As a gastroenterologist who has performed > 25,000 colonoscopies, I have seen and removed thousands of colon polyps. My ADR (adenomatous polyp detection rate) is 45-50% for screening colonoscopies. Adenomatous polyps as well sessile serrated polyps are the main precursors for the development of colon cancer. By finding those particular polyps and subsequent removal prevents colon cancer. However, the vast majority of colon polyps never develop into colon cancer. The population of the USA for ages 45-75 (the age recommended for colon cancer screening) is about 84.7 million. If my ADR reflects on the general population, then 40-42 million Americans harbor silent colon polyps. The incidence of colon cancer is about 155,000 yearly; therefore, most Americans will never develop colon cancer. The efforts of medicine should be channeled to identify individuals with the polyps that are higher risk for colon cancer development as opposed to mass screening.
YES YES YES this! Causing unnecessary utilization and harm, driving up costs, annoying our patients (try getting an 88 yo long-term care patient to go out and get a mammogram!) so that we can "check a box" -- never mind an annual flu/COVID/RSV/PNA shot. Ugh!
And even in assisted living, these shots will be given without consulting with family or an outside GP. There's huge money in these institutions and no concern for what side affects people already often on 10+ medications might suffer.
Brilliant insight once again Vinay. Nothing like spending your life mimicking Sisyphus in your quest of opening people's minds, but someone has to do it!
"Obamacare ties coverage decisions to the uspstf, which has ironically made the group more subject to lobbying pressure."
Great article by Vinay, but this shouldn't be considered ironic at all. The entire healthcare sector seems to run on regulatory capture, so it's more par for the course.
Thank you, Vinay, as always, for your intellectual rigor and honesty! I am so glad to have someone trustworthy to scrutinize the studies for us, since it is quite impossible for a lay person (such as myself, unwilling to put in the years needed to learn) to do so. Always glad to see cutting out of any kind of waste!
Abolition of this department would be a good first step in eliminating the entire public health bureaucracy. On the subject of masks and respiratory disorders, how about some scientifically valid proof of contagion before recommending "preventive" strategies that seem to be based on whims and guesses.
Agree the federal government should get out of the business of giving any medical advice. Everything they do in this space will be perceived as politicized. Best to leave it to the professional medical societies. Problems there too, but their processes are more rigorous and accountable to the profession and the public.
I am a 75+ year-old Gynecologic oncologist. My mother died of colon cancer. I have seen many men and women die of pelvic cancers with local and nodal metastasis. “All-cause mortality “ reduction is not what I seek for myself. I get annual PCA. I get colonoscopy every 3 years rs, and polyps are always removed. I want early detection, and I want vigorous treatment of all pelvic cancer except limited, histologically low grade prostate cancer, to prevent advanced pelvic cancer with pain, fistula, stomas, and obstruction. Even if my date of death is unchanged!
The outcome variable of randomized trials is important, and neither ca nicer-related mortality nor all-cause mortality captures what I consider to be the relevant issues.
I definitely agree that this is really unfortunate. They brought this on themselves. I have often wondered whether a lot of institutions are more interested in keeping themselves going than actually achieving their goals.
The question was somewhat rhetorical. Obviously self perpetuation is a key part. But the problem is that for an organization that’s trying to cure cancer or solve poverty, they don’t have any incentive to actually solve the problem. We need some kind of system for limiting the longevity of organizations that don’t solve the problems they’re meant to solve.
We may do better if all organisations had to close up shop, regardless, in 15 years or so, while documenting what, if anything, they discovered while in existence. I think we have reached the point where the negatives of having to repeatedly lose the expertise and embedded wisdom of existing organisations is smaller than the negatives of nest-feathering and institutional capture.
I’m certainly open to the idea although I think that there should be a limit to how that gets implemented. For example, in intellectual property, Sony was required to create a new Spiderman movie every few years in order to maintain the rights to the character.
I think in order to continue to exist, you have to create something that is tangibly different from what came before and what you’ve produced before. Like for example how Apple keeps coming up with new products but more recently they’ve just made marginal improvements to existing technology. Which isn’t necessarily as beneficial.
Thanks for having the courage to say this. Sadly, there’s a well-financed self-interested group on the other side, pushing lucrative, useless, and probably harmful interventions while wasting time, money, and resources.
When I consider how refreshing your good nature is, Doc, I am unsurprised that you are surprised that they are surprised.
The iron law of institution hereinafter obtains, and the combination of arrogance, incompetence and deceit forms a heady brew.
Consider how routinely "noble" lies are propagated, and that those who suppress fraud for a living are very familiar with how small lies become big ones. Incompetence and fraud are categorically discrete, but there is a great deal of overlap. Add the effect of an arrogant sense of superiority, and you have a dawning conceptualization of how that arrogance leads one accustomed to deceit, to deceive themselves into thinking that the cash flow will never cease.
Conveyance of surprise is also a common rhetorical tactic, one that the internet age has rebranded as a form of "concern trolling." Still and all, can anyone be amazed at someone defending their sinecure?
As a gastroenterologist who has performed > 25,000 colonoscopies, I have seen and removed thousands of colon polyps. My ADR (adenomatous polyp detection rate) is 45-50% for screening colonoscopies. Adenomatous polyps as well sessile serrated polyps are the main precursors for the development of colon cancer. By finding those particular polyps and subsequent removal prevents colon cancer. However, the vast majority of colon polyps never develop into colon cancer. The population of the USA for ages 45-75 (the age recommended for colon cancer screening) is about 84.7 million. If my ADR reflects on the general population, then 40-42 million Americans harbor silent colon polyps. The incidence of colon cancer is about 155,000 yearly; therefore, most Americans will never develop colon cancer. The efforts of medicine should be channeled to identify individuals with the polyps that are higher risk for colon cancer development as opposed to mass screening.
Wow, what a helpful perspective—thank you so much for sharing!
YES YES YES this! Causing unnecessary utilization and harm, driving up costs, annoying our patients (try getting an 88 yo long-term care patient to go out and get a mammogram!) so that we can "check a box" -- never mind an annual flu/COVID/RSV/PNA shot. Ugh!
Add a bone density scan while she is there! And a carotid artery study! Stat!
USPHTF recommends regular screening mammo up to age 74. Not sure about the bone scan, but likely similar. RSV and PNA aren’t annual.
And why would you have to go anywhere when you’re already in a long term care facility?
And even in assisted living, these shots will be given without consulting with family or an outside GP. There's huge money in these institutions and no concern for what side affects people already often on 10+ medications might suffer.
Brilliant insight once again Vinay. Nothing like spending your life mimicking Sisyphus in your quest of opening people's minds, but someone has to do it!
"Obamacare ties coverage decisions to the uspstf, which has ironically made the group more subject to lobbying pressure."
Great article by Vinay, but this shouldn't be considered ironic at all. The entire healthcare sector seems to run on regulatory capture, so it's more par for the course.
Thank you, Vinay, as always, for your intellectual rigor and honesty! I am so glad to have someone trustworthy to scrutinize the studies for us, since it is quite impossible for a lay person (such as myself, unwilling to put in the years needed to learn) to do so. Always glad to see cutting out of any kind of waste!
If you say: Don't touch USPSTF recommendations with a barge pole, you have more evidence to back that up than the "stand 6 ft apart" rule.
🤣🤣🤣🤣🤣
Abolition of this department would be a good first step in eliminating the entire public health bureaucracy. On the subject of masks and respiratory disorders, how about some scientifically valid proof of contagion before recommending "preventive" strategies that seem to be based on whims and guesses.
Like a breath of fresh air...thank you once again.
Great perspective, also tendentious to my vocabulary
Me too!
Do you mean conducive or beneficial to?
^also adding tendentious to my vocabulary
“AI: Tendentious means expressing a strong, biased opinion on a controversial topic instead of being fair and neutral.”
Agree the federal government should get out of the business of giving any medical advice. Everything they do in this space will be perceived as politicized. Best to leave it to the professional medical societies. Problems there too, but their processes are more rigorous and accountable to the profession and the public.
I am a 75+ year-old Gynecologic oncologist. My mother died of colon cancer. I have seen many men and women die of pelvic cancers with local and nodal metastasis. “All-cause mortality “ reduction is not what I seek for myself. I get annual PCA. I get colonoscopy every 3 years rs, and polyps are always removed. I want early detection, and I want vigorous treatment of all pelvic cancer except limited, histologically low grade prostate cancer, to prevent advanced pelvic cancer with pain, fistula, stomas, and obstruction. Even if my date of death is unchanged!
The outcome variable of randomized trials is important, and neither ca nicer-related mortality nor all-cause mortality captures what I consider to be the relevant issues.
Are there any RCTs that show a reduction in any of those outcomes?
Great assessment! There is no critical thinking in medicine. The docs in the box are there to check off boxes so they can get paid.
I definitely agree that this is really unfortunate. They brought this on themselves. I have often wondered whether a lot of institutions are more interested in keeping themselves going than actually achieving their goals.
You can stop wondering. Name an institution whose main (but always unstated) goal isn't self-perpetuation.
The question was somewhat rhetorical. Obviously self perpetuation is a key part. But the problem is that for an organization that’s trying to cure cancer or solve poverty, they don’t have any incentive to actually solve the problem. We need some kind of system for limiting the longevity of organizations that don’t solve the problems they’re meant to solve.
We may do better if all organisations had to close up shop, regardless, in 15 years or so, while documenting what, if anything, they discovered while in existence. I think we have reached the point where the negatives of having to repeatedly lose the expertise and embedded wisdom of existing organisations is smaller than the negatives of nest-feathering and institutional capture.
I’m certainly open to the idea although I think that there should be a limit to how that gets implemented. For example, in intellectual property, Sony was required to create a new Spiderman movie every few years in order to maintain the rights to the character.
I think in order to continue to exist, you have to create something that is tangibly different from what came before and what you’ve produced before. Like for example how Apple keeps coming up with new products but more recently they’ve just made marginal improvements to existing technology. Which isn’t necessarily as beneficial.
It's called the "Iron Law of Institutions." https://medium.com/@jesse.singal/the-iron-law-of-institutions-and-the-left-333c42c246af
As always, truly insightful.
Thanks for having the courage to say this. Sadly, there’s a well-financed self-interested group on the other side, pushing lucrative, useless, and probably harmful interventions while wasting time, money, and resources.
When I consider how refreshing your good nature is, Doc, I am unsurprised that you are surprised that they are surprised.
The iron law of institution hereinafter obtains, and the combination of arrogance, incompetence and deceit forms a heady brew.
Consider how routinely "noble" lies are propagated, and that those who suppress fraud for a living are very familiar with how small lies become big ones. Incompetence and fraud are categorically discrete, but there is a great deal of overlap. Add the effect of an arrogant sense of superiority, and you have a dawning conceptualization of how that arrogance leads one accustomed to deceit, to deceive themselves into thinking that the cash flow will never cease.
Conveyance of surprise is also a common rhetorical tactic, one that the internet age has rebranded as a form of "concern trolling." Still and all, can anyone be amazed at someone defending their sinecure?