Gambling with your life

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.

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.

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.

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?

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.

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.

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.

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.

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.

You should never gamble when you can't afford to lose the stakes.

How many of you can afford to lose your life?

Quote: Nareed

You should never gamble when you can't afford to lose the stakes.

How many of you can afford to lose your life?

Nonsense. Did you buy your car considering only safety? Your house? Your job? Do you wear a bullet prof vest all of the time?

We live in a world of tradeoffs, and medicine isn't an exception to that.

Quote: sunrise089

Nonsense. Did you buy your car considering only safety? Your house? Your job? Do you wear a bullet prof vest all of the time?

We live in a world of tradeoffs, and medicine isn't an exception to that.

A considered risk is not a gamble.

True, you can get killed while driving through no fault of your own, and much more so while flying, but the risk is so small it's not really a bet. Besides you do hedge for such things by getting car insurance.

If you were to have a car accident 6 times out of thirty when you drove, you wouldn't own a car then. That would be gambling.

Quote: Nareed

How many of you can afford to lose your life?

My sister in law has been a doctors office nurse for 25 years and she says the gamble is small. Most tests come back OK and they mostly pay for the doctors Mercedes and summer home. She has a very low opinion of doctors, as do many nurses, because they tend to blame all their mistakes ( and they make a lot of them) on the nurses.

Quote: EvenBob

My sister in law has been a doctors office nurse for 25 years and she says the gamble is small. Most tests come back OK and they mostly pay for the doctors Mercedes and summer home. She has a very low opinion of doctors, as do many nurses, because they tend to blame all their mistakes ( and they make a lot of them) on the nurses.

I should clarify.

Not getting an expensive, time-consuming and highly unpleasant medical test, such as a colonoscopy, for a condition the doctor thinks is unlikely, is not a gamble. Rather it is taking a measured risk weighed against inconvenience and expected benefits.

But the thread title is "Gambling with your life."

In the abstract my original answer stands: you shouldn't gamble when you can't afford to lose the stakes.

Quote: Nareed

you shouldn't gamble when you can't afford to lose the stakes.

You also shouldn't gamble when you have to go into debt to get the stakes, as the guy didn't have the money for the test.

Quote: boymimbo

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.

What is wrong with a $500 deductible? My collision insurance on my car is that much. Higher deductibloes are how costs will get lowered. Look at the possibilities:

1. This patient has the choice of paying $1,000 to go from being 98% certain to 100% certain it isn't colon cancer. He will take time to be sure it is a good choice before having it done. Since the test cost well over $1,000, his getting it does increase the cost of insurance for everyone. So with so much "skin in the game" he will make a good choice.

2. Say the deductible is lowered to a nominal amount, say $100. The patient who has to put up that little will say "SURE" and have it done. The test as we know costs well over $1,000 and increase the cost of insurance for everyone.

Now, the answer is if we had a rational system of Health Savings Accounts the "do you have $1,000 right now" would not matter as much, but the better choice woll still be there.

Quote: boymimbo

Back on topic, I would borrow, beg, and steal the $1,000.

Not me. I had this exact same thing happen to me about 5 years ago. Blood in the stool, even blood in the toilet. I also realized I had screaming roids. I looked it up on the net, deduced it was bleeding roids, and it was. I ran it by my doctor a couple years later and he didn't even look up from his notes, he concurred with my diagnosis.

Billy Connolly on the colonoscopy. Funny, but vulgar.

here

Shoot though, $1000 is not much. Have some chest pain, get a ride to ER, bunch of tests, overnight, treadmill -- voila $10,000! And that's without diagnosis or any significant treatment.

You can drive a car around without fixing it. You don't need a car to live. You can pay different amounts for car insurance and change your deductibles.

I guess the patient made the choice to have the $1,000 deductible through his private coverage, so he should have had $1,000 in emergency funds to handle the deductible.

With regards to standard deductibles, for people who don't make alot of money, $500 would represent the cost of the annual checkup that alot of people would avoid in favor of paying down a credit card, or more likely, buy an XBox.

It also gets back to the debate about discouraging preventive care [and tests], to go on and have the insurance pay zillions for something that was preventable.

Quote: odiousgambit

It also gets back to the debate about discouraging preventive care [and tests], to go on and have the insurance pay zillions for something that was preventable.

I actually don't know a lot about what is common in health care plans -- I mostly only pay attention to the plan that I have had for quite a while. That one has terms that include a moderate amount of no-deductable, no-copay preventive care each year. I assume they believe that this encourages people to get exams and do other things that help avoid the very expensive after-the-fact treatments for things that don't get diagnosed in time. Isn't this the way that most plans have been moving in recent years? Because of age, I am now starting a new plan, and I have to figure out just what the new terms really are.

Quote: odiousgambit

to go on and have the insurance pay zillions for something that was preventable.

The older I get I wonder how much is really truly 'preventable', besides never smoking. So much depends on your genes and family history, what you were born with, that preventing something should start when you're about 5 years old. Even being fat isn't as bad as they thought. Recent long term studies are showing fat people are often healthier than skinny people, given the same variables. What the medical profession doesn't know would fill an encyclopedia.

What they do know fills an encyclopedia as well :)

Genes tend to show a propensity for certain ailments rather than a definite occurrence, and then preventative steps maybe more effect for that purpose. A lot of Genetic/epiGenetic/proteomics research is all on that area, and that's what makes it hard... your dealing with probabilities and tendencies than anything hard and fast.

Quote: EvenBob

The older I get I wonder how much is really truly 'preventable', besides never smoking. So much depends on your genes and family history, what you were born with, that preventing something should start when you're about 5 years old. Even being fat isn't as bad as they thought. Recent long term studies are showing fat people are often healthier than skinny people, given the same variables. What the medical profession doesn't know would fill an encyclopedia.

I have to agree you can't prevent much, at least not directly. You obviously shouldn't smoke other than a few cigars a year at special occasions. After that is seems to come to not doing things to excess. Having buffalo wings and a draft beer once a week or so and you will be fine no matter how "bad" they are for you. Eat them daily and you are asking for trouble. You don't need to be a gym rat but you should have one activity, even walking, for 30 or so minutes a day. Whatever.

Perhaps the best advice is quit listening to the fads and experts and use common sense.

BTW: For the record I wouldn't pay $1,000 if the doctor was 98% certain it was roids. If it lasted for more time than I was comfortable with then I would have the test.

Just off hand, I'd rather do what I can to prevent hemorrhoids than go through a hemorrhoidectomy procedure!

Hey, medicine has made progress. But there's so much popularized information that it can be really confusing trying to sort things out. So many diet books have been published, it's amazing anyone has any clue at all at this point.

Quote: rxwine

So many diet books have been published, it's amazing anyone has any clue at all at this point.

Some guy just lost weight eating nothing but potatoes for 2 months. Some guy a few months ago lost weight eating nothing but Big Macs and fries.

Quote: EvenBob

Some guy just lost weight eating nothing but potatoes for 2 months. Some guy a few months ago lost weight eating nothing but Big Macs and fries.

On the other hand, Morgan Spurlock ate nothing but Big Macs and fries and got ill, so it's all a question of moderation. On the other other hand, the Nenet in Siberia eat nothing but raw, frozen reindeer meat for months at a time (because there's nothing else around), and they're remarkably healthy.

Quote: EvenBob

Some guy just lost weight eating nothing but potatoes for 2 months. Some guy a few months ago lost weight eating nothing but Big Macs and fries.

My work colleague runs Iron Man Marathons on a diet that's at least 1/3 MacDonalds... however, most of the meals he has there are the healthier options.

Diet books are faddish and mostly pseudo-science on stilts (Gillian McKeith is one of the worst offenders, but it goes across the board).

Huh? I looked at the title of this thread and thought "gambling with your life" was an interesting topic. But I look at the last few posts and it's about eating nothing but potatoes, Big Macs, or raw reindeer meat. I guess that's what suspensions do to you.

Quote: odiousgambit

It also gets back to the debate about discouraging preventive care [and tests], to go on and have the insurance pay zillions for something that was preventable.

But, from the insurance companies standpoint, it actually doesn't make sense. Chances are, by the time you actually do develop a preventable colon cancer, some other company will be insuring you.