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Not so “absurd” - you may be missing some context.

A 12-lead ecg can diagnose whether you have a-fib at the time of the ecg. The question for the doctor is whether you may have “paroxysmal” ie intermittent a-fib. So what if the Apple Watch said ‘a-fib’, but the 12-lead is negative. Most doctors are probably going to end up ordering a holter- monitor, to monitor the patient’s rhythm over 24-72 hours. Some proportion of those patients may have very short runs of a-fib, and would likely have remained blissfully ignorant (and well) without the Apple Watch. Instead, they may well end up anti-coagulated, because if that patient is not anticoagulated and gets a stroke later ( which may or may not be due to a-fib), the doctor is going to get sued. Whereas if the doc starts the patient on anticoagulants, and tells the patient that, “ there’s a risk of bleeding, but...”, that is much less likely to end up in a lawsuit.

What? That "context" seems absurd considering that the alternative is that the person has 0 warning and 0 indication of either kind of a-fib. Even if the person doesn't have paroxysmal a-fib but the Apple Watch detects an irregularity, I think it would be grossly irresponsible for a doctor to prescribe anticoags without confirming some kind of condition.

Wait, so the argument against having more data is that sometimes that data is misinterpreted or misunderstood? That does not seem like a good argument.

The cost to a false positive in terms of stress alone should not be underestimated.

If you are not going to act on the information, then the extra expense of the exam is wasted.

If you are going to act on the information, then you must weight the benefit of early detection against the damage caused by unnecessary exams and treatment when there are false positives.

False positives are specially problematic when screening a large number of healthy people.

The persistent monitoring afforded by devices such as Apple Watch will directly lead to an increase in the detection rate of any condition that they are capable of detecting. These new detections will be conditions that had been previously undetected.

Whether you class these as false positives (because the existing test suite doesn't detect them) or false negatives (because the existing test suite should have detected them) is perhaps a matter for debate. The practical outcome is more people living healthier lives because their persistent malaise has finally been identified.

At first I was wondering how scheduling someone for a long-term ECG would cause damage, then I remembered that this feature will only become available in the USA soon. Given that the USA is a country where unexpected health care can destroy a person's life through either bankruptcy or the curse of being a woman/person of colour, yes I agree that detecting a previously undetectable condition could cause damage.

There has been a lot of recent research and recommendations for policy change around reducing the frequency of screenings for various things.

Time and data will surely tell if this type of ECG screening is helpful or harmful on a population level. Certainly, some people will get a secondary ECG indicating intervention is required, and the intervention will improve their lives. Others may have a negative result from the intervention, and may never have found their way into this intervention without this screening. For some, this screening indicating a problem but a full screening indicating nothing will drive persistent anxiety.

It is absolutely not the case that more medical intervention is an unqualified good, even ignoring the economic costs.

it's a very reasonable argument if the outcomes of this are overtreatment or serious health scares and increased cost with little payoff as a result.

More data is useless if your data is mostly noise and if as a result error rate in treatment and costs rise. Add to this the strong incentive for doctors, especially in a profit-driven healthcare system to suggest action, this could easily lead to the rise of unnecessary treatment of benign abnormalities in otherwise healthy people.

This is also not speculation. Ever since the rise of diagnostics in medicine overtreatment has become more and more common. This study[1] estimates that almost a fifth of all procedures in the US are not necessary.

[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/

Interesting standpoint, one which I disagree with.

You are making a causal connection of rise in diagnostic tools => overtreatment. What is your evidence for that, apart from overtreatment increasing? I think sea levels have risen since then too, are they also an effect of too much diagnostics?

Clearly, if the data was just noise, people would eventually stop caring. But you'd have to be pretty cynical to think one of the major tech companies of the world releases a diagnostic device that has an S:N ratio that high.

A more likely explanation for the overtreatment is simply that people are getting richer, and society is providing more care -- to a fault. I know this first hand, I have had invasive surgery done that I would've been better without -- because the doctor thought it maybe might be a good thing for the future. Spoiler: it worsened the problem.

I think if it were the case that we all suffer from a bit of a-fib every now and then, and that these diagnostic tools will give false positives for this reason, then that would be news to the medical community and thus progressing our understanding. People would be told, "your watch is telling you this but we know better now." Apple might update their detection algorithm. It's such a small price to pay for the obvious advantage of preventing loss of life.

Who is arguing against more data? Even the author of the article is essentially saying “buy it if you like it, just don’t buy it as a medical device”

On the other hand, maybe more data could be harmful? You might be interested to read a classic article (Bergman, 1967, [“The morbidity of cardiac nondisease in children”](http://dabamirror.sci-hub.tw/4363/be7b5e26e14c6389108fbdc70f...)

It discusses the harm to children of their parents believing their child has a “heart problem” when they have a completely benign murmur - which raises the issue of whether you should tell a parent there is a benign heart murmur when that information might actually be harmful - and whether that risk of harm is sufficient to override the parent’s right to know.

Another example will soon be genetic testing for risk of Alzheimer’s disease - if, at present we have no way of reducing the risk, is it fair to give people that information, when we know based on many studies that such knowledge lowers patient’s quality of life?

I think free adults should have the right to do all sorts of things that others think might be harmful - but it also seems reasonable (as this article does) to make people aware of the risks of “more data”, as well as the assumed benefits

I think it's a stretch to call this murmuring anecdote a case of more data => negative outcome. It's more like telling an individual about their specific instance and then having them extrapolate from uncertain statistics and overcorrecting. Acting on bad intel, as it were, where n=1.

If you want to argue against gathering information in this way, then perhaps phrenology serves as an interesting example. We know now that most likely, it was a croc. The use of phrenology was to draw a boundary around a certain ethnicity so that it could be upheld above all other ethnicities, and so it is hard to say that the data collection itself was the problem. Sweden is having a similar but opposite problem right now -- assault and sexual assault perps are predominantly Arabic immigrants, for one reason or another -- maybe it's in part Middle Eastern culture, almost assuredly it's a lot about socioeconomic factors, but nonetheless, it is true.

The powers that be have decided that the news should not mention ethnicity or citizenship for fear of racist backlash, they have decided that the annual crime statistics reports should not mention ethnicity or citizenship, again citing fear of racist backlash. I now invite you to consider, what will the population think then, if there are no facts to refer to, nothing to dissuade the racist's viewpoint that "Muslims are bad people?" Facts are sometimes inconvenient or inflammatory, but that doesn't make them less true.

For your case, I think the problem is not one of information gathering. Doctors should still be examining the kids, I think you agree -- the problem is giving the wrong impression to the parents, or not knowing that it is in fact the wrong impression.

This watch is not a prescription, nor a doctor ordered monitor. Even more, as mentioned its detection quality/history is not as reliable as to what currently a doctor would trust (as in case of 12-probe ecg).

Heart risk is serious and by itslef warrants a GP visit or at least a question. Yet a recreational health monitoring looks similar to someone's reading a GP's handbook for fun - suddenly lots of descriptions seem to apply due to uninformed perceptions.

Either way, if one has reasons to believe being at heart risk, watch is not the first thing to buy to be pro-active/preventive.To have the watch does not mean to take care of the risk. Just like having a fitbit does not mean one is actively fit.

Exactly. And what's funny is that people seem to think that physicians make accurate judgements all the time and don't make mistakes. And that there are not a host of gray areas which are taken into consideration.

Maybe a similar example is with a dog bite. If you say 'no it was my dog and they are not rabid' then doctor says 'ok no rabies shot needed'. If you say 'it's a wild dog (or friends dog)' and you don't know if it's rabid doctor thinks 'rabies shot needed'. Even if the actual chance of rabies (in your friends dog) is quite small (if the friend doesn't know if the dog has shots I mean).

More info is not only not always helpful but comes with risks as well. If not we would monitor things more frequently than we do and the simple scale would lower the cost.

Would you say that, on the whole, physicians will make judgements that are approximately as accurate given new data about paroxysmal a-fib as they did before having this new data?

Are they already condemning people to unnecessary treatment on the off-chance that treatment is helpful?

Is there scope here for the AMA to refine procedures to suggest holding off on medication when a condition is only discovered by a persistent monitoring system such as Apple Watch?

Even if the over-medication issue increases, are the live saved via early detection of equal value to the lives damaged by unnecessary medication? If there are more lives saved than damaged, is there a net benefit to society, or are we only interested in the lives lost through action and not at all concerned about the lives lost through inaction?

Something isn’t right when you’re considering lawsuit potential when making patient care decisions.

I stand by my argument that a GP prescribing an anticoagulant based solely on an iWatch having detected a-fib is grossly negligent (just as—in keeping with my earlier comparison—he would be if he prescribed an anti-hypertensive to a patient who stated they had a BP of 180/120 at home one time).

I’m not entirely sure why you docsplained that 12-leads cannot bend spacetime and that a Holter monitor would be likely be ordered to detect intermittent arrhythmias over a longer period of time, but thanks. Can I claim CE hours for this?

The argument against more monitoring is one of false positives. Suppose the Apple Watch has a 5% false positive rate, and detects problems with 1% of 100 million users.* That's 50k extra patients going to their doctors, thinking there might be something wrong with them. The next test may have a 1% false positive rate. That would put 500 extra patients on anti-coagulants.

That may not materially change the public health calculation, or it may. But that's the calculus -- not that a GP would blindly prescribe, just that increasing the top of the funnel is not necessarily a good thing. (Plus, extra cost.)

Positives and negative impact of additional testing must be measured for optimal decisions.

* numbers to make the math easy

As opposed to the “but I might get sued” argument, I find this argument totally reasonable. Thank you for stating it so clearly.

I’m cautiously optimistic but recognize that we need more data because evidence-based medicine is all about testing hypotheses. The hypothesis here is that continuous 1-lead monitoring will provide a net benefit to the population employing it. Maybe it will and maybe it won’t; Either way I think it’s pretty cool that we’re about to amass a ton of relevant data from which we’ll be able to derive an answer.

”the next course of action would be a more reliable diagnostic, specifically a proper 12-lead EKG interpreted by a qualified medical professional, perhaps followed by…”

I think you’re missing the argument made (fairly poorly, IMO) in this article: that preventive medicine often isn’t worth the money for society.

For relatively rare diseases, false positives typically outnumber true positives by a wide margin. If that’s the case for this Apple Watch, that means many users will needlessly be stressed thinking “I’ve a heart problem”, something that will cause some loss of QALY’s (https://en.wikipedia.org/wiki/Quality-adjusted_life_year) and will trigger tests that will take resources that may better be spent elsewhere.

That’s for society, though. Richer I ndividuals may not care about the extra costs, and people doing lots of checkups may be less stressed about false positives.

I don't know how it works in the US, but in the Australian public system you cannot organise a medical intervention without the right results from the proper tests. The Apple Watch in this scenario becomes a symptom for the doctor to assess in order to plan for diagnostic tests, not a diagnostic test in and of itself.

In rural New Mexico, EMTs can do finger sticks and King airways and epi injections and certain other interventions that normally require a medic because our transport times are long. But yeah, we also do ECGs all the time.

What worries me is that a 1-lead ECG is not worth much. If a 12-lead is only 90% accurate, a 1-lead is bound to be much worse.

Even if "tests" (omg no!) are ordered, they're not going to jump directly to invasive procedures like biopsies or catherization (have had both!$. They're going to do exactly what you've described as a "lowly emt" - thank you for posting this.

Screw this "doctor" and their FUD.