I went to the dermatologist and today and I have some sort of cyst on my ear. He said it was nothing. He said the options are to remove it surgically, to use some sort of cream to remove it over time, or to do nothing.
I asked about the benefits of removing it. He said that they’d be able to biopsy it and be 100% sure that it’s nothing. I asked “as opposed to… how confident are you now?” He said 99.5 or 99.95% sure.
It seems clear to me that the costs of money, time and pain are easily worth the 5/1000(0) chance that I detect something dangerous earlier and correspondingly reduce the chances that I die. Like, really really really really really clear to me. Death is really bad. I’m horrified that doctors (and others) don’t see this. He was very ready to just send me home with his diagnosis of “it’s nothing”. I’m trying to argue against myself and account for biases and all that, but given the badness of death, I still feel extremely strongly that the surgery+biopsy is the clear choice. Is there something I’m missing?
Also, the idea of Prediction Book for Doctors occurred to me. There could be a nice UI with graphs and stuff to help doctors keep track of the predictions they’ve made. Maybe it could evolve into a resource that helps doctors make predictions by providing medical info and perhaps sprinkling in a little bit of AI or something. I don’t really know though, the idea is extremely raw at this point. Thoughts?
1) surgery is dangerous. Even innocuous surgeries can have complications such as infection that can kill. There’s also complications that aren’t factored into the obvious math, for example ever since I got 2 of my wisdom teeth out, my jaw regularly tightens up and cracks if I open my mouth wide, something that never happened beforehand. I wasn’t warned about this and didn’t consider it when I was deciding to get the surgery.
2) If it’s something dangerous, you’re very likely to find out anyway before it becomes serious. eg, if it’s a tumor, it’s going to keep growing and you can come back a month later and get it out then with little problem.
3) even if it’s not nothing, it might be something else that’s unlikely to kill you. Thus the 5/1000 chance of death you’re imagining is actually a 5/1000 chance of being not nothing.
Are you just making these points as things to keep in mind, or are you making a stronger point? If the latter, can you elaborate? Are you particularly knowledgeable?
The point is your consideration of “if surgery, definitely fine” vs “if no surgery, 5/1000 chance of death” are ignoring a lot of information. You’re acting like your doctor is being unreasonable when in fact they’re probably correct.
Stronger point: since we are at Less Wrong, think Bayes Theorem. In this case, a “true positive” would be cancer leading to death, and a “false positive” would be death from a medical mishap trying to remove a benign cyst (or even check it further). Death is very bad in either case, and very unlikely in either case.
P (death | cancer, untreated) - this is your explicit worry
P (death | cancer, surgery)
P (death | benign cyst, untreated)
P (death | benign cyst, surgery) - this is what drethelin is encouraging you to note
P (benign cyst)
P (cancer)
My prior for medical mishaps is higher than 0.5% of the time, but not for fatal ones while checking/removing a cyst near the surface of the skin. As drethelin’s #2 notes, this is not binary. If it is not a benign cyst, you will probably have indicators before it becomes something serious. Similarly, you have non-surgical options such as a cream or testing. Testing probably has a lower risk rate than surgery, although if it is a very minor surgery, perhaps not that much lower.
If the cyst worries you, having it checked/removed is probably low risk and may be good for your mental health. But now we might have worried you about the risks of doing that (sorry) when we meant to reduce your worries about leaving the cyst untreated.
In general if you list everything you can think of and give it probability scores, you ignore unknown unknowns.
For medical interventions like surgery unknown unknowns are more likely to be bad than to be good.
As a result it’s useful to have a prior against doing a medical intervention if there no strong evidence that the intervention is beneficial.
Maybe we need to visualize surgery different. I used to think about it like replacing a part in a car. Why not just do it if the part is not working too well.
Maybe we should see it as damage. It’s like someone attacking you with a knife. Except that the intention is completely different, they know what they are doing, their implements are far more precise and so on, so the parallel is not very good either, I am just saying that “recovering from an appendicitis” could be at least visualized as something closer to “recovering after a nasty knife fight” than to “just had the clutch in my car replaced”.
When he said “99.5 or 99.95%” I rather doubt he meant to give the precise odds. I think that what he meant was “There is a non-zero probability that the cyst will turn out to be an issue, but it is so small I consider it insignificant and so should you”. Trying to base some calculations on the 0.5% (or 0.05%) chance is not useful because it’s not a “real” probability, just a figurative expression.
Great point. He did seem to pause and think about it, but still a good point. It seems notably likely that you’re right, and even so, I doubt that his confidence is well-calibrated.
I think you should use the cream for a week, to start with.
Also, thought experiment: Suppose a person is going to live another 70 years. If undergoing some oversimplified miracle-cure treatment will cost, one way or another, 1 week of their life, what chance of “it’s just a cyst” will they accept? 99.97%. So from the doctor’s perspective (neglecting other risks or resources used, taking their ’99.95%′ probability estimate at face value, and assuming that a biopsy is some irreplaceable road to health), your condition is so likely to be benign that the procedure to surgically check spends your life at about the same rate as it saves it.
The biggest thing is that the doctor’s priorities are not your priorities. To him, a life is valuable… but not infinitely valuable -estimates usually puts the value of a life at (ballpark) 2 million dollars. When you consider the relative probability of you dying, and then the cost to the healthcare system of treatment, he’s probably making the right decision (you of course, would probably value your own life MUCH MUCH higher). Btw, this kind of follows a blindspot I’ve seen in several calculations of yours—let me know if you’re interested in getting feedback on it.
Finally, there are two other wrinkles—the possibility of complications and the possibility of false positives from a biopsy. The second increases the potential cost, and the first decreases the potential years added to your life. Both of these tilt the equation AGAINST getting it removed.
The biggest thing is that the doctor’s priorities are not your priorities. [...] When you consider the relative probability of you dying, and then the cost to the healthcare system of treatment
The doctor has no incentive to minimize the cost of treatment. He makes money by having a high cost of treatment.
Even adamzerner probably doesn’t value his life at much more than, say, ten million, and this can likely be proven by revealed preference if he regularly uses a car. If you go much higher than that your behavior will have to become pretty paranoid.
That is an issue with revealed preferences, not an indication of adamzerners preference order. Unless you are extraordinarily selfless you are never going to accept a deal of the form: “I give you n dollars in exchange for me killing you.” regardless of n, therefor the financial value of your own life is almost always infinite*.
*: This does not mean that you put infinite utility on being alive, btw, just that the utility of money caps out at some value that is typically smaller than the value of being alive (and that cap is lowered dramatically if you are not around to spent the money).
I think you are mistaken. If you would sacrifice your life to save the world, there is some amount of money that you would accept for being killed (given that you could at the same time determine the use of the money; without this stipulation you cannot be meaningfully be said to be given it.)
(Two people mentioned this so I figure I’ll just reply here.)
Re: doctors perspective. I see how it might be rational from his perspective. My first thought is, “why not just give me the info and let me decide how much money I’m willing to invest in my health?”. I could see how that might not be such a good idea though. From a macro perspective, perhaps those sorts of transaction costs might not be worth the benefits of added information → increased efficiency? Plus it’d be getting closer to admitting to how much they value a life, which seems like it’d be bad from an image perspective
I guess what I’m left with is saying that I find it extremely frustrating, I’m disappointed in myself for not thinking harder about this, and I’m really really glad you guys emphasized this so I could do a better job of thinking about what the interests are of parties I interact with (specifically doctors, and also people more generally). I feel like it makes sense for me to be clear that I would like information to be shared with me and that I’m willing to spend a lot of money on my health. And perhaps that it’s worth exercising some influence on my doctors so they care more about me. Thoughts?
The doctor you are with has a financial interest to treat you. When he advises you against doing something about the cyst he’s acting against his own financial interests.
Overtreatment isn’t good if you value life very much. Every medical interventions comes with risks. We don’t fully understand the human body, so we don’t know all the risks.
From the perspective of the doctor the question likely isn’t: “How much money is the patient willing to invest in health” but “How much is the patient willing to invest for the cosmetic issue of getting rid of an ugly cyst”.
If I remember right the best predictor for a doctor getting sued is whether patients perceive the doctor to be friendly.
Advising against a unnecessary practice might be malpractice but informing a patient about the option to do so, especially when there are cosmetic reasons for it, shouldn’t be a big issue.
Even good doctors can get sued. But it speaks to more about why people sue; (doctors did a bad human-interaction job rather than they did a negligent job)
I do wonder about the nature of doctoring. Do you happen to get 3% (arbitrary number) wrong; and if you are also bad at people-skills, this bites you. whereas if you get 3% wrong and you are good at people skills you avoid being sued 99% of those 3% of cases.
A perspective on the nature of medical advice:
There exist people who are so concerned about not dying that they would do anything in their power to survive medically, and organise for themselves regular irrelevant medical tests. They are probably over-medicated and wasting a lot of time. i.e. a brain scan for tumours (where no reason to think they exist is present).
There exist people who get yearly mammograms.
there exist people who probably get around to their (reccomended yearly) mammogram every few years.
There exist people who have heart attacks from long term lifestyle choices.
There exist people who are so not concerned about dying that they smoke.
This is the range of patients that exist. You sound like you are closer to the top in terms of medical concern. The dermatologist has to consider where on the spectrum you are when devising a treatment as well as where the condition is on the spectrum of risk.
For a rough estimate (not a doctor) I would say the chance of a cyst on your ear killing you in the next 50 years would be less than the chance of getting an entirely different kind of cancer and having it threaten your life. (do you eat burnt food? bowel cancer risk. Do you go in the sun? skin cancer risk)
If it can be removed by cream; it will still be gone. The specialist should suggest a biopsy to cover their ass, but really; it could be 99 different types of skin growths or few type of cancerous growth. With no other symptoms there is no reason to suspect any danger exists.
the numbers you suggested sound like they were fabricated when given to you. Which is a reason to not mathematically attack them; but take them on the feeling value of 99.99% thumbs up. (and its really hard and almost impossible to find 0.01% so medically we don’t usually bother)
1) See another doctor to get a second opinion. (And possibly a third opinion, if you don’t like the second doctor.) Keep looking for a doctor until you find one that explains things to you in enough detail so that you understand thoroughly. Write down the questions you want answered ahead of time, and take notes during your appointment. “I am confident” is a bullshit answer unless you understand what possibilities the doctor considered, why the doctor thinks this one is the most likely, what the possible approaches to dealing with it if it turns out to be “not fine” are, and their advantages and disadvantages, what warning signs to look for that might indicate it is not fine, and the mechanism by which the cream option would work.
Unfortunately, the state of medical knowledge is such that there may not be good answers to all of the questions. The best the doctor may be able to do is “I don’t know” for some of them. But you can get a better understanding of the situation than you have now, and a better understanding of where there are gaps in the medical knowledge.
2) Read a bunch of scientific papers about cysts and biopsies and tests so that you understand the possibilities and the risks better.
3) Also read about medical errors and risks of surgeries. People following doctor’s instructions is one of the leading causes of death in the USA. I read an article about it in JAMA a few years ago. There might be more up-to-date papers about it by now. Having a medical procedure done is not a neutral option when it comes to affecting your chances to continue living.
For example, here’s a paper that indicates that prostate biopsies could increase the mortality rate in men. This is just one study, not enough information to make an informed decision.
Boniol M, Boyle P, Autier P, Perrin P. Mortality at 120 days following prostatic biopsy: analysis of data in the PLCO study. Program and abstracts of the 2013 American Society of Clinical Oncology Annual Meeting and Exposition; May 31-June 4, 2013; Chicago, Illinois. Abstract 5022.
http://onlinelibrary.wiley.com/doi/10.1002/ijc.23559/full
If brevity was the issue, I wouldn’t have expected him to say 5 instead of 9. And I would have expected him to use stronger language than he did. My honest impression is that he thinks that the chances that it’s something are really small, but nothing approaching infinitesimally small.
I’d say an expert in any field has better intuitions (hidden, unverbalized knowledge) than what they can express in words or numbers. Therefore, I’d assume that the decision that it’s not worth doing the examination should take priority over the numerical estimate that he made up after you asked.
It may be better to ask the odds in such cases, like 1 to 10,000 or 1 to a million. Anyway, it’s really hard to express our intuitive, expert-knowledge in such numbers. They all just look like “big numbers”.
Another problem is that nobody is willing to put a dollar value on your life. Any such value would make you upset (maybe you are the exception, but most people probably would). Say the examination costs $100 (just an example). Then if he’s 99.95% sure you aren’t sick, and 0.05% sure you are dying and sends you home, then he (rather your insurance) values your life at less than $200,000. This is a very rough estimation, but it seems in the right ballpark for what a general stranger’s life seems to be valued by the whole population. Of course it all depends on how much insurance you pay, how expensive the biopsy is etc. Maybe you are right that you deserve to be examined for your money, maybe not. But people tend to avoid this sort of discussion because it is very emotionally-loaded. So we mainly mumble around the topic.
People are dying all the time out of poverty, waiting on waiting lists, not having insurance, not being able to pay for medicaments. But of course people who have more money can override this by buying better medical care. Depending on the country there are legal and not-so-legal methods to get better healthcare. You could buy a better package legally, put some cash in the doctor’s coat, etc.
You need to consider that the people who’d do your biopsy can do other things as well, for example work on someone’s biopsy who has a chance of 1% of dying instead of your 0.05% (assuming this figure is meaningful and not just a forced, uncalibrated guess).
If you confronted your doctor with these things, he’d probably prefer to just revoke that probability estimate and just say his expert opinion is that you don’t need the biopsy, end of story. It would be very hard for you to argue with this.
Depending on the country there are legal and not-so-legal methods to get better healthcare. You could buy a better package legally, put some cash in the doctor’s coat, etc.
It’s quite easy to get more expensive healthcare. On the other hand that doesn’t mean the healthcare is automatically better.
If you are willing to pay for any treatment out of your own pocket then a doctor can treat you in a way that’s not being payed for by an insurance company because it’s not evidence-based medicine.
It can still be evidence-based, just on a larger budget. I mean, you can get higher quality examinations, like MRI and CT even if the public insurance couldn’t afford it. Just because they wouldn’t do it by default and only do it for your money doesn’t mean it’s not evidence based. Evidence-based medicine doesn’t say that this person needs/doesn’t need this treatment/examination, it gives a risk/benefit/cost analysis. The final decision also depends on the budget.
Therefore, I’d assume that the decision that it’s not worth doing the examination should take priority over the numerical estimate that he made up after you asked.
It seemed to me that the proposition was made under false assumptions. Specifically, I value my life way more than most people do, and I value the costs of time/money/pain less than most people do. He seemed to have been assuming that I value these things in a similar way to most people.
But people tend to avoid this sort of discussion because it is very emotionally-loaded. So we mainly mumble around the topic.
Yeah, I understand this now. Previously I hadn’t thought enough about it. So given that I am willing to spend money for my health, and that I can’t count on doctors to presume that, it seems like I should make that clear to them so they can give me more personalized advice.
Specifically, I value my life way more than most people do, and I value the costs of time/money/pain less than most people do. He seemed to have been assuming that I value these things in a similar way to most people.
How do you know? Because you do things like flossing every day?
Healthcare economics quite frequently mean that a person prefers to pay more rather than less to signal to themselves that they do everything in their power to stay alive.
People quite frequently make bad health decisions because buying an expensive treatment feels like they do something to stay healthy will it’s much more difficult emotionally to do nothing.
I understand that for a lot of people, the X isn’t about Y thing applies. That investing in health might be about signaling to oneself/others something. But I assure you that I genuinely do care. Maximizing expected utility is a big part of how I make decisions, and I think that things that reduce the chances of dying have very large expected utilities (given the magnitude of death). That said, I’m definitely not perfect. I ate pizza for lunch today :/
So given that I am willing to spend money for my health, and that I can’t count on doctors to presume that, it seems like I should make that clear to them so they can give me more personalized advice.
“Willing to spend money” meaning that you’re willing to pay out of pocket for medical procedures? Or that you are willing to fight your insurance so that it pays for things it doesn’t think necessary?
And doctors are supposed to ignore money costs when recommending treatment (or lack of it) anyway. If you want “extra attention”, I suspect that you would need to proactively ask for things. For example, you can start by doing a comprehensive blood screen—and I do mean comprehensive—including a variety of hormones, a metals panel, a cytokine panel, markers for inflammation, thryroid, liver, etc. etc. You will have to ask for it, assuming you’re reasonably healthy a normal doctor would not prescribe it “just so”.
I’m willing to spend out of pocket. More generally, I value my life a lot, and so I’m willing to undergo costs in proportion to how much I value my life.
I’m willing to undergo costs in proportion to how much I value my life.
You’re constrained by the size of your pocket :-) Being willing to spend millions on saving one’s life is not particularly relevant if you current bank balance is $5.17.
Very rich people can (and do) hire personal doctors. That, however, has its own failure modes (see Michael Jackson).
Yeah, I know. It’s just hard to be more specific than that. I guess what I mean is that I am willing to spend a much larger portion of my money on health than most people are.
I went to the dermatologist and today and I have some sort of cyst on my ear. He said it was nothing. He said the options are to remove it surgically, to use some sort of cream to remove it over time, or to do nothing.
I asked about the benefits of removing it. He said that they’d be able to biopsy it and be 100% sure that it’s nothing. I asked “as opposed to… how confident are you now?” He said 99.5 or 99.95% sure.
It seems clear to me that the costs of money, time and pain are easily worth the 5/1000(0) chance that I detect something dangerous earlier and correspondingly reduce the chances that I die. Like, really really really really really clear to me. Death is really bad. I’m horrified that doctors (and others) don’t see this. He was very ready to just send me home with his diagnosis of “it’s nothing”. I’m trying to argue against myself and account for biases and all that, but given the badness of death, I still feel extremely strongly that the surgery+biopsy is the clear choice. Is there something I’m missing?
Also, the idea of Prediction Book for Doctors occurred to me. There could be a nice UI with graphs and stuff to help doctors keep track of the predictions they’ve made. Maybe it could evolve into a resource that helps doctors make predictions by providing medical info and perhaps sprinkling in a little bit of AI or something. I don’t really know though, the idea is extremely raw at this point. Thoughts?
1) surgery is dangerous. Even innocuous surgeries can have complications such as infection that can kill. There’s also complications that aren’t factored into the obvious math, for example ever since I got 2 of my wisdom teeth out, my jaw regularly tightens up and cracks if I open my mouth wide, something that never happened beforehand. I wasn’t warned about this and didn’t consider it when I was deciding to get the surgery.
2) If it’s something dangerous, you’re very likely to find out anyway before it becomes serious. eg, if it’s a tumor, it’s going to keep growing and you can come back a month later and get it out then with little problem.
3) even if it’s not nothing, it might be something else that’s unlikely to kill you. Thus the 5/1000 chance of death you’re imagining is actually a 5/1000 chance of being not nothing.
Are you just making these points as things to keep in mind, or are you making a stronger point? If the latter, can you elaborate? Are you particularly knowledgeable?
The point is your consideration of “if surgery, definitely fine” vs “if no surgery, 5/1000 chance of death” are ignoring a lot of information. You’re acting like your doctor is being unreasonable when in fact they’re probably correct.
Stronger point: since we are at Less Wrong, think Bayes Theorem. In this case, a “true positive” would be cancer leading to death, and a “false positive” would be death from a medical mishap trying to remove a benign cyst (or even check it further). Death is very bad in either case, and very unlikely in either case.
P (death | cancer, untreated) - this is your explicit worry P (death | cancer, surgery) P (death | benign cyst, untreated) P (death | benign cyst, surgery) - this is what drethelin is encouraging you to note P (benign cyst) P (cancer)
My prior for medical mishaps is higher than 0.5% of the time, but not for fatal ones while checking/removing a cyst near the surface of the skin. As drethelin’s #2 notes, this is not binary. If it is not a benign cyst, you will probably have indicators before it becomes something serious. Similarly, you have non-surgical options such as a cream or testing. Testing probably has a lower risk rate than surgery, although if it is a very minor surgery, perhaps not that much lower.
If the cyst worries you, having it checked/removed is probably low risk and may be good for your mental health. But now we might have worried you about the risks of doing that (sorry) when we meant to reduce your worries about leaving the cyst untreated.
In general if you list everything you can think of and give it probability scores, you ignore unknown unknowns. For medical interventions like surgery unknown unknowns are more likely to be bad than to be good.
As a result it’s useful to have a prior against doing a medical intervention if there no strong evidence that the intervention is beneficial.
Maybe we need to visualize surgery different. I used to think about it like replacing a part in a car. Why not just do it if the part is not working too well.
Maybe we should see it as damage. It’s like someone attacking you with a knife. Except that the intention is completely different, they know what they are doing, their implements are far more precise and so on, so the parallel is not very good either, I am just saying that “recovering from an appendicitis” could be at least visualized as something closer to “recovering after a nasty knife fight” than to “just had the clutch in my car replaced”.
What do you think?
Why do you think we need to do so?
agreed; if you are getting it done; and prefer the higher chance of life; get it done without being fully anaesthetized.
Possibly by a plastic surgeon; they seem to have profits to burn on quality equipment from people doing unnecessary (debatable) cosmetic procedures.
You’re probably misreading your doctor.
When he said “99.5 or 99.95%” I rather doubt he meant to give the precise odds. I think that what he meant was “There is a non-zero probability that the cyst will turn out to be an issue, but it is so small I consider it insignificant and so should you”. Trying to base some calculations on the 0.5% (or 0.05%) chance is not useful because it’s not a “real” probability, just a figurative expression.
Great point. He did seem to pause and think about it, but still a good point. It seems notably likely that you’re right, and even so, I doubt that his confidence is well-calibrated.
I think you should use the cream for a week, to start with.
Also, thought experiment: Suppose a person is going to live another 70 years. If undergoing some oversimplified miracle-cure treatment will cost, one way or another, 1 week of their life, what chance of “it’s just a cyst” will they accept? 99.97%. So from the doctor’s perspective (neglecting other risks or resources used, taking their ’99.95%′ probability estimate at face value, and assuming that a biopsy is some irreplaceable road to health), your condition is so likely to be benign that the procedure to surgically check spends your life at about the same rate as it saves it.
The biggest thing is that the doctor’s priorities are not your priorities. To him, a life is valuable… but not infinitely valuable -estimates usually puts the value of a life at (ballpark) 2 million dollars. When you consider the relative probability of you dying, and then the cost to the healthcare system of treatment, he’s probably making the right decision (you of course, would probably value your own life MUCH MUCH higher). Btw, this kind of follows a blindspot I’ve seen in several calculations of yours—let me know if you’re interested in getting feedback on it.
Finally, there are two other wrinkles—the possibility of complications and the possibility of false positives from a biopsy. The second increases the potential cost, and the first decreases the potential years added to your life. Both of these tilt the equation AGAINST getting it removed.
The doctor has no incentive to minimize the cost of treatment. He makes money by having a high cost of treatment.
Right, MattG is 100% backwards.
Even adamzerner probably doesn’t value his life at much more than, say, ten million, and this can likely be proven by revealed preference if he regularly uses a car. If you go much higher than that your behavior will have to become pretty paranoid.
That is an issue with revealed preferences, not an indication of adamzerners preference order. Unless you are extraordinarily selfless you are never going to accept a deal of the form: “I give you n dollars in exchange for me killing you.” regardless of n, therefor the financial value of your own life is almost always infinite*.
*: This does not mean that you put infinite utility on being alive, btw, just that the utility of money caps out at some value that is typically smaller than the value of being alive (and that cap is lowered dramatically if you are not around to spent the money).
I think you are mistaken. If you would sacrifice your life to save the world, there is some amount of money that you would accept for being killed (given that you could at the same time determine the use of the money; without this stipulation you cannot be meaningfully be said to be given it.)
Good point.
(Two people mentioned this so I figure I’ll just reply here.)
Re: doctors perspective. I see how it might be rational from his perspective. My first thought is, “why not just give me the info and let me decide how much money I’m willing to invest in my health?”. I could see how that might not be such a good idea though. From a macro perspective, perhaps those sorts of transaction costs might not be worth the benefits of added information → increased efficiency? Plus it’d be getting closer to admitting to how much they value a life, which seems like it’d be bad from an image perspective
I guess what I’m left with is saying that I find it extremely frustrating, I’m disappointed in myself for not thinking harder about this, and I’m really really glad you guys emphasized this so I could do a better job of thinking about what the interests are of parties I interact with (specifically doctors, and also people more generally). I feel like it makes sense for me to be clear that I would like information to be shared with me and that I’m willing to spend a lot of money on my health. And perhaps that it’s worth exercising some influence on my doctors so they care more about me. Thoughts?
The doctor you are with has a financial interest to treat you. When he advises you against doing something about the cyst he’s acting against his own financial interests.
Overtreatment isn’t good if you value life very much. Every medical interventions comes with risks. We don’t fully understand the human body, so we don’t know all the risks.
From the perspective of the doctor the question likely isn’t: “How much money is the patient willing to invest in health” but “How much is the patient willing to invest for the cosmetic issue of getting rid of an ugly cyst”.
If the surgery isn’t necessary, and something goes wrong during it, does the doctor need to worry about getting sued?
If I remember right the best predictor for a doctor getting sued is whether patients perceive the doctor to be friendly.
Advising against a unnecessary practice might be malpractice but informing a patient about the option to do so, especially when there are cosmetic reasons for it, shouldn’t be a big issue.
Even good doctors can get sued. But it speaks to more about why people sue; (doctors did a bad human-interaction job rather than they did a negligent job)
I do wonder about the nature of doctoring. Do you happen to get 3% (arbitrary number) wrong; and if you are also bad at people-skills, this bites you. whereas if you get 3% wrong and you are good at people skills you avoid being sued 99% of those 3% of cases.
A perspective on the nature of medical advice: There exist people who are so concerned about not dying that they would do anything in their power to survive medically, and organise for themselves regular irrelevant medical tests. They are probably over-medicated and wasting a lot of time. i.e. a brain scan for tumours (where no reason to think they exist is present). There exist people who get yearly mammograms. there exist people who probably get around to their (reccomended yearly) mammogram every few years. There exist people who have heart attacks from long term lifestyle choices. There exist people who are so not concerned about dying that they smoke.
This is the range of patients that exist. You sound like you are closer to the top in terms of medical concern. The dermatologist has to consider where on the spectrum you are when devising a treatment as well as where the condition is on the spectrum of risk.
For a rough estimate (not a doctor) I would say the chance of a cyst on your ear killing you in the next 50 years would be less than the chance of getting an entirely different kind of cancer and having it threaten your life. (do you eat burnt food? bowel cancer risk. Do you go in the sun? skin cancer risk)
If it can be removed by cream; it will still be gone. The specialist should suggest a biopsy to cover their ass, but really; it could be 99 different types of skin growths or few type of cancerous growth. With no other symptoms there is no reason to suspect any danger exists.
the numbers you suggested sound like they were fabricated when given to you. Which is a reason to not mathematically attack them; but take them on the feeling value of 99.99% thumbs up. (and its really hard and almost impossible to find 0.01% so medically we don’t usually bother)
My advice would be:
1) See another doctor to get a second opinion. (And possibly a third opinion, if you don’t like the second doctor.) Keep looking for a doctor until you find one that explains things to you in enough detail so that you understand thoroughly. Write down the questions you want answered ahead of time, and take notes during your appointment. “I am confident” is a bullshit answer unless you understand what possibilities the doctor considered, why the doctor thinks this one is the most likely, what the possible approaches to dealing with it if it turns out to be “not fine” are, and their advantages and disadvantages, what warning signs to look for that might indicate it is not fine, and the mechanism by which the cream option would work.
Unfortunately, the state of medical knowledge is such that there may not be good answers to all of the questions. The best the doctor may be able to do is “I don’t know” for some of them. But you can get a better understanding of the situation than you have now, and a better understanding of where there are gaps in the medical knowledge.
2) Read a bunch of scientific papers about cysts and biopsies and tests so that you understand the possibilities and the risks better.
3) Also read about medical errors and risks of surgeries. People following doctor’s instructions is one of the leading causes of death in the USA. I read an article about it in JAMA a few years ago. There might be more up-to-date papers about it by now. Having a medical procedure done is not a neutral option when it comes to affecting your chances to continue living.
For example, here’s a paper that indicates that prostate biopsies could increase the mortality rate in men. This is just one study, not enough information to make an informed decision.
Boniol M, Boyle P, Autier P, Perrin P. Mortality at 120 days following prostatic biopsy: analysis of data in the PLCO study. Program and abstracts of the 2013 American Society of Clinical Oncology Annual Meeting and Exposition; May 31-June 4, 2013; Chicago, Illinois. Abstract 5022. http://onlinelibrary.wiley.com/doi/10.1002/ijc.23559/full
(deleted—everything I said was said by others already)
Saying 99.9999% seems a mouthful. Would you have preferred an answer like this instead: https://www.youtube.com/watch?v=7sWpSvQ_hwo :)
If brevity was the issue, I wouldn’t have expected him to say 5 instead of 9. And I would have expected him to use stronger language than he did. My honest impression is that he thinks that the chances that it’s something are really small, but nothing approaching infinitesimally small.
I’d say an expert in any field has better intuitions (hidden, unverbalized knowledge) than what they can express in words or numbers. Therefore, I’d assume that the decision that it’s not worth doing the examination should take priority over the numerical estimate that he made up after you asked.
It may be better to ask the odds in such cases, like 1 to 10,000 or 1 to a million. Anyway, it’s really hard to express our intuitive, expert-knowledge in such numbers. They all just look like “big numbers”.
Another problem is that nobody is willing to put a dollar value on your life. Any such value would make you upset (maybe you are the exception, but most people probably would). Say the examination costs $100 (just an example). Then if he’s 99.95% sure you aren’t sick, and 0.05% sure you are dying and sends you home, then he (rather your insurance) values your life at less than $200,000. This is a very rough estimation, but it seems in the right ballpark for what a general stranger’s life seems to be valued by the whole population. Of course it all depends on how much insurance you pay, how expensive the biopsy is etc. Maybe you are right that you deserve to be examined for your money, maybe not. But people tend to avoid this sort of discussion because it is very emotionally-loaded. So we mainly mumble around the topic.
People are dying all the time out of poverty, waiting on waiting lists, not having insurance, not being able to pay for medicaments. But of course people who have more money can override this by buying better medical care. Depending on the country there are legal and not-so-legal methods to get better healthcare. You could buy a better package legally, put some cash in the doctor’s coat, etc.
You need to consider that the people who’d do your biopsy can do other things as well, for example work on someone’s biopsy who has a chance of 1% of dying instead of your 0.05% (assuming this figure is meaningful and not just a forced, uncalibrated guess).
If you confronted your doctor with these things, he’d probably prefer to just revoke that probability estimate and just say his expert opinion is that you don’t need the biopsy, end of story. It would be very hard for you to argue with this.
It’s quite easy to get more expensive healthcare. On the other hand that doesn’t mean the healthcare is automatically better.
If you are willing to pay for any treatment out of your own pocket then a doctor can treat you in a way that’s not being payed for by an insurance company because it’s not evidence-based medicine.
It can still be evidence-based, just on a larger budget. I mean, you can get higher quality examinations, like MRI and CT even if the public insurance couldn’t afford it. Just because they wouldn’t do it by default and only do it for your money doesn’t mean it’s not evidence based. Evidence-based medicine doesn’t say that this person needs/doesn’t need this treatment/examination, it gives a risk/benefit/cost analysis. The final decision also depends on the budget.
It seemed to me that the proposition was made under false assumptions. Specifically, I value my life way more than most people do, and I value the costs of time/money/pain less than most people do. He seemed to have been assuming that I value these things in a similar way to most people.
Yeah, I understand this now. Previously I hadn’t thought enough about it. So given that I am willing to spend money for my health, and that I can’t count on doctors to presume that, it seems like I should make that clear to them so they can give me more personalized advice.
How do you know? Because you do things like flossing every day? Healthcare economics quite frequently mean that a person prefers to pay more rather than less to signal to themselves that they do everything in their power to stay alive.
People quite frequently make bad health decisions because buying an expensive treatment feels like they do something to stay healthy will it’s much more difficult emotionally to do nothing.
I understand that for a lot of people, the X isn’t about Y thing applies. That investing in health might be about signaling to oneself/others something. But I assure you that I genuinely do care. Maximizing expected utility is a big part of how I make decisions, and I think that things that reduce the chances of dying have very large expected utilities (given the magnitude of death). That said, I’m definitely not perfect. I ate pizza for lunch today :/
“Willing to spend money” meaning that you’re willing to pay out of pocket for medical procedures? Or that you are willing to fight your insurance so that it pays for things it doesn’t think necessary?
And doctors are supposed to ignore money costs when recommending treatment (or lack of it) anyway. If you want “extra attention”, I suspect that you would need to proactively ask for things. For example, you can start by doing a comprehensive blood screen—and I do mean comprehensive—including a variety of hormones, a metals panel, a cytokine panel, markers for inflammation, thryroid, liver, etc. etc. You will have to ask for it, assuming you’re reasonably healthy a normal doctor would not prescribe it “just so”.
I’m willing to spend out of pocket. More generally, I value my life a lot, and so I’m willing to undergo costs in proportion to how much I value my life.
You’re constrained by the size of your pocket :-) Being willing to spend millions on saving one’s life is not particularly relevant if you current bank balance is $5.17.
Very rich people can (and do) hire personal doctors. That, however, has its own failure modes (see Michael Jackson).
Yeah, I know. It’s just hard to be more specific than that. I guess what I mean is that I am willing to spend a much larger portion of my money on health than most people are.
Is that a revealed preference? ;-)