dudestupid
dudestupid
Joined: Sep 11, 2010
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December 8th, 2010 at 6:32:27 PM permalink
I saw a patient last week in a difficult situation and realized his problem could best be stated in terms of gambling.

He came to me with blood in his stool. I'm pretty darn sure it was hemorrhoids. But blood in the stool can be a sign of colon cancer. He is over 50. The answer to this is usually easy. I recommend a routine colonoscopy to everyone over 50 for colon cancer screening. So he has 2 reasons to get the test done.

He has private insurance, but his plan has a $1000 co-pay on colonoscopies. He recently lost his job, and is on his wife's insurance. He doesn't have $1000.

If you were to come to me, and ask me to bet $1000 that the bleeding is from hemorrhoids, I would take that bet without hesitation. (not really, that would be ethically wrong, but you know what I mean).
But if you were to ask me to bet my life on that, no way. For this man, there is no option. He doesn't have $1000 to wager. He can only wager with his life. He'll probably be fine. The odds are greatly in his favor, there's a very small chance he has cancer.

For background, here's the odds (http://seer.cancer.gov/statfacts/html/colorect.html):
2.04% of men will develop cancer of the colon and rectum between their 50th and 70th birthdays compared to 1.53% for women.
5.12% of men and women born today will be diagnosed with cancer of the colon and rectum at some time during their lifetime.

I can't extrapolate his personal risk of colon cancer, but given his history of blood in the stool, it's going to be higher than 2%.

A lot of medicine comes down to gambling. You bet with money and you bet with your health. It really sucks when you run low on your bankroll of either.
Toes14
Toes14
Joined: May 6, 2010
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December 8th, 2010 at 6:44:35 PM permalink
Wow, what a lousy insurance plan. (I should know - I'm a health insurance underwriter.)

Good comparison. Although in real life, he could probably work out a payment plan, or take a lesser job just for the insurance.
"Bite my Glorious Golden Ass!" - Bender Bending Rodriguez
dudestupid
dudestupid
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December 8th, 2010 at 7:09:41 PM permalink
Quote: Toes14

Wow, what a lousy insurance plan. (I should know - I'm a health insurance underwriter.)

Good comparison. Although in real life, he could probably work out a payment plan,



He is currently working on figuring out a payment plan. I see similar cases like this every week (involving medications, referrals, etc), but this one was easily explainable with clear-cut risks and readily available figures, so it inspired me to post.
ahiromu
ahiromu
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December 8th, 2010 at 7:22:46 PM permalink
Heh, kind of comparable to Russian roulette. I mean let's say you would win 1 million and 5/6 of the bullet slots are empty. Would you take it, really?
Its - Possessive; It's - "It is" / "It has"; There - Location; Their - Possessive; They're - "They are"
sunrise089
sunrise089
Joined: Jul 12, 2010
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December 8th, 2010 at 7:38:43 PM permalink
Quote: ahiromu

Heh, kind of comparable to Russian roulette. I mean let's say you would win 1 million and 5/6 of the bullet slots are empty. Would you take it, really?

I'd not take the 5/6 shot for any amount of money. I would certainly take my chances at some level of risk though.

@op - your analogy holds, but the math is more complicated. The patient has a 2% or greater chance of having the disease, but what does detection do to his prognosis? We should really push early detection for skin or breast cancer, but with pancreatic cancer (which isn't very treatable) it really isn't as vital. The patient may actually have made a rational decision, and the insurance company might be too with a high deductible for what seems at first the sort of preventative test you want to encourage.

True story - PhD economist I loosely work with was told by his doctor to get a test. The economist asked the cost, the chance of an accurate detection, false positives, false negatives, and risks and rewards to treatment. The doctor was unable/unwilling to provide the info, so my coworker researched things himself and turned down the test against the doctors advice. In that case the math wasn't even close since it turned out, iirc, that the condition being tested for was so rare at my coworkers age and with his medical history, and the false positive rate was so high. He'd have literally gained no statistically significant information from the outcome.
boymimbo
boymimbo
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December 8th, 2010 at 7:52:11 PM permalink
Ah, the state of Health Care in America. Recently unemployed, can't afford health care, so he's forced to gamble his life because he doesn't have $1000 to pay because he lost his job. I guess he'll have to find work to be able to afford to get his care. My guess is that he isn't a smoker and is in general good health. Obamacare won't make anything better. This patient probably isn't the kind of bum that everyone says will benefit from a socialized health care system. Sorry for the rant, but my brother in law just cut back in their health care coverage to the point where he has a $500 deductable, and now he is going to delay routine checkups because he doesn't want to pay the deductable. I know this will attract some comments from AZ and Bob, oh well.

Back on topic, I would borrow, beg, and steal the $1,000.
----- You want the truth! You can't handle the truth!
EvenBob
EvenBob
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December 8th, 2010 at 8:05:35 PM permalink
Quote: Toes14

Wow, what a lousy insurance plan. .



Look at Michael Douglas, the actor. He went to his doctor in Jan with a sore throat that wouldn't heal and they did every test and shrugged their shoulders, even though he's a heavy drinker and smoker. He went back in June with throat cancer and will probably be gone in a few months. Who dropped the ball? He said he knew the chain smoking was bad, but he has way 'too much stress' in his life to quit. Dying will definitely take care of the stress.
"It's not enough to succeed, your friends must fail." Gore Vidal
dudestupid
dudestupid
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December 8th, 2010 at 9:50:41 PM permalink
Quote: sunrise089


@op - your analogy holds, but the math is more complicated. The patient has a 2% or greater chance of having the disease, but what does detection do to his prognosis?



And in comparison to most decisions I have to make during a 15-30 minute visit, this math is fairly simple. The supporting data for most conditions usually isn't that clear cut. The benefits to early detection of colon cancer and (most importantly) pre-cancerous polyps are pretty well established. When you start talking about prostate or lung cancer, things get VERY muddy.

I do NOT want to imply that a decision not to get tested is irrational. I would be in a different situation than him, because I would have access to the money. If I were a subsistence farmer in Haiti, saving up $1000 and blowing it on a screening colonoscopy would probably be irrational.

Regarding your co-worker, it's a common situation. As much as would like to claim we doctors could balance all these probabilities in our head, we're usually not that smart, and don't have that much time. And when a professor does crunch the numbers, we often end up with statistics like "the risk of getting cancer from a single [TSA xray] scan at about 1 in 30 million" which is near useless for decision making.

Am I willing to risk a 2 in 30 million chance of cancer to take a round trip to Vegas? Yeah, I guess so. Driving around town is far more dangerous. But do we want to risk that on a national basis? Now, keep in mind that statistics extrapolated out to "1 in 30 million" are highly suspect anyway.
Asswhoopermcdaddy
Asswhoopermcdaddy
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December 9th, 2010 at 8:40:58 AM permalink
As an alternative to the $1000 colonoscopy, why not do a blood test to look for cancer markers? If he has colon cancer, shouldn't there be a high probability that markers will show up in the blood work which would be covered under most standard annual physicals? If negative, then like you said, the best bet is on hemorrhoids.
Nareed
Nareed
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December 9th, 2010 at 8:42:40 AM permalink
You should never gamble when you can't afford to lose the stakes.

How many of you can afford to lose your life?
Donald Trump is a fucking criminal

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