Read this piece after seeing your comment on Emily Oster’s substack. There are other harms to mammography in that the very high rate of false positives creates burden of time, anxiety, and quite a lot of money for the patient. It’s not uncommon for these scenarios to take many weeks, if not months, plus thousands of dollars to iron out. And while I go back and forth on the way anxiety as a harm should be depicted (I don’t think women’s choices should be limited by how anxious it might make them), it is true that women are less likely to get mammograms in the future if they go through a false positive (this could be good or bad depending on their risk factors, and I suppose). I also think universal recommendations are harmful in that they perpetuate a cookie-cutter approach while ignoring a very small group of people under and over 40 who could absolutely benefit from enhanced surveillance or other prophylactic measures. There is a study called the Wisdom Study that I am a participant in (check it out!). and it’s seeking to determine whether the standard US approach is better/worse than an individualized screening approach based on your lifestyle, race, family history, and genetics. My “start” age was set at 49, and I have definitely experienced heightened resistance to this well-informed decision I’ve made by my providers once the USPTF switched gears. If feels super paternalistic. I’d love to know what you think and if you would recommend it to your patients. https://www.thewisdomstudy.org/
Thank you for looking at issues like this. I am a retired physician and only began late in my career to question the mainstream orthodoxy in our profession. Everything is so hopelessly corrupt, as well as scientifically unsound, it will be a great challenge for you to maintain your love and compassion for your patients. I read another of your articles and you seem to have one foot in the transcendent, or at least philosophical, which will help you greatly and I wish you the greatest peace in your life and career!
It occurred to me some time ago, but at a point much further along in my medical career than yours, that the path to becoming a physician subselected for rule followers and not for doubters or heterodox thinkers. To some extent in undergrad and pretty much entirely in med school and residency, doing well is about repeating and doing what you’re told. We’re conditioned to think there’s a right answer or a right way and it is absolutely what we’ve been told or shown. Getting over that notion requires dealing with an uncomfortable degree of cognitive dissonance that many can’t handle. Add in financial incentives and the notion of motivation conditions cognition becomes very apparent. Almost 100 years ago Upton Sinclair wrote it’s nearly impossible to get a person to understand something when their salary depends on not understanding. Add in the near complete lack of price transparency in medicine and you have the problem Milton Friedman noted 60 years ago- the most inefficient outcome is when you use somebody else’s money to purchase on somebody else’s behalf as you won’t care about neither price or quality. That’s our medical insurance system today. My daughter does investment banking which generally has a poor ethical reputation, but it’s amazing how much transparency is demanded at every step of every deal. Medicine could learn a lesson. I’m proud of my long career in EM. I think medicine does so many things well, but we’re headed in a concerning direction and I think pharma and insurance know they have a lot of unquestioning middlemen in the physician population. Thanks for doing the work you do.
I recently went to my general doctor because of some breast puckering. She didn’t think it much but ordered an ultrasound to check things out with the possibility of a mammogram if anything showed up. When I contacted the breast department, I was told I would need to get a mammogram along with the ultrasound. I protested and got the mammogram cancelled over the phone. When I arrived for the appointment, however, I was told that I would have to get the mammogram anyway and the ultrasound afterwards. I was very taken aback and unprepared for this so the whole experience was very unnerving. I have no history of breast cancer in my family and no other warning signs. In the end, nothing was found and I was left recovering from the difficult experience. The puckering was determined to be caused by me coming to the end of my years of breastfeeding.
This piece caught my eye and I was intrigued after the experience I had recently. No one should feel this pressure if there is the possibility to do more harm than good.
Read this piece after seeing your comment on Emily Oster’s substack. There are other harms to mammography in that the very high rate of false positives creates burden of time, anxiety, and quite a lot of money for the patient. It’s not uncommon for these scenarios to take many weeks, if not months, plus thousands of dollars to iron out. And while I go back and forth on the way anxiety as a harm should be depicted (I don’t think women’s choices should be limited by how anxious it might make them), it is true that women are less likely to get mammograms in the future if they go through a false positive (this could be good or bad depending on their risk factors, and I suppose). I also think universal recommendations are harmful in that they perpetuate a cookie-cutter approach while ignoring a very small group of people under and over 40 who could absolutely benefit from enhanced surveillance or other prophylactic measures. There is a study called the Wisdom Study that I am a participant in (check it out!). and it’s seeking to determine whether the standard US approach is better/worse than an individualized screening approach based on your lifestyle, race, family history, and genetics. My “start” age was set at 49, and I have definitely experienced heightened resistance to this well-informed decision I’ve made by my providers once the USPTF switched gears. If feels super paternalistic. I’d love to know what you think and if you would recommend it to your patients. https://www.thewisdomstudy.org/
Thank you for looking at issues like this. I am a retired physician and only began late in my career to question the mainstream orthodoxy in our profession. Everything is so hopelessly corrupt, as well as scientifically unsound, it will be a great challenge for you to maintain your love and compassion for your patients. I read another of your articles and you seem to have one foot in the transcendent, or at least philosophical, which will help you greatly and I wish you the greatest peace in your life and career!
It occurred to me some time ago, but at a point much further along in my medical career than yours, that the path to becoming a physician subselected for rule followers and not for doubters or heterodox thinkers. To some extent in undergrad and pretty much entirely in med school and residency, doing well is about repeating and doing what you’re told. We’re conditioned to think there’s a right answer or a right way and it is absolutely what we’ve been told or shown. Getting over that notion requires dealing with an uncomfortable degree of cognitive dissonance that many can’t handle. Add in financial incentives and the notion of motivation conditions cognition becomes very apparent. Almost 100 years ago Upton Sinclair wrote it’s nearly impossible to get a person to understand something when their salary depends on not understanding. Add in the near complete lack of price transparency in medicine and you have the problem Milton Friedman noted 60 years ago- the most inefficient outcome is when you use somebody else’s money to purchase on somebody else’s behalf as you won’t care about neither price or quality. That’s our medical insurance system today. My daughter does investment banking which generally has a poor ethical reputation, but it’s amazing how much transparency is demanded at every step of every deal. Medicine could learn a lesson. I’m proud of my long career in EM. I think medicine does so many things well, but we’re headed in a concerning direction and I think pharma and insurance know they have a lot of unquestioning middlemen in the physician population. Thanks for doing the work you do.
I recently went to my general doctor because of some breast puckering. She didn’t think it much but ordered an ultrasound to check things out with the possibility of a mammogram if anything showed up. When I contacted the breast department, I was told I would need to get a mammogram along with the ultrasound. I protested and got the mammogram cancelled over the phone. When I arrived for the appointment, however, I was told that I would have to get the mammogram anyway and the ultrasound afterwards. I was very taken aback and unprepared for this so the whole experience was very unnerving. I have no history of breast cancer in my family and no other warning signs. In the end, nothing was found and I was left recovering from the difficult experience. The puckering was determined to be caused by me coming to the end of my years of breastfeeding.
This piece caught my eye and I was intrigued after the experience I had recently. No one should feel this pressure if there is the possibility to do more harm than good.
Stephanie, thank you so much for your comment - it means a lot coming from you. Hope all is well!