Dr. Matt Zirwas argues cheap, frequent ultrasound screenings alter clinical risk by enabling continuous monitoring over invasive follow-ups

I was wrong about the Midjourney ultra-sound scanner.

Well, maybe not wrong, but at a minimum I missed something obvious because I was thinking like a doctor who's been practicing for 25 years.

And I didn't explain my point well.

First, where I was wrong:

All historical precendent that showed that widespread screening imaging is net neutral or harmful was imaging that was expensive, inconvenient, gated by physicians and couldn't practically be repeated frequently short term.

If the Midjourney ultrasound is high resolution, harmless, inexpensive and convenient, people can get an initial scan, then if there are abnormalities concerning for cancer, they can get weekly follow up scans to see if it's growing/changing, and if it's not, they can leave it alone.

In retrospect, that is obvious but it never occurred to me.

Now, you'd assume that that approach would have to lead to it being useful and saving lives, and it probably will. But we won't really know it does until we have a couple years of data. Lots of things that seem obvious in medicine end up being wrong once we collect data.

Second, what I didn't explain well:

It's not that I think non-doctors are 'too dumb' to use the results effectively.

Its that historically it was literally impossible to use the results effectively, and that is super, super counterintuitive. It seems obvious that finding stuff early is beneficial, but experience has shown that it isn't.

Here's why:

The vast majority of abnormalities (i.e. possible cancer) isn't cancer - like over 90% of them, ends up being harmless - something thay your body could have handled on it's own.

But the only way to find out was to have invasive, risky procedures to biopsy or remove what was found.

And overall, the side effects from all the risky, invasive procedures to track down the over 90% of stuff that was harmless equal or outweigh the benefit from removing the less than 10% of stuff that wasn't harmless.

If the MIdjourney device can be repeated frequently, like weekly, at a low cost and is harmless, it could negate the need for the risky, invasive procedures.

Not saying it will, but it seems like it could and I confidently posted yesterday that it was a bad idea.

I was wrong to confidently post that.

I usually agree with Dr. Locasale.

But not on this.

A $100 full-body ultrasound on asymptomatic people, sold as a wellness service, will open a massive can of financial worms for individuals. You’ll pay around $100 for the scan, there’s a 90% chance they find something you’ll worry about, your insurance won’t cover the expensive follow-up they recommend, so you’ll be deciding whether to spend thousands to relieve anxiety about something with a 98% chance of being nothing.

How’d I get there?

Enough screening full body MRIs have been done to give us a good idea of the size of the can and what’ll be in it.

Roughly 90% of asymptomatic people who get a screening full body MRI have an abnormality. We have decades of diagnostic imaging with millions and millions of followed-up findings that allow 2/3 of those to be classified as incidental findings that definitely don’t need further work up.

Of the roughly 1/3 they can’t be sure about, after work up, 10% of them (4% of people who got a scan) end up with something important, and about 1.5% of people have a cancer detected.

And the existing evidence says finding those lesions doesn’t improve overall mortality. I know that’s hard to believe, but it’s true. Look up Korean thyroid ultrasounds or German melanoma screening.

Now extend it to a modality we have no baseline data on follow-up of lesions. Midjourney has been explicit that the early scans train the model and diagnostic accuracy comes later.

For the first year or two, it’s reasonable to say 90% of people who get a scan will have an abnormality they can’t rule out as concerning, and it’ll be up to the individual to pay to train Midjourney’s model.

Insurance probably won’t cover the follow-up scan or biopsy with an established modality, because there’s no evidence saying it needs follow-up.

So 90% of people who get scanned will be worried and facing the decision of whether to pay out of pocket for the expensive follow-up. A small percentage of those will have side effects and complications from the follow-up testing. And remember, 98% of the findings are nothing.

You can argue affluent people could get one, chase down all the abnormals, then repeat a scam (sorry, meant scan) every 3 months to look for changes. But that just leads to over-diagnosis with no mortality benefit.

So, rich people get scanned every 3 months with subsequent overtesting and overdiagnosis, normal people get anxious over things that are 98% likely to be fine, nobody has a survival benefit and Midjourney gets their model trained for free.

I wonder who’s coming out ahead here?

I was wrong about the Midjourney ultra-sound scanner.

Well, maybe not wrong, but at a minimum I missed something obvious because I was thinking like a doctor who's been practicing for 25 years.

And I didn't explain my point well.

First, where I was wrong:

All historical precendent that showed that widespread screening imaging is net neutral or harmful was imaging that was expensive, inconvenient, gated by physicians and couldn't practically be repeated frequently short term.

If the Midjourney ultrasound is high resolution, harmless, inexpensive and convenient, people can get an initial scan, then if there are abnormalities concerning for cancer, they can get weekly follow up scans to see if it's growing/changing, and if it's not, they can leave it alone.

In retrospect, that is obvious but it never occurred to me.

Now, you'd assume that that approach would have to lead to it being useful and saving lives, and it probably will. But we won't really know it does until we have a couple years of data. Lots of things that seem obvious in medicine end up being wrong once we collect data.

Second, what I didn't explain well:

It's not that I think non-doctors are 'too dumb' to use the results effectively.

Its that historically it was literally impossible to use the results effectively, and that is super, super counterintuitive. It seems obvious that finding stuff early is beneficial, but experience has shown that it isn't.

Here's why:

The vast majority of abnormalities (i.e. possible cancer) isn't cancer - like over 90% of them, ends up being harmless - something thay your body could have handled on it's own.

But the only way to find out was to have invasive, risky procedures to biopsy or remove what was found.

And overall, the side effects from all the risky, invasive procedures to track down the over 90% of stuff that was harmless equal or outweigh the benefit from removing the less than 10% of stuff that wasn't harmless.

If the MIdjourney device can be repeated frequently, like weekly, at a low cost and is harmless, it could negate the need for the risky, invasive procedures.

Not saying it will, but it seems like it could and I confidently posted yesterday that it was a bad idea.

I was wrong to confidently post that.