Dave was one of the best people in the tech space -- genuinely honest, super-smart and just an all-around good guy. He was one of the few people I really looked up to and admired in the valley. This is a huge loss today.
> David Goldberg, one of Silicon Valley’s most high-profile, well-regarded and well-liked entrepreneurs, died suddenly last night of undetermined causes.
I know of 2 guys who had a case of "sudden death" in the valley, both from heart attack, both were using stimulants and working very long hours in their startups. I know from previous threads that a lot of folks in the valley use stimulants to get through nights without sleep, to work with high focus, but guys you have to be careful. Stimulant use aside, keep in mind cardiovascular diseases is one of _the_ bigger killers out there. Cancer gets a lot of attention, and it's a big killer, but most people don't realize how many people are beaten by cardiovascular diseases. Eat healthy, and exercise to prevent these problems. Get a comprehensive exam from your physician annually for good measure.
I'm a retired radiologist with a huge experience performing coronary CT angiography (CCTA). This is an amazingly accurate exam, superior to cardiac catheterization and stress tests. Radiation dose from this exam has been dramatically reduced in recent years,
Having seen thousands of these studies I can state that many people have severe coronary artery disease at young ages (in their thirties). They are at risk for sudden death. Often they come in for the exam because a parent or sibling died prematurely either recently or at the same age as they are now.
What's interesting, in my experience, is that very often when siblings get the exam, the one with obvious risk factors such as obesity, smoking, diabetes, etc has a normal exam result and the sib with no risk factors (other than maybe sharing a bad family history) has severe disease.
We often use coronary CTA to rule out coronary disease in low risk chest pain, but I can't say I would recommend it as a routine test due to the radiation and the dye load. We know that the fatty streak begins in childhood and it must be true that there is a lot of clinically undetected coronary disease. When it comes to sudden cardiac death for a young man, I'd also be concerned about electrical abnormalities such as the Brugada syndrome / channelopathies / accessory pathway syndromes. Drug use is another important factor in general, not that I would think it to be relevant here.
If I have a CCTA test done and it shows early signs of heart disease, what can I do about it? I am 31 healthy, eat relatively good, exercise everyday, don't drink or do drugs. I'm just wondering what you can even really do? Are there (or will there be) drugs that can dissolve the hardened fat (and whatever else) in your arteries?
uhm, by all accounts (especially the video in this thread where he says as much) this guy was far past the working-long-hours phase - the company was mature and he stressed work life balance. i think mentioning stimulant abuse here is a little ... shitty of you, to be honest.
some people just die young/young-ish of natural causes. i personally know several people who have had freak heart attacks or brain conditions and passed away. it's sad, but a fact of life (and death).
Generally places stress work life balance because the organization doesn't actually afford its members a work life balance, so the perception of it existing has to be constructed through propaganda.
i.e. If you already have work life balance, there's not need to stress it.
This is completely wrong. In our area (Silicon Valley) it is common and expected to push hard and work long hours. It is an extremely competitive environment and unless you're forced to go home most people work late into the night.
Not making an effort and letting your employees know that you don't expect them to work nights and weekends means you are ignoring the societal norms in our field and most likely have engineers working their way towards burnout.
This is just not true. Tech culture is rife with long days, nights, and weekends. In my experience, companies that truly care about work life balance often have to remind people of this just due to the fact that so many people are used to this culture and often have a difficult time escaping the mindset.
why is it shitty? I didn't take it as him implying that's how the CEO died, just that it's an issue that happens a lot in silicon valley and it's dangerous because you can die unexpectedly due to a heart attack.
Worst case, he's implying that illegal drug use is a factor in the death of somebody known to people here. Best case, he's bringing up something irrelevant on a thread where people are paying their respects and/or dealing with a deep and sudden loss and is doing it in a way where he's oblivious to the possible implication. Either way, I think shitty is a reasonable word.
If he wants to talk about an issue in Silicon Valley, he can do it pretty much anywhere but this one page.
No, what's shitty here is you twisting my words. I never said anything about illegal drug use. I have friends who were getting ADHD medicine (subscribed by a licensed psychiatrist), but had to stop because of heart problems. THIS IS COMMON. As I said, cardiovascular diseases are an amazingly big killer of life. That is what I'm talking about. I think it's an apt time to mention this -- people are emotionally engaged, it's this time to be informed of actions we can do to care for ourselves: be cautious of stimulants (not just illegal ones), eat well and healthy, and make time to exercise.
I did not twist your words. You also never said anything about legal drug use, so when I said "worst case" I was pointing out one end of a scale of possible interpretations. That you were talking about technically legal abuse of drugs is on the scale I describe.
I stand by my point: either you were suggesting that drug abuse might be a factor here or you were bringing up something approximately irrelevant. Either way, that's shitty. Let people have their time to pay their respects and mourn without you jumping in with your kids-eat-your-veggies hobbyhorse.
Of course you stand by your point, how often do you see people online not stand by their point. That would be the unusual thing.
It's been observed many times before that when someone online starts describing another persons stance as "either you X or you Y" they're generally involved in a false dichotomy.
So congratulations wpeitri, you're just like almost everyone else on the internet. You have an opinion and nothing will convince you otherwise.
I am often convinced otherwise. Just not in this case.
By the way, your I-am-the-superior-intellect pose would be more convincing with better spelling. Note also that "It's been observed" and "they're generally" is classic weasel wording. [1] If you think the truth lies outside my constructed dichotomy, by all means make it clear what you are claiming the truth is.
You know, I never said anything about 'illegal drug use'. Maybe I chose poor words that would have one think I meant that? But I made several comments elaborating that's not what I meant after having made the initial comment. You made your posts after I made those comments. And I'm telling you now too that's not what I meant -- and I told you that before too -- it's just not what I meant. So there's really no reason to keep going on about this, do we agree?
Maybe take a break and smell the fresh air? I hope all is well with you.
Whether or not it was about illegal drug use, I believe your comment was still inappropriate. That it could be read as implying the recently deceased guy was a junkie made it especially so, but even without that I think it was woefully inconsiderate.
I don't have any need to keep talking about it, and you seem unwilling to come to grips with my actual point, so if you'd like to be done with it, I'm not stopping you.
And if I had responded with an absolute you would have attacked that instead.
It isn't really about me using weasel words or swapping the i/e in your name, it's about you using character assassination in your head to convince yourself I can't possibly have a point.
It's just another variation of the "intelligent discourse" idea that gets bandied about quite often on these sorts of boards.
We have every right to communicate, no one has verbally attacked anyone else, if it really bothers you just skip on by instead of taking the time to make sure we're aware that you're judging everyone involved in the conversation.
Oh no, sorry, I did not mean to imply it was stimulant abuse. But you know even normal use of stimulants is a sudden killer for some people with cardiovascular problems. I mentioned it mainly because I've read many threads on HN indicating that stimulant usage is kind of high in this field... and that's fine, as it's prescribed to folks with disorders like ADHD. You just have to be very careful with it though, because again, cardiovascular diseases are one of the biggest killers. Easiest way to prevent is to eat healthy and exercise, it's really as simple as that.
Hard to believe this was just death by "natural causes." It's dangerous to speculate, yes, but I think we can all safely assume that he had access to the best of the best in terms of healthcare. To die suddenly at his age with no warning signs at all is very strange.
Even if you can afford it, you've got to ask for it, if you're in the tech field. A professional basketball player, and probably also a coach, is going to have their physical health watched over, whether they take the initiative or not. Wealthy people in many other fields are free to go to the doctor as rarely or as often as they want.
That said I think his wife probably made sure he got good access to healthcare, if he didn't take the initiative himself. But it probably is somewhere between every three months and every year. Major sports players, top celebrities or Paul Atreides have the level of access that make it extremely rare, but a well connected tech executive just has a level of access that reduces the risk somewhat.
>>> Even if you can afford it, you've got to ask for it.
This. A thousand times.
So many people in the valley just lose track of time, or they put their health on the back burner for just one more month, or miss that yearly physical, and then suddenly it catches up with them.
Saying he was a proponent of work life balance does not mean his job was a walk in the park either. You're in one of the most competitive markets, with a successful startup. I can easily see why executives at his lever would start to cut corners on their health.
It's too bad really. He sounds like one of the guys you would really root for to be successful. At the very least, I'm glad he was able to achieve some of his dreams - something a large portion of the population never get a chance at.
If anything it should remind everybody. Take a break, call your family and tell them you love them, hug your kids and tell them you love them. You never know man, you just never know when your time is going to be up.
Dave was an inspiration for people like me who work at SurveyMonkey and try to achieve a work life balance. He encouraged us to keep reasonable hours and to be home to spend time with our families and he did the same.
I wont try to speculate what actually happened out of respect for him and his family but I can assure you that he was not the standard silicon valley go hard all night type of CEO.
Adderall raises one's blood pressure to a dangerous level. It is smarter to avoid such drugs and at most rely on caffeine. Work smartly, not like a maniac.
Way too many people dismiss sleep apnea. Folks, it can kill you - or cause other serious problems. In addition to narcolepsy, your general metabolism can get messed up too.
I spent 4+ years not getting any REM sleep and my metabolism STILL suffers as a result - even 14 years after starting on CPAP and using it EVERY night since then.
It's too long to go into here - but I did a writeup years ago about my "journey", along with my wife's issues with PCOS (Polycystic Ovarian Syndrome).
Do you snore (badly)? Do you find yourself tossing and turning a LOT at night? Do you wake up gasping or with a general sense of dread/fear? Are you super-tired during the day? Have you ever fallen asleep while typing, while at a stoplight in your car, etc? Talk to a doctor about having a sleep study done. It might save your life.
Another good question, do you wake up to urinate in the night? That was one of my indicators of my sleep disorder, as I sleep through the night now.
I was diagnosed with sleep hypopnea, which is not as severe as sleep apnea. The difference between the two is how low your pulse ox falls while you have stopped breathing. I think my diagnosis was an artifact of the sleep study however because they didn't really let me sleep very much during the study.
I am using a CPAP and my health has greatly improved. Lower blood pressure, feeling like I got real rest during the night, improved cognitive function. Still dealing with some metabolic issues, which I am trying to resolve with diet, eating habits and exercise.
PS I knew I snored. I never imagined I had sleep apnea until I got married and my wife observed that I would stop breathing in the middle of the night.
Waking up to urinate in the middle of the night could also mean that you're over 40 and probably male (though women often have the same issue for different reasons).
You're kind of freaking me out here. My dad tosses and turns, doesn't get much sleep, has to pee at night, wakes up in fear in the past often as I'd wake him up after I'd come running to his room at night because I heard crazy sounds of him gasping for air. He generally doesn't get super-tired during the day though, but he's not super active anymore and drinks his coffee still.
Anyway he's seen a doctor many times, mostly for heart/cancer stuff, but also specifically for his sleeping problems. But there was never this response that his life was in danger and that he needed studies done because it might kill him, while the healthcare system is quite advanced here...
I was an apnea baby, and died on my parents a number of times as a child due to it. Thankfully these days it's a million times better: the only time I have issues is when I sleep on my back.
> Metabolic rate does vary, and technically there could be large variance. However, statistically speaking it is unlikely the variance would apply to you. The majority of the population exists in a range of 200-300kcal from each other and do not possess hugely different metabolic rates.
Note that caloric intake is exceptionally difficult to measure accurately (even for people who consistently log calories), so it would probably be unwise to attempt to self-diagnose. If you suspect you have a problem, you should consult a physician.
Doesn't make sense to speculate, could be a million things like heart attack, stroke, kidney failure, aneurysm, complications with undiagnosed diabetes etc etc
"Stop all the clocks, cut off the telephone,
Prevent the dog from barking with a juicy bone,
Silence the pianos and with muffled drum
Bring out the coffin, let the mourners come.
Let aeroplanes circle moaning overhead
Scribbling on the sky the message He Is Dead,
Put crepe bows round the white necks of the public doves,
Let the traffic policemen wear black cotton gloves.
He was my North, my South, my East and West,
My working week and my Sunday rest,
My noon, my midnight, my talk, my song;
I thought that love would last for ever: I was wrong.
The stars are not wanted now: put out every one;
Pack up the moon and dismantle the sun;
Pour away the ocean and sweep up the wood.
For nothing now can ever come to any good."
There is some speculation that Goldberg died in Mexican drug violence (courtesy of the Jalisco New Generation Cartel), and that this is being suppressed for reasons unknown - perhaps to limit the damage to Facebook's brand and stock price, perhaps for more sinister reasons.
It's so sad when people die suddenly. SurveyMonkey itself hasn't even updated their team page [1]. I wonder what happened? Heart attack? I feel for Sheryl Sandberg...she seems like an exceptionally decent and grounded person, which in my experience is rare among obscenely wealthy people.
My thought are with Dave's family. It's a morbid coincidence that I was sitting here, filling out my will using http://getyourshittogether.org/ when I came across this HN post. I had been avoiding filling it out for months because it never felt important enough to do. Finally last night I decided that I was going to fill it all out today. Just as I started to fill it out, I thought "Oh let me just check HN and reddit once." Then I saw this post and your comment.
After I hit reply here, I'm going to finish the entire document before I come back here. I have too many loved ones to leave stranded in this world after me just because I was too lazy and distracted to do what's needed.
As an estate lawyer, the biggest issue I see with these types of estate plan services is that amateurs use them and fuck up their documents. Either they execute the documents incorrectly (in which case you might as well not have it), they let beneficiaries serve as witnesses, the documents don't plan for obvious contingencies, or they set up trusts and then neglect to transfer any assets to them (in which case the trust is useless). If you are not dealing with estate matters on a daily basis, then you don't know what you don't know about it. If you have a few assets to try to get to the next generation, you can afford to go see a lawyer. Go find a lawyer who will do your estate plan on a flat fee basis. You'll know exactly the cost and you won't get hit by an attorney charging you by the hour and running up the hours.
Agreed. I studied law although I didn't graduate, and estate law has so many little twists and turns that it's worth paying a lawyer to tackle it; I can't think of much worse than my death causing even more stress and fighting between those left behind due to an ill-defined will.
I should have clarified that I'm going to a lawyer once I gather all of my data. There's no way I can use the above template because it's customized for the State of Washington and I'm in Florida. Starting with a free template helps me create a plan and collect the bulk of the material even before I meet someone. Hopefully if I do my homework, then I'm not wasting the attorney's time on basic questions and can use that for clarification on some of the more complex issues.
When I started to see similar things happen to friends or acquaintances when I was about the same age every time I heard of someone getting sick or dying prematurely I would say to myself "time to buy that Porsche you always wanted". So I did. My parents generation worked hard but never spent any money always assuming they would live to a ripe old age.
Silly for you. But for him it meant enough that he decided to spend his cold hard earned cash on it and that's good enough for most and probably should be good enough for you.
One mans expensive toy is anothers childhood dream or self promised reward for decades of hard work.
And who knows, it may turn out to be a good investment in the longer term, Porsches and Ferraris have a way of keeping their value (provided you don't drive them too much or wrap them around a tree).
No matter where you spend it, money goes somewhere. Why shouldn't people at Porsche be able to earn money from someone who wants and is able to afford one of their cars?
What is not silly? Someone invented a way of enjoying things after you die? Or is there a template for being happy that we all must adhere? Let me guess: "spend quality time with the people you love", "travel the world and experience more", "achieve something that will remembered" and other typical b..it.
It's obviously not about money, he was trying to say that one should not pass everything off until you are older, because there is always a Chance that you wont get old.
I will take this time to write something I wrote on Steve Jobs death: go get a comprehensive health check today. In our community, we are data driven about everything, except our health and body. I will copy what I wrote 1304 days ago, https://news.ycombinator.com/item?id=3080327
In January 2009 I was Stage 5 chronic kidney disease, in July 2009 I had a kidney transplant.
Looking back there were so many telltale signs that I had over the last six months, which I was ignoring as I was busy building my startup. A regular health check has the potential to catch a problem like this. I now nag each of my friends and family in having an annual health check.
Its the best time you can spend.
This was not the first time I made a mistake like this. When I was a kid, I had trouble seeing my teacher's blackboard. I just kept moving closer to the blackboard. I saw a doctor when I had trouble understanding what the teacher was writing from the first row.
Problems like this creep up on you over years, and they are so gradual you don't realize them.
You wont run your site without a Google Analytics/Pingdom. Dont do it with your life. If you haven't had a health check, get it done today.
My spouse -- an md -- cringed a bit when I read your post. And not because it's not well meaning, or important, but because without qualifying what "comprehensive health check" means, that check could very well do you more harm than good.
So, yes. Please find a good primary care physician you trust and visit on an annual basis. Make sure you update that phsyician with what's going on in your life. That includes any family history, pain, issues etc. When in doubt, see another physician. But please don't go out and get a full MRI of your body just because (which, you are not saying, but does happen). There are enough VOMITs[0] in the course of normal defensive medicine. Don't go looking for problems because -- although they'll definitely help you look -- you might not be better off for it.
I went to the urgent care when I had what I thought was hemmoroids - the urgen care doctor hadn't seen anything quick like what she saw and sent me for a colonoscopy. Normally "they" recommend starting periodic colonoscopies at 50.
When the procedure was finished, I was told they would analyze the result, but I had a cancerous tumor and they sent me for a CT scan which confirmed stage iv colon cancer with liver metastasis. I'm now 8 months into chemo and after having my sigmoid colon removed, seem to have "stable disease" in my liver. I was otherwise asymptomatic.
Another chap at my company wasn't so lucky. He got hit by a car and lost consciousness. They did an MRI to check out his brain - and found tumors. A CT scan showed the same don't diagnosis as me, but his was far more advanced, with mean mastastasasis to the liver, lungs and brain. He passed away about 5 months later and was otherwise asymptomatic.
In both our cases, A blood test given after the diagnosis (CEA) showed highly elevated numbers - perhaps two orders of magnitude from nominal.
So my question would be: given that this blood test was a marker for our disease, why can't it be given more regularly as part of a routine checkup? I realize there are other reasons for a false positive, but couldn't it be an indication that further testing should be done? Yes a CT scan can cost $1500, but my chemo costs $12,000 per month.
The issue is either False positive followed by heavyweight, risky and invasive checks or the non-committal of many radiology reports "further evaluation recommended..."
Basically, radiologists are more afraid of being sued for missing something then they are of being sued for being too cautious. Evasive language is a defence against the latter.
This is a uniquely American condition BTW. Most other places, the liability rules are different and doctors aren't as afraid of lawsuits / insurance premium hikes.
I'm 44. They said the tumor may have been detectable 10 years ago. There is no history of colon cancer in my family, although my father had prostate cancer treated in his fifties. (He's 89 now and still drives have myself to his weekly poker game. Does pretty well at it too, from what I hear.)
Colon cancer can be effectively treated when Caught in it's early stages. During my (first) colonoscopy they found another tumor that got removed in the first of several surgeries, and it had clear margins and required to further treatment.
I would actually be more critical of "regular checkups" than your post. If we are looking at being "data driven" when it comes to our health, the jury is definitely still out on even having annual physicals for otherwise relatively young, symptom free individuals: http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-p...
A central problem is that you get loads of false positives when you are screening symptom-free individuals, and these false positives can cause real harm: beyond anxiety, they often bring on potentially painful, expensive and side-effect causing treatments. Just see the recent recommendations over the PSA test: http://en.wikipedia.org/wiki/Prostate_cancer_screening.
Definitely go to the doctor if you notice any symptoms or worrisome changes. For other types of screenings, be aware that the recommendations often change and that there is a real cost/benefit analysis (even in terms of your own body, not just financial cost) to be done.
As a recent sufferer of health anxiety, I couldn't agree more. You can really go overboard with tests that are often harmful, and without a really deep understanding of statistics, it's difficult to understand exactly what they mean.
I am thankful every day that I had a great GP who both did enough to be prudent, and also helped me stay balanced and not go overboard, in just the right way. I could have been a lot worse off had I continued to pursue treatment.
That said, in a state where anxiety is controlled and my health is now stable, it's still important to be aware of changes and new symptoms, and to have an annual standard physical with a doctor you trust and stick with consistently so they know you and your body over time. Just don't go overboard.
I learnt something related to this from a brain surgeon relating to actual positives.
Say that a random scan uncovers that you have a minor brain aneurysm. The aneurysm's size and location implies it has a chance of rupture of around 0.2% per year. The operation to resolve the aneurysm, however, may have a 5% risk of death.
Weighing up the decision to have an operation is incredibly difficult, since most would be rather distracted by the idea of a ticking timebomb going off in their head at any time, yet the risk of the operation is more immediately significant. If undetected, the aneurysm may never rupture, or it may grow to a size where it causes other symptoms and can then be operated on.
(Or, of course, as in the case of a young friend of mine in his then early 20s, pretty much anyone can keel over at any time due to an undetected aneurysm anyway.. it's totally pot luck.)
Short-term point sampling can do you more harm than good—this is as true in medicine as it is in investing.
There's nothing wrong with getting an MRI every year if you aren't actually looking at it on its own, but rather diffing it in a time-series, and extracting chartable statistics from it, to see if anything in your body is getting progressively [adjective]er each year.
This approach won't actually tell you if you've got six months to live, but it's not supposed to. It's to show you that your liver has been getting 10% more scarred over with each visit, so—with evidence!—you'd better lay off the booze already. Or to find something like arteriosclerosis before it presents clinically.
You don't need them to be 100% utilized, it's not the machines that are the problem but the technicians operating them and the doctors interpreting the results and so on.
There is a whole team clustered around an MRI machine and tying up the machine is effectively tying up the team.
If everybody got an MRI every year on the off chance they might have something then the machines would not be available to those that actually need them (because they have symptoms that require an MRI to narrow in on a cause).
And that's besides the whole fall-out further down the chain in case something does show up that does not generate symptoms and even further down the chain where probably un-necessary operations will be performed on symptom-less patients.
Doing the right amount of screening is a really hard problem. Getting an MRI done every year just because you can afford it is probably not even near the right amount.
The idea, here, would be to make MRIs both cheaper, safer, and less trusted for their predictive power.
Imagine if you could get an MRI the way you currently get a blood pressure test or ultrasound or x-ray. Imagine a simplified MRI machine in every GP's office 40 years from now. Imagine the machine having a networked software layer integrated that doesn't even allow the raw static-image data out to the doctors, but instead just reports out weighted-average feature-change velocity heatmaps.
Presumably, the only people getting an MRI done every year now are the ridiculously rich, who could buy an MRI machine of their own, and a hospital wing to put it in. But the theory behind getting one isn't bad. It's just scarcity, and the effect scarcity has on the level of trust we put in the few samples we can beg, borrow or steal.
An MRI is not some magical device, it's more like an advanced way to do tomography and interpreting the results and preparing you for the scan is non-trivial and likely will remain so even if the cost of the MRI machine drops to '0'.
So you're going to need the crew of attendants and interpreters with associated costs regardless of the price of the machine.
What cheap MRI machines will do is marginally reduce the cost of a scan, which would be a good thing but over the life of the machine it is the people that make up the bigger chunk of the cost.
Mobile MRI machines are currently truck sized, something that could be moved around in a suitcase and set up on the spot would be a game changer in the third world (as would be cheaper MRI machines to begin with), but for the first world it wouldn't be so much of a change.
What did change things dramatically was the reduction in the cost of ultra-sound but the complexity of an ultra-sound scanner compared to an MRI machine is orders of magnitude less, interpreting the results is still not the job of the tech administering the scan (though in the case of say a look at an infant in utero even a lay person can make out what is what and that's already useful).
Healthcare costs are an interesting subject of study, you could easily make a career out of that.
So you're saying executive physicals like this [1] are bad? Personally, I'd like to know if I'm dying. Many cancers and other serious problems betray few if any symptoms before it's too late to treat them.
Depends on your situation, but yes... they can be bad. First of all, false positive tests are a thing. It happens. More importantly, let's say you are diagnosed with something untreatable and terminal. Do you really want to know before you have to? Or perhaps it's something technically treatable, but with a low chance of cure and at a high cost to quality of life?
The thing to think about when you test for something, is what are you prepared to do about it if the results are positive? Not everyone will answer this question the same way.
Yeah, having looked at some of the potential outcomes of false positives, I have no interest in whole-body scans. One day they'll be a great idea, but for now, I'm skipping them.
We could argue about what comprehensive means, but if you see my post below, the test I recommended has blood work for internal organs health check, chest xray, abdomen ultrasound and (pap smear/mamogram etc depending on gender/age). This requires one single blood draw, and no significant levels of radiation.
Most tests do have some degree of false positives, but there a number of defensive diagnostic tests which are nearly error free and clinically significant
To name some:
* BUN + Serum creatinine - Kidney health
* LFT - Liver health
* Sugar levels - Early detection of diabetes
I am not recommending a MRI, but everyone should get an annual health check, for some values of comprehensive.
It would be great to have a Hackers Guide to Healthcare. What's important, what the numbers mean, etc. I understand that certain tests (e.g. PSA) have false positives, but if we ever want to crawl out of the Dark Ages, we need to make some forward progress. Wearables, "tricorders", and early detection blood tests should be able to offer us something better in our lifetimes.
Not disagreeing about your post at all, which sounds entirely reasonable to me (I'm not a doctor), but I think this is worth emphasising:
> Most tests do have some degree of false positives,
I think many people don't appreciate the danger of false positives.
The complications that can come from unnecessary treatments, the dangers that more invasive tests might cause, the aggregate effect of all the time and expense the extra testing causes (e.g. by putting a strain on hospitals who may need that MRI for someone else), the negative emotional consequences of the stress from the false diagnosis, the possible financial implications etc. Even a very small chance of a false positive can have huge consequences if the test is deployed widely enough.
>"I think many people don't appreciate the danger of false positives."
Yes, but to most people, we compare that danger with the danger of a positive test that never gets done. More information is never a bad thing. And I'm reasonably sure that for almost every test that can have a dangerous false-positive, there is also a corresponding test that can corroborate those results, if not detect the false-positive.
Yes, absolutely this. And I'd like to add that one should also practice sickness prevention in addition to health problem fixing. Just like you'd like to avoid writing imperative spaghetti code in programming, it's also a good idea to not live a "spaghetti" life-style. That is, avoid the urge to frequently overwork and under-sleep, the sedimentary life-style of excess food/drink and insufficient exercise, and the constant self-applied pressure that you have to be better than someone else right now. Instead, go for a balanced life of work and rest, plenty of exercise, and trust yourself that you're going at a good pace and all good things take time.
Also, avoid being caught in modern media's constant drive toward polarizing sensationalism; your own life is actually fair simpler and more enjoyable than the internet and TV would have you believe (if you live in the first world)
Flip side - Many doctors will see a high cholesterol number and immediately try to put you on statins. Which is not really that clear cut, statins have a lot of side effects that are downplayed by the sellers - and a lot less potential upside in otherwise healthy people with high cholesterol (because the fundamental cholesterol test given is flawed, the better tests are more expensive and harder to read (variables like cholesterol size and such matter a lot, but not even in the standard test))
So sure - get health checks done. Then be prepared to spend weeks or months double checking what your doctor is telling you, and possibly getting 2nd opinions and more tests.
Personal story: Head health test. High A1C. Diagnosed Diabetic, despite being a very fit triathlete who hasn't drank soda in 6 years and eats < 20g of sugar a day. Literally had near 2 weeks of full blown panic attack. Tried to change my diet to crazy low glycemic index food and eat 8 times a day to try and get my A1C down without medicine.
2 weeks later got into a 2nd doctor for another opinion. Turned out my test was just bunk. A1C is fantastic. Apparently it happens all the time (a bad test). My first doctor did not tell me this at ALL.. just told me I was a diabetic and to stop drinking so much Soda.
My takeaway? If not showing signs, don't bother with routine tests. Too many medical quacks.
Another story.
mid 50's, reasonably active and healthy, start to develop BHP (slow stream). Urologist does a PSA test even though I had one a few months before. Long story short, prostate cancer. Had robotic surgery, all good.
67, been following a congenital heart murmur for years. Cholesterol at 130. Noticed my running and biking dropping performance dropping off, so think time for a heart valve replacement. Routine pre-op catheterization shows coronary artery blockage. Have bypass and valve replacement, doing great. But 130 was too much cholesterol for me apparently. On statins and down to 95! I am now 68, no prostate, artificial heart valve, bypassed coronary artery, but feel great and am still active.
Glad the heart surgery took place after I started medicare though. Say want you want about government ineptitude administering anything, but medicare works.
On the other hand, you may have had the exact same blockage happen if you WERE taking statins. The research around people with "low" cholesterol is (to the best of my knowledge) very lacking.
Basically.. lots of things can be found by a test (say a slow or non-growing tumor) that the risk of removing them is > than the risk of leaving them alone.
Of course doctors are paid for doing work not for leaving it alone, so which do you think they will choose?
If you don't trust your doctor, step one would be to find one that you do trust. If you don't trust any doctor, then you're going to have a difficult life should you encounter serious health problems.
And yes, you should stop drinking soda, diabetic or not. Nothing bad will come from not drinking it, but plenty of bad things can come from drinking it. Telling you this doesn't make either your doctor or me a "quack".
Except I didn't drink soda. I hadn't drank soda for like 6 years. The doctor didn't take ANY effort to determine what my actual habits were. He had an 8 minute appointment.. decided I must drink soda, and told me to stop.
How does that help you test for early stage cancer markers? That tests usually isn't in the batch of regular (and it's quite expensive), but it does make a difference between death an survival.
Yeah, pancreatic cancer patient here. Mine presented as acid reflux, which my GP treated with Prilosec. Only after I went anemic and the ER staff scanned for a bleeder did they find the 8-9 cm tumor. Push your GP if necessary for some soft-tissue radiology if you feel "not right". Wish I'd caught mine a couple months earlier.
(Six months after surgery - I'm well so far, still doing chemo for the next three months. We'll see, we'll see.)
Glad you are doing well. Pancreatic cancer is probably the scariest of all cancers, and I can hardly imagine your ordeal.
Still, one needs to be careful about taking one incident and generalizing from that. There is, for example, a very real possibility that performing an ionizing-radiation scan for every patient who presented with acid reflux would cause more cancer than it cured.
It's the saying doctors learn in medical school. "When you hear hooves, think horses not zebras."
Probably 99 out of 100 people with GP's symptoms (if not more) actually do have acid reflux. It therefore makes medical sense to assume that until additional symptoms indicate a different conclusion.
The general issue is that doing more tests can catch more things earlier. But all tests have false positives, and false positives can lead to more tests and in some cases to unneeded treatment, which can cause more harm than good.
It's perhaps unintuitive, but more testing isn't always good. The benefits need to outweigh the risks, and it isn't always the case. There are ongoing debates about who should be screened for various types of cancer, for example, and the "right" answer changes over time - as we find ways to reduce false positives, as we find better treatments, as we better understand the diseases, etc.
It's tempting to do more tests because it feels like you're doing something. You don't want to get sick later and feel like you could have prevented that. But that's an irrational form of thinking. All that we can do is make the best choice now, given our current information. As GP's links mention, the best choice we have now often seems like "avoid tests that aren't clearly needed."
The assumption that "it does make a difference between death an survival" in not necessarily born out by the data.
There has been a big push back recently against using an improvement in 5 year survival rate as an indication of success in the war on cancer. For example, if a new diagnostic test lets you find out you have cancer earlier, but you still end up dying at the same age you would anyway, the 5 year survival rate would go up, with no real benefit to you. In fact, there could be lots of real negatives, like anxiety and an increase in other tests and procedures that don't actually improve your lifespan or quality of life.
I'm not sure I understand your point - are you arguing that finding cancer earlier does not increases chances of treatment and survival? Do you have any reliable data on that?
The conclusion:
"Although 5-year survival is a valid measure for comparing cancer therapies in a randomized trial, our analysis shows that changes in 5-year survival over time bear little relationship to changes in cancer mortality. Instead, they appear primarily related to changing patterns of diagnosis."
When I had cancer I just wanted it gone. Since it could be cut out, I went with that. Every time I caught a cold I worried that it had returned. I did not want to be on the wrong side of a statistical curve. That others survived would not have comforted me as much as knowing that I would survive. Your mileage may vary.
And how does testing for early stage cancer markers help you? It's not a rhetorical question, clinical studies have been unable to show the positive effect that you assume (and actually these tests may do more harm than good).
As per my previous post, a CEA blood test would have shown mine two orders of magnitude higher than normal. Further non invasive tests would have found my tumor, possibly before it metastasized. Or maybe not. But for the cost of my chemo, you could do 100 CT scans. (And I have to have one every two months.)
Your CEA levels were two orders of magnitude higher than normal at a point were it was sufficiently advanced to be diagnosed from symptoms (as it fortunately happened in your case). If you want to diagnose early, you need a much lower threshold and the CEA test is not good enough. It's not like people have not been trying to find screening protocols...
> In screening for colorectal cancer, the aim should be to detect disease at either Dukes’ A or B stage. Malignancy detected at more advanced stages is unlikely to be more treatable than that detected through the usual course of events. Using an upper limit of normal of 2.5 μg/L, Fletcher (19) calculated that CEA has a sensitivity of 36% and a specificity of 87% in screening for Dukes’ A and B colorectal cancer. These findings, combined with the low prevalence of this malignancy in unselected populations, render the positive predictive value of CEA unacceptably low and thus of little value in screening healthy subjects. For the present, therefore, we must rely on fecal occult blood and endoscopy to screen for colorectal cancer (20).
What does 36% sensitivity and 87% specificity mean? Imagine that you test ten thousand 40-year olds and twenty-five of them do actually have colon cancer (this is more or less consistent with statistics telling that 0.23 of them will be diagnosed with colon cancer before turning 50). You will get a true positive result in 9 cases (out of 25) and a false positive in 1297 (out of 9975). So only 0.7% of the positive cases are real, and you missed two thirds of the cancers.
They are feel good exercises, until they aren't ... Don't think of all OK result as money wasted, its insurance to catch any chronic illness in time.
I would consider tests comprehensive if tests all major internal organs (kidney, liver, heart, spleen + common cancers depending on gender/age), you can come up with one after talking to a physician. Because I am based in India, I can only recommend India specific one, https://www.apollohospitals.com/preventive-health-care-check... are generally good.
Thanks for the pointer. How much does a comprehensive test cost in India and are the test records given to the patient? I've wondered whether traditional Ayurveda and modern medicine are complementary.
Do they draw blood and ask for a urine sample? Do they make you strip down and examine you from head to toe? Do they make you "turn and cough"? Do they listen to your heart and lungs? Do they look in your mouth? Do they look in your eye? Do they ask you about your health history?
If some or all of these are "no", it's not a comprehensive exam.
Some of these aren't even up to date. Lets stop acting like we're health experts here. If your doctor is still making you do "turn and cough", then your doctor is using out of date practices (source: my GF is a doctor). Similar to another person's post above, she cringes at posts like this. You SHOULD go to the doctor to get check up each year, but you should not just go get every test under the sun just in case. There's a reason when you go in for your yearly check up, the doctor does what they do. Perhaps it's more important in this discussion to say that there's a reason your doctor doesn't do every test under the sun on these checkups.
Could we also stop acting like our girlfriend being a doctor makes us qualified to give medical advice? What evidence in particular, aside from your girlfriend, do you have for the claim that the groin exam for inguinal hernias is outdated? Is this subject in your girlfriend's field? What publications does she cite?
>What do you mean by comprehensive health check? What tests should I do?
Start by NOT asking random people on the internet.
Ask your doctor about what tests to do and he'll tell you based on your age / history, and you can trust him better than a random stranger or some web post.
Hacker news is a community of (from what I've seen) strong critical thinkers, with a poster in a thread often having a specific background in the field being discussed. Doctors aren't mythical beings, and discourse here about what medical tests are 'worth it' seems both appropriate and really interesting.
>Hacker news is a community of (from what I've seen) strong critical thinkers
If I met a community of strong critical thinkers about Chemistry or Civic Engineering I wouldn't ask them advice for my software stack.
Besides, with the exception of a 20% or less who knows what they're talking about (and those only for narrow Computer Science or Engineering fields each), the others might as well be on Reddit. You can find tons of uninformed opinion about anything here. Plus a huge tendency to go with the latest fads (Rails, then JS, then Go, then Rust, etc).
Oh come on... outside of a few notable individuals, nobody really knows who anybody here is, or what their credentials are to talk about anything.
Law and Medicine are two of the things most likely to precipitate a lot of online commentary by people who don't have the first clue of what they're talking about.
I find the discussion in this thread so frustrating (not your or anybody's fault).
It's 2015, and there's still no general agreement on which tests to run to tell if you are healthy or not. We don't even have firm evidence whether your annual physical with a doctor is a net positive or negative.
Meanwhile, people are dying decades prematurely due to uncaught illnesses that we know how to fix.
We have a check engine light for our car engine. Why on earth don't we have one for our bodies yet?
Click and Clack would refer to the check engine light as the "empty your wallet light" (paraphrasing).
If your car starts easily and runs well, has no changes in fuel economy, and you have been keeping up with basic maintenance, it's probably fine.
Same with people. Sure there are some people who just drop dead out of the blue. But most people have symptoms. Unexplained weight gain or loss. Fatigue. Difficulty sleeping. Changes in bodily functions. For most people, if you have no symptoms and feel healthy, you most likely are. If you have family history of certain problems, of course be more vigilant about that.
We can't possibly continually test everybody for everything that might possibly be wrong with them, at least not until we have Star-Trek style medical devices. Unjustified testing in the absence of symptoms will simply further drive up the cost of medical care for those who really need it. One could argue that it already has.
There are two questions - whether someone who can afford it would receive a net benefit from more testing and whether we want to pay for that for everyone. Many of the answers given to the question of whether more tests are worthwhile don't make this distinction.
Getting unnecessary tests can do more harm then good. Please don't try to get every test 'just because'. Here is a good resource that recommends what preventative measures are recommended for people of different age groups and such (recommended by my MD girlfriend):
In game theory and probability, it is almost always considered better to have data about something so that you can act appropriately. (I admit there are some theoretical exceptions, but I don't think they apply here). Even if you are healthy and young, it's better to hold your own data than not.
Sometimes, thanks to technology, we don't know who has access to our data and whether this is going to be used against us: for example, will we have an impossibly high insurance premium attached to us for life - with the data in our hands, we lose the right to use insurance to even out that risk.
Sometimes, in medicine, there are ethical considerations, that the eventual treatment for a screened condition presents its own risk that people may not wish to decide and the healthcare system might not be well-equipped to manage.
Nonetheless, I still personally prefer to have the data than not. I want to decide my own healthcare needs based on my own knowledge and understanding of my own risks. This is "data driven".
Most of chronic diseases progress slowly and have no external signs in early stages. Most of them are also much simpler to treat in early stages.
> I fail to see how screening of healthy, relatively young, people would be "data driven".
So just by looking at yourself, you don't know if you are healthy, only that you look healthy. The tests are to ensure that you are, and to give you time and flexibility of treatment if you are not.
Thanks for sharing! Having known and worked with you for years I could not agree more. I ran the startup life for 6 years and it'll eat you alive if you let it.
What a sad and terrible loss, my heartfelt condolences to Sheryl and her family..
I wanted to add my thoughts about false positives and executive health checkups, which fall under the larger umbrella of screening. I conduct executive checkups fairly regularly, but i’m not promoting anything here. I just want to share a personal philosophy that you, as a patient, could adopt to reduce risk.
Firstly, it should be stated that the utility and performance of any diagnostic test that has a binary outcome (eg. diseased/healthy) depends on 1) its intrinsic test characteristics 2) the prevalence of the disease in the population being tested[1], 3) the available diagnostic/treatment options for positive people, and 4) the threshold chosen to call something ‘positive’ since you are virtually always measuring a continuous variable.
People talk about false positives often, but you should know that there is some room for judgement here. The typical threshold for PSA has historically been 4.0 ng/mL. Above this is considered a positive screen, and you are recommended further testing to confirm prostate cancer, which can be invasive and lead to complications (bleeding, nerve damage, etc). This kind of two-stage testing is a common theme. The issue is that PSA values in people with cancer and people without cancer are normally distributed and have some overlap. A value of 4.0 is in the overlap zone, and the vast majority of people with 4.0 will not have cancer. However, lets say hypothetically that guidelines changed and we now use 20. At this level, most people who test positive probably have something bad, and the risk:benefit ratio is in favor of confirmatory testing and probably in favor of treatment too. I won’t bother going into it, but there’s a fair amount of liability, psychology and economics at play when choosing thresholds. Biochemical tests like PSA do have some variance, but are mostly reliable. It’s more complicated with imaging and amorphous things like mammograms that have some operator variability in judgement (and hence more liability).
This was a long-winded way to say that information is not necessarily bad, but it’s what you and your doctor choose to do with it. There’s room for discussing probabilities, and the various available pathways. Trust is huge. Your doctor will act in your best interests when he feels safe from lawsuits, otherwise he'll be focused on not missing anything regardless of likelihood or cost. The financial misalignment of our system doesn’t help in building trust either. Most first-stage screening tests have very minimal risk involved. Things like checking your blood pressure, cholesterol, glucose, doing a treadmill stress test, reviewing your meds, vaccinations, etc which are part of these annual checkup programs are, on balance, usually good ideas.
Of course we dont know why he died but I echo the sentiment that you need to be getting annual physicals and blood work to catch potential issues sooner rather than later.
A few years ago a nurse told me my blood pressure was a bit high but I didnt think it was that high to worry about so I never followed up on it. Then a few months ago I went for a dental check up where they checked my blood pressure and after a particularly chaotic morning the nurse told me my blood pressure was 220 over 150, which is crazy high blood pressure The dentist ended the appointment and told me very strongly to go straight to the doctor. When I got there my pressure had gone down to 150 / 90, but the doctor started me on a low dose of blood pressure medicine. It costs $5.00 per month, and who knows what health disaster was awaiting me had I not discovered this.
Even if you are relatively normal weight, in your 20s, and healthy, you could still have issues and not realize it until you have a check up.
My blood pressure hits 150/90 somewhat regularly (the local gym had an automated cuff which I use to measure it). When I was about 29 I was concerned enough to ask the specialist physician who I see for an unrelated chronic condition. He was concerned enough by my readings to order a 24 hour blood pressure study. He didn't start me on any drugs when the 24 hour study showed that my BP dropped overnight. Indeed, my medical aid (Heath insurance) also has a fairly high threshold for funding BP meds as a chronic condition. I still see the doctor regularly, and although my BP has not dropped below 140/90 on any occasion that he has seen me he considers it normal (I think he regards it as "white coat hypertension").
It seems that doctors in South Africs have a fairly high threshold for prescribing medications for blood pressure to younger people. The contrast with your case in the U.S., where the doctor started you on BP meds immediately is quite striking.
Same here in germany. I am frequently in the 140-150/90-95 range especially when in the doctors office, but he checked everything extensively and told me i should first try to workout more, eat healthier and then come back in a year because pressure was normal overnight.
He also encouraged me to do marathon training as ultrasound scans and stress ECG showed that everything seems alright with my cardiovascular system. Personally when i get a high reading it still freaks me out a bit though, but i don't want to start taking meds at age 32, so i double down on my sport and eating habits.
What are the side effects of your blood pressure medicine? Do you regularly exercise? Meditate? Have you looked into treating blood pressure other ways than a pill?
Knowing something (blood pressure is high) is cool.. but turning that into (I must pop pill X) doesn't always seem like the best strategy.
As if I said anywhere in my post "I must pop pill x." Side effects = none. Cost = negligible. Could I afford to exercise more and lose a few pounds? Sure. But that is not going to reduce what was too high blood pressure quickly enough to not be a risk, particularly upping my exercise regimen with untreated high blood pressure.
Many modern blood pressure medicines have almost no side effects for the gross majority of those taking them. I had a very similar experience to the person you're replying to.
I am active, eat healthy, and have tried to go off of my high blood pressure meds more than once, but each time, my blood pressure creeps back up. Modern medicine is a wonderful thing. Don't be scared of medicine when it's the right option.
This questions often pops up whenever there's a thread about someone passing away on the front page. I think it's problematic since it will be up to the admins to decide whether a person was "important" enough to have a black bar. A very hard task where each consideration will be controversial. Therefore I don't think they should do it all.
I think it's a difficult task in that you can't include everyone...but I think it'd be fine if the admins did it by personal consensus...I imagine who they think would be noteworthy would be in line with what most users think.
No one gives a shit about the people that died yestarday http://www.philly.com/philly/news/nation_world/20150503_U_S_... but when this fat idiot dies, its a big deal and makes it to the top of HN. No shit, survey monkey is a billion dollar company. Dont worry I am expecting down votes from angry bigots.
Whoah. Uncalled for dude. This is a tech site you have to remember, he's a CEO of a tech site/husband to SS/seems like he was a big figure in the community.
I'm sure every single one of us cares that people died yesterday. Don't want to get into a big debate, jus sayin. #deepbreaths
In an oddly related way this reminds me of a time prior to the Internet. In that era you would open up the Yellow Pages and call a company or a store and ask them if they "carried such and such widget". They would reply "no". You would then say "do you know of anyone who does" hoping for a tidbit of info or direction on who you could contact next. The person on the other end would inevitably tell you to, as if this was valuable info, "why don't you try the Yellow Pages?". People really did that. The irony is not that you got their number from the YP but that they thought they were giving you good advice by telling you to use something that was as ubiquitous as doing a google search is today.
It's an understandable question. Many media outlets are treading carefully, identifying him by his accomplishments (successful entrepreneur and investor) and position (CEO of SurveyMonkey), when in fact the main reason people have heard of Dave Goldberg is that his wife is Facebook COO and Lean In author Sheryl Sandberg. And, while it's true that you could figure out his identity using a search engine (as one commenter suggested), few sources would be so blunt in their explanation of the story's apparent importance, so I think asking the question here isn't out of line. (CNN.com, to its credit, ran the story under the headline "Facebook exec's husband dies".)
I saw someone say on Twitter "Dave defined the word 'mensch'" - very true.