Tag Archives: colonoscopy

Faulty Math Behind Over-Treatment

The American Cancer Society (ACS) recently decided that, because the rate of colon cancer has increased by an “alarming” 22% in the 45-to-49-year old cohort this century, colon screenings should start at age 45.

This is a very instructive decision, though not because it is a good idea. Rather, it’s instructive because it’s a “teachable moment” about why Americans suffer from over-diagnosis and over-treatment so much more than people in other modern economies, with worse outcomes to show for it.

One reason is the failure of our medical and public health community to understand the difference between relative risk and absolute risk.

On one hand, a smoker might have a relative risk of heart attacks that is only a few times greater than the risk for nonsmokers. However, with Americans suffering 400,000 heart attacks a year, many of us do whatever we can to avoid small increases in relative risk of a heart attack because the absolute risk is so great.

On the other hand, suppose the relative risk of an unsafe airline is 10 times the risk of a safe airline. But with about three crashes a year (in a very bad year) over the course of 30 million flights, even a whopping tenfold increase in relative risk would bring your absolute risk of crashing up to a trivial 1-in-a-million. Here at Quizzify, we’d still opt for the unsafe airline if it has more legroom and a better mileage program.

See also: A Road Map for Health Insurance

And that brings us to exactly what the American Cancer Society miscommunicated…with a disturbing twist, as you’ll see below.

This “alarming” 22% increase in relative risk over the course of this century translates into an increase in the absolute rate of colon cancer in the <50 cohort from 0.006% to 0.007%. Yes, 0.001 percentage point more of the <50 population in this country will get colon cancer now than 18 years ago.

Further, suppose half of that 0.007% had a family history (or some other major risk factor) and would be advised by their doctor to get screened regardless of guidelines for the average person. That leaves roughly 0.0035% of the 45- to 49-year-old population who could possibly benefit from a random screen. That’s not much different from your lifetime odds of getting struck by lightning.

And a screen is far from a lifesaver, in general. Quite the contrary, statistically speaking it is likely to find the slow-growing tumors while missing the more aggressive, faster-growing tumors that begin between screens. Screening is not a surefire way to detect cancer, by any means.

The Disturbing Twist: The Hazards of Screening

That trivial benefit must be weighed against the nontrivial harms. The risk of a complication, such as a perforation, is estimated at between 1.6% and 1.8%. In all fairness to the ACS, it isn’t insisting that the screen be done via a colonoscopy, though the non-invasive screens have such high positive/inconclusive test rates that they often lead to colonoscopies. That makes the rate of complications about 3,000 times the odds of having your life saved by early diagnosis of colon cancer.

See also: How Telehealth Changes Senior Care

Of course, the worst complication is death, and the mortality rate from colonoscopies (0.02%) appears to be, on its face, much higher than the rate of lives that would be saved. However, in all fairness, the mortality rate, like the complication rate, in general, increases with advancing age. Hence maybe the mortality rate in the 45- to 50-year-old cohort isn’t any higher than — and might even be slightly lower than — the rate at which early detection will save lives.

So what’s an employer to do? We’d say, stay on the sidelines. Let employees work this one out for themselves, with their doctors. Or show them this post. But don’t encourage them to run out and get screened on the basis of a recommendation that is at best controversial and at worst harmful.

Why To-Do Lists Don’t Work

Do you really think Richard Branson and Bill Gates write a long to-do list with prioritized items as A1, A2, B1, B2, C1 and on and on?

In my research into time management and productivity best practices, I’ve interviewed more than 200 billionaires, Olympians, straight-A students and entrepreneurs. I always ask them to give me their best time management and productivity advice. And none of them has ever mentioned a to-do list.

There are three big problems with to-do lists:

First, a to-do list doesn’t account for time. When we have a long list of tasks, we tend to tackle those that can be completed quickly, leaving the longer items left undone. Research from the company iDoneThis indicates that 41% of all to-do list items are never completed!

Second, a to-do list doesn’t distinguish between urgent and important. Once again, our impulse is to fight the urgent and ignore the important. (Are you overdue for your next colonoscopy or mammogram?)

Third, to-do lists contribute to stress. In what’s known in psychology as the Zeigarnik effect, unfinished tasks contribute to intrusive, uncontrolled thoughts. It’s no wonder we feel so overwhelmed in the day but fight insomnia at night.

In all my research, there is one consistent theme that keeps coming up:

Ultra-productive people don’t work from a to-do list, but they do live and work from their calendar.

Shannon Miller won seven Olympic medals as a member of the 1992 and 1996 U.S. Olympic gymnastics team, and today she is a busy entrepreneur and author of It’s Not About Perfect. In a recent interview, she told me:

“During training, I balanced family time, chores, schoolwork, Olympic training, appearances and other obligations by outlining a very specific schedule. I was forced to prioritize…To this day, I keep a schedule that is almost minute-by-minute.”

Dave Kerpen is the cofounder of two successful start-ups and a New York Times-best-selling author. When I asked him to reveal his secrets for getting things done, he replied:

“If it’s not in my calendar, it won’t get done. But if it is in my calendar, it will get done. I schedule out every 15 minutes of every day to conduct meetings, review materials, write and do any activities I need to get done. And while I take meetings with just about anyone who wants to meet with me, I reserve just one hour a week for these ‘office hours.'”

Chris Ducker successfully juggles multiple roles as an entrepreneur, best-selling author and host of the New Business Podcast. What did he tell me his secret was?

“I simply put everything on my schedule. That’s it. Everything I do on a day-to-day basis gets put on my schedule. Thirty minutes of social media–on the schedule. Forty-five minutes of email management–on the schedule. Catching up with my virtual team–on the schedule…Bottom line, if it doesn’t get scheduled, it doesn’t get done.”

There are several key concepts to managing your life using your calendar instead of a to-do list:

First, make the default event duration in your calendar only 15 minutes. If you use Google Calendar or the calendar in Outlook, it’s likely that when you add an event to your calendar it is automatically scheduled for 30 or even 60 minutes. Ultra-productive people only spend as much time as is necessary for each task. Yahoo CEO Marissa Mayer is notorious for conducting meetings with colleagues in as little as five minutes. When your default setting is 15 minutes, you’ll automatically discover that you can fit more tasks into each day.

Second, time-block the most important things in your life, first. Don’t let your calendar fill up randomly by accepting every request that comes your way. You should first get clear on your life and career priorities and pre-schedule sacred time-blocks for these items. That might include two hours each morning to work on the strategic plan your boss asked you for. But your calendar should also include time blocks for things like exercise, date night or other items that align with your core life values.

Third, schedule everything. Instead of checking email every few minutes, schedule three times a day to process it. Instead of writing “Call back my sister” on your to-do list, go ahead and put it on your calendar or even better establish a recurring time block each afternoon to “return phone calls.”

That which is scheduled actually gets done.

How much less stress would you feel, and more productive would you be, if you could rip up your to-do list and work from your calendar instead?

Are Obamacare Wellness Programs Soon to Be Outlawed?

The Equal Employment Opportunity Commission (EEOC) filed suit Aug. 20 against a Wisconsin company, Orion Energy Systems, which severely penalized and then fired an employee who refused to participate in the type of wellness program now encouraged by the Affordable Care Act. The EEOC is arguing that there was “no business necessity” for this program and that the exam and other intrusive screening were “not job-related.”

If the EEOC were to prove that the standards it cites (part of the Americans with Disabilities Act) apply to wellness programs, this has strong implications for the Insurance Thought Leadership community. This could spell the end of workplace wellness generally, and specifically could expose your clients with penalty-based or mandatory medical wellness programs to similar lawsuits.

Although the White House is probably hoping the EEOC loses, winning this suit should be a layup. It can easily be shown that medical wellness programs are not job-related and have no business necessity. Quite the contrary, the three most basic provisions of “medicalizing” the workplace with wellness — health risk assessments (HRAs), biometric screens and enforced doctor visits — are more likely to harm employees than benefit them.

HRAs makes employees disclose things like whether they routinely examine their testicles (which men are not supposed to do) or whether women intend to become pregnant. These HRAs then also give feedback with no basis in medicine, such as recommending a prostate cancer test that the federal government strongly advises against and perpetuating the myth that all women under 50 should get regular mammograms.

Biometric screens pose an even greater risk to health than HRAs. Although medical societies are urging fewer screenings to avoid overdiagnosis and overtreatment, employer human resource departments can’t get enough of them, thanks to incentives created by Obamacare. The inevitable consequence: More people identified for “early intervention” to treat clinically insignificant conditions. For instance, an overzealous Nebraska colonoscopy screen caused the state’s vendor to trumpet that it saved the lives of 514 state employees who never had cancer in the first place. Yet instead of calling for an investigation, the state promoted this and other equally fallacious results successfully enough to win their program  the C. Everett Koop wellness award.

Biometric screens usually include weigh-ins and penalties for refusing to participate (or, sometimes, for not losing weight). Shaming people into losing weight is unhealthy and unproductive, and body image issues reinforced by workplace “biggest loser contests” affect 20 million women and can be fatal.  Meanwhile, weight has only a slight effect on health spending during the working years, and, if economic incentives could generate sustained weight loss, Oprah Winfrey would have kept her weight off instead of giving up her lucrative Optifast endorsement contract. Medical science has no clue what causes obesity. Some novel theories are being proposed, but, whatever the cause, Obamacare-inspired fines are not the cure.

Forcing employees to go to the doctor when they aren’t sick is perhaps the most curious and expensive wellness requirement. The clinical literature is quite clear about the futility of this custom, which may do more harm than good. Obviously checkups can’t save money if all they do is increase diagnoses and treatments with no offsetting benefit to actual health. Perhaps employee checkups are job-related in a few fields – public safety, airlines, sports, adventure travel – but otherwise it’s hard to see how worthless checkups improve an employee’s ability to answer the phone or do most other typical job-related tasks.

The ADA standard is “business necessity,” meaning these hazards and punishment might be acceptable if money was being saved or morale was being improved, but – as the book Surviving Workplace Wellness shows, quite the opposite is true. No wellness vendor has ever shown savings that weren’t obviously made up, and most won’t defend their own claims. Even Nebraska somehow “found” huge savings despite all these unnecessary cancer treatments and no meaningful change in employee health, savings claims that their vendor now refuses to defend. Further, the wellness industry’s own recently published analysis shows no savings.

Likewise, morale impacts are so negative that CVS and Penn State employees rose up in revolt against them. Increasing employee resistance also explains why employers have needed to almost triple fines since 2009 (now averaging $594) against employees who refuse to allow their companies to pry, poke and prod them.

Perhaps Orion Energy’s defense could be that trying to control employee health behaviors and fining employees who eat too many Twinkies is a “business necessity” because it shows employees who’s the boss. There is, after all, no provision in employment law that requires employers to be nice.

That defense might win the suit but also generate some headlines worthy of late-night talk shows.  Still it’s hard to imagine any other defense succeeding.

Insurance brokers and consultants need to follow developments closely. If the suit succeeds, you’ll need to caution your clients to scale back on “playing doctor” with employees, and certainly on penalties for non-compliance. Orion’s penalty was draconian – a few hundred dollars in fines is probably still OK. Focusing wellness efforts on less sexy issues like serving healthy food and getting employees to exercise more should also keep your clients out of trouble.

The worst development would be a flood of these lawsuits, but we at ITL will follow up with what you can do to avoid being one of the targets.