

Overkill - danso
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande/

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aylons
One thing this article touches, but does not give enough attention to (maybe
because it is so counter-intuitive and hard to explain) is the false positive
paradox.

To put in perspective, you should only do a test if you have good a priori
chance of having a positive. Even a test with 1% false-positive rate you give
you back much more false positives than real positives if the a priori chance
is 0.1%.

This is counter intuitive, I'm not good at explaining stuff, so I'll give
Doctorow the word, through this excerpt in Wikipedia:
[http://en.wikipedia.org/wiki/False_positive_paradox](http://en.wikipedia.org/wiki/False_positive_paradox)

Probabilistics and statistics are hard, very important an counter-intuitive.
Med and pre-med, and even high schools really should teach much more math than
they do right now.

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doctorCoder
Counterpoint here, the false positive paradox won't surprise many physicians.
It stems from concepts that are well-known among my colleagues and have been
tested on each of my licensure exams. We apply them at least 10s of times each
day.

You can read more about those concepts here- (Note: "a priori" === "pretest
probability" in MD speak)
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636062/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636062/)
[https://en.wikipedia.org/wiki/Likelihood_ratios_in_diagnosti...](https://en.wikipedia.org/wiki/Likelihood_ratios_in_diagnostic_testing)

~~~
shas3
I will add my anecdote to support this comment. Being an EE with probability-
heavy background, I tried to give a "you guys don't use prior probabilities"
sermon to a physician and his physician-in-training daughter. I was made to
eat my words by their reply, which was essentially that it is something they
are all taught and use all the time in assessing risks, interpreting results,
etc.

The one time I had to pay $500 for some tests not covered by insurance, but
egregiously wrong in the context of my ailment, the referral was from a nurse
practitioner.

Two things: 1\. Perhaps doctors don't uniformly apply their training in
interpreting test results and analyzing risks? (It is after all, quite common
in all professions to forget some parts of one's training)

2\. In addition to doctors, there are also technicians and nurse
practitioners, who some times may not have the rigorous training that one
associates with med school.

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neuro_imager
We tend to remember the one wasteful case and forget the next 25 which were
all reasonable - the old man with the worsening shortness of breath, the
middle aged guy with gross hematuria, the drunk who crashed into a parked car
riding his moped, the kid with the early onset puberty for a bone age study.

Dr. Gawande is a smart person, a contemporary of Ezra Klein and Ezekiel
Emanuel, and a lifelong politically involved leftist. His essays on waste in
medicine over the past 10 years have shaped progressive thinking on the
subject, with citations from everyone from President Obama (during the sale of
Obamacare) and many others. His political alignment is why Dr. Gawande cannot
speak the obvious heresy that the United States' insane malpractice climate
has anything to do with overtesting (although he has considered that in a
prior book). He has made his career promoting the idea of waste and
accordingly sees it behind every bush. I don't mention this to say that there
is no merit to some of his observations; just to provide context of his
background, alignment, and world view.

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nkzednan
duplicate of:
[https://news.ycombinator.com/item?id=9485389](https://news.ycombinator.com/item?id=9485389)

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fiatjaf
When a third-party is paying all procedures are recommended.

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DanBC
That's demonstrably false. See, for example, the English NHS where there is
clear guidance about what tests are appropriate.

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sukilot
NHS is firs party when NHS is making recommendations.

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DanBC
NHS is not making the recommendations, NICE make the recommendations.

