people, so rely on the FREE public system. Apart from my GP visit, I paid nothing but time and worry - living as a patient while referrals dragged on and on for months between each part of my diagnosis journey that turned out to eventually be benign (for now). As a child I had ongoing kidney infections which were caused by the ureter valves not working as they should. I had surgery to reimplant them. Fast forward to a couple years ago where a routine bloods check showed my creatinine was abnormally high. Check again a few weeks later. Talk to doctor, with my history i get referred to renal, while doctor assures me it could just be my normal but we need to investigate.
5 months later I get the appointment with renal. She refers me for ultrasound, which is another 4 months wait. They find a dilated ureter which usually means an obstruction, so I'm referred to urology for a CT or MRI. Another 5 nervous months pass, no CT yet in the public system, so I get another renal appointment. She's furious I've had to wait this long for something that could be very serious and pushes the referral again. 3 months later I get the CT, and I'm called back a few hours later to come in the next morning. So I'm scared because nobody I know has gotten that kind of call in the public system unless something is seriously wrong - it's either a quick phone call or waiting days to weeks to eventually get a call from your doctor or a letter than says everything is fine. So they must've found something and I'm getting surgery, that's all this could mean! So I'm setting up my life to make sure that if that does eventuate then everyone is prepared to take over while I recover. The appointment comes and he asks me to describe exactly what I went through as a child (to my best ability). Then he says oh yep - that completely tracks with what we found, its common for ureters to dilate after that surgery, you have mild scarring from childhood, and everything is fine. Just keep doing what you're doing with regular bloods and managing BP.
17 months between that initial blood test and the results. Living as a scared patient for those 17 months to find out nothing was "wrong". If I had private health insurance or thousands of dollars to get the scans privately, this process would have been a few weeks at most.
The harm vs benefit vs waste (of time and money) aspects of screening are well established as anyone with an MPH, e.g. Dr Benjoseph, knows very well. And overtreatment and over-testing are real abuses of a doctor's stewardship and patient safety roles.
ATST, there are very sensible critics of screening for breast cancer, colon cancer and prostate cancer, based on principles mentioned above.
I agree in principle, but I think too much weight is put on patient fear from false positives. We all have different reactions, everyone should have the option to have more screening tests paid for by insurance or Medicaid. Probably not the more expensive tests, but prostate exams are relatively safe and inexpensive. Based on a recent symptom free sonogram, I wish I had received it at least one year earlier. My 6 cm kidney tumor might have been my much smaller then.
I don’t disagree yet it’s a complex issue. Naturally every patient is able to decline a screening test and critics frequently mention anxiety as a cost. (The only one I would push back on is cervical cancer screening.) Yet analyses of survival benefit often show little to no advantage.
Death from prostate cancer is awful and extremely painful. But prostate biopsies and surgeries cause infections and sexual and urinary dysfunction. PSA is not very good at detecting who is likely to develop widespread disease.
Wishing there had been a way to find your cancer earlier is natural but apparently it is uncommon enough that the costs- radiation, utilization, $, unknown (unlikely) benefit preclude even a large trial, and ultrasound can miss small tumors and mis-identify complex cysts and solid tumors. Personally, I don’t want my premiums or Medicare $ going to tests that are as likely to harm as to benefit.
The three authors of Sensible Medicine Substack disagree on colon cancer screening and are smarter than me.
While anyone can refuse a screening test, most can’t receive one that isn’t on the recommended list. If I’m the one-in-a-million whose ultrasound revealed a large tumor before becoming symptomatic, then maybe routine ultrasounds aren’t worth the cost. I realize my bias from being the rare person who found the tumor while pre symptomatic .
Based on my kidney tumor’s size, there is an 80% chance it is cancerous, and the treatment is the same regardless of whether it is benign: partial or complete removal of the kidney. I don’t know how fast kidney tumors grow, or even whether catching cancer at stage one instead of stage two makes a difference in survival. But it seems like it would help.
I understand. I and researchers as well as other docs truly wish for more effective screening of any and all cancers.
As the article notes, one actually can get screenings that have zero evidence base behind them. In toto, over 1000 patients or so, such screenings do nothing or do more harm than good. I see a lot of non-indicated screening, particularly in cardiac care.
I know in my brain that you are right. I’m still processing my own unusual results. Go in worried about my prostrate , and come out with an unsuspected kidney problem.
The cascade you describe has an end point, and part of it is my table. The line about a nonspecific finding sending someone into a workup with contrast and sometimes a biopsy passes quickly over what a biopsy is for the person having it: a consent conversation, a fasting period, an anesthetic, and a recovery. Nearly all of those procedures are safe and nearly all are uneventful. But low risk is a statement about a population, and the person in front of me is one body, and I meet them at the point where the abstraction has become a needle and a stranger standing at their head. That cost never appears anywhere near the price of the scan.
My perspective on preventative medicine has become at lot sharper and critical as to how we can advance it after my father died last month.
Two brain aneurysms, one was 18.88mm with a Harold bleed. My Dad survived *3* surgeries in 8 days, only to die 4 weeks later from a mysterious brain bleed (blood was seeping into three distinct brain regions) with no apparent source.
39 days in the hospital, 27 days in the ICU. Thankfully we're Canadian, because that cost is astronomical. With more money spent on presentation and research, could there be a better outcome? A way that the money to try to save my Dad could have been better used cause we didn't need to end up here?
Doctors can't agree on whether or not his 1st degree family members should be checked, as genetics are the only potential risk factor, but even that we don't fully understand. My family immigrated from Slovakia, so the whole two 1st degree relatives before getting checked doesn't track. People in our family have died, we never scan heads, we have no idea how we got here.
Is there a path to prevention here? Or is this part of the tragedy people will need to live through until we advance medicine? Hard to say I suppose.
"A radiologist at Johns Hopkins warned that popularizing these scans without medical indications diverts scarce capacity from a system that already lacks it. Every hour of magnet time spent reading a healthy 34-year-old’s incidentalomas is an hour not spent on someone with a diagnosis."
I understand that sentiment, but don't see it that way.
Supply adjusts to meet demand. Markets adapt. If demand increases in an economy with free-market consumers (here, the healty seeking imaging), supply increases. And in an economy like imaging, with higher overall production of imaging, net imaging prices will actually decrease (economies of scale, improved efficiency).
Meaning the extra imaging in the long run should help (not hurt) the health of others, right?
Supply and demand - sure! However it's not just the scan itself, but the people qualified to read them. You can make the scanning process as efficient as possible and improve technology, but making sure that nothing is missed by a team of humans under the pump is crucial. You need more trained people to do that, and funding for them is generally where tax money is not going. It should, but it doesn't.
I’ve had multiple MRIs of my head and neck. I was once in the machine for an hour! It’s a miserable experience . Why anyone would want to do it if it’s not needed is beyond me.
I’ve had incidental findings from *necessary* imaging (X-rays and CT scans for injuries). Two out of three turned out to be useful information. The third — a liver cyst — just led to (what turned out to be) an unnecessary MRI. But the first two were things than warranted further diagnostic attention and ongoing monitoring — thyroid nodules, and a prolapsed cervical disc. One nodule was concerning enough that I needed a needle biopsy. The prolapsed disc explained ongoing pain patterns I’d been experiencing, and led me to change some of my yoga practice to protect my neck. That’s a good thing.
I mention this not to support the idea of a full-body scan (or anything that huckster Huberman pushes), but to point out that not all incidental findings are nothing.
I have never had a mammogram, and I will never have another colonoscopy. Is it fear management? No. I refuse to spend another part of my life within what I call "the medical machine." I spent 15 years within it, battling lymphoma. They got their pound of flesh. Yes, they were helpful with that particular problem. But that is simply not how I want to live. I refuse the paradigm. AMA.
I could not love this post more. Our system is such a mess—the people who most need screening must wait or cannot access it due to cost or other barriers, while wealthy people get the healthcare equivalent of the Disney FastPass. Never enough radiologists to read any of it, and then TikTok can completely undermine confidence in science-supported prevention. The arrogance that “doing your own research” is somehow equivalent or superior to expertise from extensive training and career experience fuels all of this nonsense and just makes no one healthier. It’s beyond comprehension and possibly beyond fixing.
Very interesting and yet disconcerting. Unfortunate so many fall for the misinformation and marketing. Our social media is now checking way too many negative boxes. Personally I don't see much good there anymore without some strict guidelines limiting outright lies and nonsense. This needs to be addressed to provide actual facts and risk considerations for decision making. The wealthier fear-driven will always pursue more attention and reassurance regardless.
If you want a carnival ride through nonsense that spins around logic like a mad teacup, get on this article.
At stake here is preventive care—and why some people get whole-body MRIs (costly, heavily marketed) while others won’t get mammograms (covered by insurance and recommended by guidelines). Are they the same people?
The author invokes six years of “teaching and preaching” about prevention, then suggests that healthy habits cannot trend because there is no product attached. Is that an argument, or an anecdote about her own experience?
Paid for versus covered: A man pays for an MRI; a woman declines a covered mammogram. I don’t see how the method of payment changes what either scan can find.
“No doctor’s referral needed” does not mean “medically unreasonable.” Screening involves people without symptoms. The question is whether this particular screening test helps them.
The repeated use of “product” is interesting. So is the sentence, “The evidence has not kept up with the marketing.” Shouldn’t that be the other way around?
An MRI finding can supposedly “reorganize your sense of yourself,” so you start living as a patient with a problem. That's a risk.
A neurosurgeon’s reluctance to operate on an asymptomatic patient based on one MRI scan tells us something about the threshold for brain surgery. What does it tell us about the overall value of the scan?
What do you think about MRI usage for disc, tendon and ligament diagnosis. Patients with multiple sites of pain or changing pain conditions could benefit from having all their joints scanned, instead of just the body part that warrants it.
Excellent article. The topic was explored with great compassion, and understanding 👏🏽
compassion for whom?
When patients see me with yet another incidentaloma l, I let them know they are a VOMIT. Victim of Modern Imaging Technology.
wow
Loved this article team, thank you. Very well written and considerate, with plenty of "aha" moments. This part stood out to me:
"...a waiting period that can stretch for months or years before anyone can tell you what it was. One of the JAMA authors described how that process reorganizes your sense of yourself, so that you start living as a patient with a problem even when the finding eventually proves benign."
I am from NZ. We have universal public healthcare. We also have private healthcare insurance, so people who have the money can "skip the line" and get procedures, scans, etc done in much nicer clinics and in a much faster time frame. I am not one of those people, so rely on the FREE public system. Apart from my GP visit, I paid nothing but time and worry - living as a patient while referrals dragged on and on for months between each part of my diagnosis journey that turned out to eventually be benign (for now). As a child I had ongoing kidney infections which were caused by the ureter valves not working as they should. I had surgery to reimplant them. Fast forward to a couple years ago where a routine bloods check showed my creatinine was abnormally high. Check again a few weeks later. Talk to doctor, with my history i get referred to renal, while doctor assures me it could just be my normal but we need to investigate.
5 months later I get the appointment with renal. She refers me for ultrasound, which is another 4 months wait. They find a dilated ureter which usually means an obstruction, so I'm referred to urology for a CT or MRI. Another 5 nervous months pass, no CT yet in the public system, so I get another renal appointment. She's furious I've had to wait this long for something that could be very serious and pushes the referral again. 3 months later I get the CT, and I'm called back a few hours later to come in the next morning. So I'm scared because nobody I know has gotten that kind of call in the public system unless something is seriously wrong - it's either a quick phone call or waiting days to weeks to eventually get a call from your doctor or a letter than says everything is fine. So they must've found something and I'm getting surgery, that's all this could mean! So I'm setting up my life to make sure that if that does eventuate then everyone is prepared to take over while I recover. The appointment comes and he asks me to describe exactly what I went through as a child (to my best ability). Then he says oh yep - that completely tracks with what we found, its common for ureters to dilate after that surgery, you have mild scarring from childhood, and everything is fine. Just keep doing what you're doing with regular bloods and managing BP.
17 months between that initial blood test and the results. Living as a scared patient for those 17 months to find out nothing was "wrong". If I had private health insurance or thousands of dollars to get the scans privately, this process would have been a few weeks at most.
The harm vs benefit vs waste (of time and money) aspects of screening are well established as anyone with an MPH, e.g. Dr Benjoseph, knows very well. And overtreatment and over-testing are real abuses of a doctor's stewardship and patient safety roles.
ATST, there are very sensible critics of screening for breast cancer, colon cancer and prostate cancer, based on principles mentioned above.
I agree in principle, but I think too much weight is put on patient fear from false positives. We all have different reactions, everyone should have the option to have more screening tests paid for by insurance or Medicaid. Probably not the more expensive tests, but prostate exams are relatively safe and inexpensive. Based on a recent symptom free sonogram, I wish I had received it at least one year earlier. My 6 cm kidney tumor might have been my much smaller then.
I don’t disagree yet it’s a complex issue. Naturally every patient is able to decline a screening test and critics frequently mention anxiety as a cost. (The only one I would push back on is cervical cancer screening.) Yet analyses of survival benefit often show little to no advantage.
Death from prostate cancer is awful and extremely painful. But prostate biopsies and surgeries cause infections and sexual and urinary dysfunction. PSA is not very good at detecting who is likely to develop widespread disease.
Wishing there had been a way to find your cancer earlier is natural but apparently it is uncommon enough that the costs- radiation, utilization, $, unknown (unlikely) benefit preclude even a large trial, and ultrasound can miss small tumors and mis-identify complex cysts and solid tumors. Personally, I don’t want my premiums or Medicare $ going to tests that are as likely to harm as to benefit.
The three authors of Sensible Medicine Substack disagree on colon cancer screening and are smarter than me.
https://www.sensible-med.com/p/the-hubris-of-screening-for-disease
While anyone can refuse a screening test, most can’t receive one that isn’t on the recommended list. If I’m the one-in-a-million whose ultrasound revealed a large tumor before becoming symptomatic, then maybe routine ultrasounds aren’t worth the cost. I realize my bias from being the rare person who found the tumor while pre symptomatic .
Based on my kidney tumor’s size, there is an 80% chance it is cancerous, and the treatment is the same regardless of whether it is benign: partial or complete removal of the kidney. I don’t know how fast kidney tumors grow, or even whether catching cancer at stage one instead of stage two makes a difference in survival. But it seems like it would help.
I understand. I and researchers as well as other docs truly wish for more effective screening of any and all cancers.
As the article notes, one actually can get screenings that have zero evidence base behind them. In toto, over 1000 patients or so, such screenings do nothing or do more harm than good. I see a lot of non-indicated screening, particularly in cardiac care.
I know in my brain that you are right. I’m still processing my own unusual results. Go in worried about my prostrate , and come out with an unsuspected kidney problem.
The cascade you describe has an end point, and part of it is my table. The line about a nonspecific finding sending someone into a workup with contrast and sometimes a biopsy passes quickly over what a biopsy is for the person having it: a consent conversation, a fasting period, an anesthetic, and a recovery. Nearly all of those procedures are safe and nearly all are uneventful. But low risk is a statement about a population, and the person in front of me is one body, and I meet them at the point where the abstraction has become a needle and a stranger standing at their head. That cost never appears anywhere near the price of the scan.
My perspective on preventative medicine has become at lot sharper and critical as to how we can advance it after my father died last month.
Two brain aneurysms, one was 18.88mm with a Harold bleed. My Dad survived *3* surgeries in 8 days, only to die 4 weeks later from a mysterious brain bleed (blood was seeping into three distinct brain regions) with no apparent source.
39 days in the hospital, 27 days in the ICU. Thankfully we're Canadian, because that cost is astronomical. With more money spent on presentation and research, could there be a better outcome? A way that the money to try to save my Dad could have been better used cause we didn't need to end up here?
Doctors can't agree on whether or not his 1st degree family members should be checked, as genetics are the only potential risk factor, but even that we don't fully understand. My family immigrated from Slovakia, so the whole two 1st degree relatives before getting checked doesn't track. People in our family have died, we never scan heads, we have no idea how we got here.
Is there a path to prevention here? Or is this part of the tragedy people will need to live through until we advance medicine? Hard to say I suppose.
Thanks for this excellent post.
"A radiologist at Johns Hopkins warned that popularizing these scans without medical indications diverts scarce capacity from a system that already lacks it. Every hour of magnet time spent reading a healthy 34-year-old’s incidentalomas is an hour not spent on someone with a diagnosis."
I understand that sentiment, but don't see it that way.
Supply adjusts to meet demand. Markets adapt. If demand increases in an economy with free-market consumers (here, the healty seeking imaging), supply increases. And in an economy like imaging, with higher overall production of imaging, net imaging prices will actually decrease (economies of scale, improved efficiency).
Meaning the extra imaging in the long run should help (not hurt) the health of others, right?
Supply and demand - sure! However it's not just the scan itself, but the people qualified to read them. You can make the scanning process as efficient as possible and improve technology, but making sure that nothing is missed by a team of humans under the pump is crucial. You need more trained people to do that, and funding for them is generally where tax money is not going. It should, but it doesn't.
There aren’t a lot of people who can afford to self pay for an optional MRI. I don’t think there are enough to mow the price down very much.
I’ve had multiple MRIs of my head and neck. I was once in the machine for an hour! It’s a miserable experience . Why anyone would want to do it if it’s not needed is beyond me.
I’ve had incidental findings from *necessary* imaging (X-rays and CT scans for injuries). Two out of three turned out to be useful information. The third — a liver cyst — just led to (what turned out to be) an unnecessary MRI. But the first two were things than warranted further diagnostic attention and ongoing monitoring — thyroid nodules, and a prolapsed cervical disc. One nodule was concerning enough that I needed a needle biopsy. The prolapsed disc explained ongoing pain patterns I’d been experiencing, and led me to change some of my yoga practice to protect my neck. That’s a good thing.
I mention this not to support the idea of a full-body scan (or anything that huckster Huberman pushes), but to point out that not all incidental findings are nothing.
I have never had a mammogram, and I will never have another colonoscopy. Is it fear management? No. I refuse to spend another part of my life within what I call "the medical machine." I spent 15 years within it, battling lymphoma. They got their pound of flesh. Yes, they were helpful with that particular problem. But that is simply not how I want to live. I refuse the paradigm. AMA.
Why do you come here to provoke? Are you lonely?
I thought you folks could use someone not from your bubble. I am on a mission of mercy. LOL
The problem is expecting an MRI to be a crystal ball.
I could not love this post more. Our system is such a mess—the people who most need screening must wait or cannot access it due to cost or other barriers, while wealthy people get the healthcare equivalent of the Disney FastPass. Never enough radiologists to read any of it, and then TikTok can completely undermine confidence in science-supported prevention. The arrogance that “doing your own research” is somehow equivalent or superior to expertise from extensive training and career experience fuels all of this nonsense and just makes no one healthier. It’s beyond comprehension and possibly beyond fixing.
Very interesting and yet disconcerting. Unfortunate so many fall for the misinformation and marketing. Our social media is now checking way too many negative boxes. Personally I don't see much good there anymore without some strict guidelines limiting outright lies and nonsense. This needs to be addressed to provide actual facts and risk considerations for decision making. The wealthier fear-driven will always pursue more attention and reassurance regardless.
Great article. Keep them coming.
If you want a carnival ride through nonsense that spins around logic like a mad teacup, get on this article.
At stake here is preventive care—and why some people get whole-body MRIs (costly, heavily marketed) while others won’t get mammograms (covered by insurance and recommended by guidelines). Are they the same people?
The author invokes six years of “teaching and preaching” about prevention, then suggests that healthy habits cannot trend because there is no product attached. Is that an argument, or an anecdote about her own experience?
Paid for versus covered: A man pays for an MRI; a woman declines a covered mammogram. I don’t see how the method of payment changes what either scan can find.
“No doctor’s referral needed” does not mean “medically unreasonable.” Screening involves people without symptoms. The question is whether this particular screening test helps them.
The repeated use of “product” is interesting. So is the sentence, “The evidence has not kept up with the marketing.” Shouldn’t that be the other way around?
An MRI finding can supposedly “reorganize your sense of yourself,” so you start living as a patient with a problem. That's a risk.
A neurosurgeon’s reluctance to operate on an asymptomatic patient based on one MRI scan tells us something about the threshold for brain surgery. What does it tell us about the overall value of the scan?
What do you think about MRI usage for disc, tendon and ligament diagnosis. Patients with multiple sites of pain or changing pain conditions could benefit from having all their joints scanned, instead of just the body part that warrants it.