“Suspected” Afib leads to Waste of $$$$ and Spec. Issuance

Discussion in 'Medical Topics' started by 422Phil, Jan 7, 2021.

  1. Jeff Oslick

    Jeff Oslick En-Route

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    It probably wasn't hyperbole. I had to learn the lesson the hard way because of the FAA as well. FAA required a follow-up CT after kidney stone. Got hit with a $3,000 bill for it from a large healthcare provider (it was "covered", but it hit my high-deductible plan). Next time I needed a CT for the FAA, I went to the clinic literally across the street and it was about $350. All this to document what the urologist said all along were a few small retained stones positioned in an way that they weren't ever coming out. My urologist humored the FAA, but said all along none of the follow-up testing was medically necessary. I've been on BasicMed since day 1 that it was available as an option.
     
  2. WDD

    WDD Cleared for Takeoff

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    and if you show it to him your AME sees it and ............
     
  3. Aviator305

    Aviator305 Pre-takeoff checklist

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    This charge is readily believable. The tests listed by the OP are far cheaper than an out of pocket CT scan.
     
  4. X3 Skier

    X3 Skier En-Route PoA Supporter

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    I will ask my Cardiologist to prescribe one;) Wonder if my insurance weasels will allow it.

    Cheers
     
  5. tmyers

    tmyers En-Route

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    I read this with great interest, since medical costs were a contributing factor in my decision to sell the Arrow and then eventually just hanging up the headsets. There is nothing in my post that is any different than what has already been said. I hold no ill will toward the FAA, but they do seem to be just a bit ouy of control at times. I am reminded of an old saying, "Absolute Power corrupts absolutely", maybe that is not fair, but it is how I feel.

    I think is was 2013 when my PCP also noticed something that concerned him, a pronounced heart murmur. He correctly suggested I see a cardiologist who presented a diagnosis of Aortic Stenosis. Even though it was Medically gauged to be mild it had to be mentioned to the FAA. I grounded myself immediately and was then diagnosed with OSA, High Blood Pressure and Type II Diabetes. With the excellent help of Dr Bruce, I was able to navigate the FAA Minefield and ended up with a whopping 3 SI's with the FAA. We did this for 3 years at high costs, but I did get to see Dr Bruce at least once a year. Eventually I had to weight cost to benefit of owning and even flying and while getting out was a difficult decision, it was the beter choice.

    During this journey I also had to almost beg my Cardiologist to keep performing the tests that the FAA was mandating I have. At one point it was also requested I have a 24 hr Holter test. My Cardio and his assistant went nuts, making similar comments as have been expounded in this thread. In their opinion the request was medically unfounded and not related in the least to the AS, OSA, or Diabetes. At one point they simply refused and as mentioned earlier, I had to beg them to just do it to satisfy the FAA.

    I can remember having to scold my PCP assistant for using those stupid wrist devices for measuring my BP, they always read much higher than an old fashioned Blood Pressure Cuff and stethoscope. At some point my PCP explained it to her and that I couldn't have these high BP readings in my chart.

    I can also remember sitting on the side of my bed with my CPAP on just breathing through it to get to the FAA mandated 6 hrs of sleep. Once, doing this while at the 6Y9 Fly-In, sitting on the bed of my Motorhome waiting on the 6 hour milestone so I could walk over to see my friends, Brad, Diz, Dr Bruce and his wife. I have never needed more than 4 to 5 hours sleep a night but the FAA insisted I get 6.

    It is ironic that Basic Med was passed soon after I sold the Arrow. Based on the rules of engagement I still quality for basic med as I held a valid medical with in the 10 years before it's inception. Unfortunately my most recent Echo cardiogram indicates an aortic valve opening of .95 cm2, which is below what I remember being the FAA's threshold of 1.0 cm2. It seems many forget that Basic Med is not a free pass that exempts you from meeting some minimum requirements of the FAA.

    That was three years ago, I am doing well, and considered to be in excellent health by my physicians. I am scheduled for another Echo this summer to see how things have progressed and anticipate I will be a candidate for (TAVR) Trans-catheter Aortic Valve replacement in the next two or three years.

    When we all decided to take on this Aviation thing we jumped into someone else's playground and have to abide by their rules to be able to play. Doesn't matter if we think it is right or even fair. We all have to educate ourselves to maintain some control over our medical care.

    Enough rambling!!
     
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  6. Aviator305

    Aviator305 Pre-takeoff checklist

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    Great post. It sometimes seems to be a forgotten truth that these digital blood pressure measuring devices are trying to reproduce by way of a transducer and signal processing what the human ear does so easily. The digital devices produce consistent results to track trends which can be very helpful in certain settings like an inpatient ward with 50 patients that need to be monitored 3-4x day for days to weeks, but if one really wants the best for an individual the old fashioned analog sphygmomanometers are closer to the truth in the correct hands (and it’s not difficult at all to do..just a very little tad more inconvenient).
     
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  7. Daleandee

    Daleandee Line Up and Wait

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    I fly under the LSA rules and I really like it. I have no health concerns and could pass a 3rd class but I see no reason to enter into the tangled web of the FAA bureaucracy. What the OP tells about is exactly what I, and many others, fear. The system they have set up isn't helping as much as they may perceive it does.

    Sport Pilot & now Basic Med are proving that medical issues involving pilot crashes are not a major factor. Last time I looked the two major factors in flight accidents were, 1) loss of engine power, & 2) loss of control in flight. The second is likely a result of the first (when it occurs) as the pilot tries to force the aircraft into an unrealistic approach and the all to familiar stall/spin appears.

    This is the same FAA that now allows a second person in the cockpit during flight testing on homebuilt aircraft. I get it that some aircraft require a second crew member but for many of the small single engine experimentals being built I can't see the reasoning for putting another life at stake during initial flight testing if there is one good & qualified pilot to fly the plane.

    But I digress ... maybe this should be on the "rant" thread ... :D
     
  8. bbchien

    bbchien Touchdown! Greaser!

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    Apple watches have led several of guys into needless trouble....
     
  9. MacFly

    MacFly Line Up and Wait

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    More likely it was those guys’ doctors that led them into needless trouble. In a competent medical system, the most trouble an Apple Watch could get you into is a Zio patch.
     
  10. PaulS

    PaulS Touchdown! Greaser!

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    Yup, caffeine can be bad news. I was told to decaffeinate many years ago and don't miss it at all.
     
  11. Daleandee

    Daleandee Line Up and Wait

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    It can be but doesn't have to be. I like to focus on all the good things about it: https://www.heart.org/en/news/2018/09/28/is-coffee-good-for-you-or-not

    One quote from the article:
    Drink up! :D
     
  12. bbchien

    bbchien Touchdown! Greaser!

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    And I should be responsible for another doc's blithe acceptance of the apple corporation claim, becuase why?

    I tell pilots, just like the attorneys, "get good advice". And in Federal medicine, I have yet to find a competent one. With the exception of ONE who is also an "advanced" AME.
     
  13. MacFly

    MacFly Line Up and Wait

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    I don't know what you're responsible for. You indicted the watch. I'm saying it was the doctor that failed if he/she initiated treatment on info from the watch alone.

    You didn't specify what kind of "needless trouble" Apple Watches have caused these guys you were referring to. I'd be interested to see your data, what the trouble was, and which version of the watch.
     
  14. bbchien

    bbchien Touchdown! Greaser!

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    Well an apple watch can record Einthoven lead II if you wear it on the right wrist and place your left great toe on the crystal.

    Sorry, MacFly, the notion that it can even record the proper lead to determine if it's AFib or PSVT is just laugahble. https://en.wikipedia.org/wiki/Einthoven's_triangle

    All electrocardiographers know that if you're not watching that lead, you can and do get fooled. Of course, that's 2nd year in med school stuff....
     
  15. MacFly

    MacFly Line Up and Wait

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    Uh huh. Thanks for the lesson in rudimentary cardiac electrophysiology.

    I think that you think that I am defending the Apple watch as a medical device. I’m not, but tell me about the “needless troubles” you assert that the watch causes?
     
  16. bbchien

    bbchien Touchdown! Greaser!

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    You apparently needed that lesson, Doctor.

    Airman sez, my Apple Watch sez a fib “
    Doc takes word for it, enters diagnosis.
    Stress Treadmill
    Echo
    24 hr holter, never mind afib isn’t found.

    now pilot gets an SI for variable AV conduction delay or PSVT, and has to satisfy agency every year.

    what doc needed to do is a 14 day recording to disprove the Apple Watch. Wrong diagnosis based on no being able to distinguish the differential items on the list. Doc, is a maroon.

    airman retains me. Implanted loop recorder shows no afib in Six Months. Agency sez, we want to watch him for a few years.....

    I sez to airman, find a different doc (fire the guy).
    Apple needs to temper its claim that it can diagnose AFib, with “a lesser degree of accuracy”. Got it?
     
    Last edited: Jan 11, 2021
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  17. MacFly

    MacFly Line Up and Wait

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    Odd that you think that. Anyway, the electrophysiology doesn’t matter. The failure here, and what you apparently aren’t grasping that I’m saying, is that the failure isn’t the watch...it’s a rudimentary device. The failure is the patient’s doctor that took the watch’s word for it as the sole reason to do the work up, initiate treatment, or put it into the medical record.
     
    Last edited: Jan 11, 2021
  18. bbchien

    bbchien Touchdown! Greaser!

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    It is also the claim by apple, which isn’t “modest....not entirely untrue but a bit overstated.

    The pilots believe it. Just like the claim that CT calcium score can determine that you have CAD...it’s notQUITE so.....but Heart Check America would lead you to believe so.

    follow the money, Doctor.
     
  19. MacFly

    MacFly Line Up and Wait

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    I can’t keep up with the thread of the conversation, Bruce. Now we’re following money?
     
  20. AKiss20

    AKiss20 Pre-takeoff checklist

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    Apple's language on this feature (emphasis mine):

    INDICATIONS FOR USE (NON-EU REGIONS)

    The Irregular Rhythm Notification Feature is a software-only mobile medical application that is intended to be used with the Apple Watch. The feature analyses pulse rate data to identify episodes of irregular heart rhythms suggestive of atrial fibrillation (AF) and provides a notification to the user. The feature is intended for over-the-counter (OTC) use. It is not intended to provide a notification on every episode of irregular rhythm suggestive of AF and the absence of a notification is not intended to indicate no disease process is present; rather the feature is intended to opportunistically surface a notification of possible AF when sufficient data are available for analysis. These data are only captured when the user is still. Along with the user’s risk factors, the feature can be used to supplement the decision for AF screening. The feature is not intended to replace traditional methods of diagnosis or treatment.
    The feature has not been tested for and is not intended for use in people under 22 years of age. It is also not intended for use in individuals previously diagnosed with AF.

    Source: https://www.apple.com/legal/privacy/Instructions-for-Use-Irregular-Rhythm-Notifications.pdf

    I don't see anywhere where Apple is claiming physicians should be using Apple Watch data as a sole source of information on which to base a diagnosis, or even use it as a supplement to a diagnosis. Their language is that it can be used as a supplement for a decision to screen for AFib. What aspect of their language do you feel is overstated?
     
    Last edited: Jan 11, 2021
  21. X3 Skier

    X3 Skier En-Route PoA Supporter

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    • Seems to me if Apple advertises such a feature as a “supplement the decision for AF screening.” an unsuspecting person might then tell their PCP the watch identified a possible Afib condition and then finds themselves in the same situation as the OP.
    Cheers
     
  22. AKiss20

    AKiss20 Pre-takeoff checklist

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    Isn't it the job of the physician to take that information into consideration and then decide for themselves based on all available data a)whether or not AFib is at all likely and order more tests and b) submit a diagnosis of AFib? To me the language from Apple says physicians should treat the Apple Watch data just as seriously as any other "suggested diagnosis" from a patient. Anywhere from not at all to very seriously based on other available data and risk factors. It is the job of the physician to understand the limitations and capabilities of any source of information prior to using it. Just as with pilots it is our job to understand the limitations and capabilities of any of the hardware we use to fly the plane, regardless of what the marketing copy of either may state.

    My final 2 cents.
     
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  23. WDD

    WDD Cleared for Takeoff

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    I believe:
    • Apple watch provides data at some degree of validity as to whether or not you have an a fib.
    • A patient reported that to his doctor
    • Doctor took that comment and put in chart, establishing a diagnosis
    • That diagnosis got to the AME, got to the FAA
    • Result was requirement of many, lengthy, and expensive tests
    Morale of the story: If your doctor is likely to put in notes which constitutes a diagnosis based on a comment about an apple watch, you need a new doctor.

    Follow the money: I THINK that the comment was the doctor put that diagnosis in the charts to profit from additional and unnecessary tests. Or that the medical industrial complex is geared to making things complex and expensive to generate profits on unnecessary testing.

    Not really sure the intent of the comment.
     
  24. Tarheelpilot

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    The pilot sounds like an idiot as well. No need to be a doctor to understand the Apple Watch is not able to diagnose anything meaningful.
     
  25. wsuffa

    wsuffa Touchdown! Greaser!

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    That assumes the doc has enough time and wherewithal to do so in today's environment of limited insurance payments (less for medicare). There are some that are more than willing to not do the full workup, dispense pills like candy, and see what happens. Of course, to get reimbursed (and in some cases to dispense the pills) he must enter diagnosis codes into the "system". For most of the public, that's good enough. For pilots, it's not.
     
  26. Lindberg

    Lindberg En-Route

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    Seems quite clear what the problem is here, and it is not the watch or the patient. I'm confident that if I'd said something like this to my PCP (now retired because don't get me started on politics) he would have told me that he gave me regular EKGs, that I have never had any symptoms of AFIB, and to stop looking at the watch. In fact my BP machine has a light for "irregular heartbeat," which he thought was funny. There's no chance he would have ordered testing OR entered a diagnosis based on what my watch said. That's right up there with letting a patient diagnose himself on WebMD. Maybe we just need to stop pushing the good doctors out of the practice of medicine.
     
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  27. danhagan

    danhagan Pattern Altitude

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    I get a LOT of airmen with misdiagnosed conditions. We have a great cardiologist here that works with us to correct the bad calls. There are quite a few misdiagnosed kidney stones as well. One of the "screener" companies that rolls around here mobile offering to look for aneurysms, plaque etc. generates a number of false positives as well. Last one was a "large liver cyst" that was actually the patient's normal inferior vena cava (blame that one on both the sonographer and interpreting physician). Luckily, patient had a phone image of said "cyst" and we reproduced same image with color flow to demonstrate it was the normal vein also included "their" image on the final report to the official referring physician trying to diagnose after the "screeners".

    In short, be careful ... imaging reports CAN have a corrective addendum applied if you fight them to correct it.
     
  28. MalibuJim

    MalibuJim Pre-Flight

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    OP,

    Fortunately, I have Kaiser Insurance (never thought I would ever say that), but I was able to get them to do all kinds of elective testing, including MULTIPLE MRI's, Stress EKG, Nuclear Heart, CT Scans, and even an ELECTIVE angiogram. All just to satisfy the witch hunt that is the FAA. My bills totaled over $120k and nothing turned up. Good thing is that I have had EVERYTHING looked at and tested including cognitive tests, and everything looks good, so at least I got that peace of mind.
     
  29. AKiss20

    AKiss20 Pre-takeoff checklist

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    Well that again sounds like a fault in both the physicians personally and our entirely ineffective and ridiculous medical insurance system (I will stop there lest I stray afoul of the ROC), not the claims of Apple which was the original thing I was replying to.
     
  30. PaulS

    PaulS Touchdown! Greaser!

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    Apple shouldn't even be suggesting Afib, shouldn't even mention it. It's horsecrap and I'm betting there are a lot of people being run through tests unnecessarily because of Apple trying one up everyone with marketing.
     
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  31. AKiss20

    AKiss20 Pre-takeoff checklist

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    The data I have found does not agree with your statement that it is "horsecrap". On what data did you base your assessment? I don't think anyone is claiming it is 100% reliable or accurate, but the data does suggest it has utility and is not based on nothing. Note that there is data from other manufacturers in the third reference below, so this isn't just an Apple thing. Many wearable manufacturers are including such features.

    1) https://www.ajmc.com/view/giant-study-suggests-apple-watch-accurately-catches-afib
    2) https://www.nejm.org/doi/full/10.1056/NEJMoa1901183
    3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787392/
     
    Last edited: Jan 11, 2021
  32. PaulS

    PaulS Touchdown! Greaser!

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    I'm not qualified to go down this road with you.

    But from my layman point of view, I looked at the conclusion of the 2nd study, of the watch reported AFIB cases, the watch correctly predicted 34% of them. Many of those cases were in AFIB for an hour or longer, these people had to have been feeling symptoms. My concern is the 66% who were flagged and didn't have AFIB. Were they sent down a road of tests and anxiety needlessly? Probably.

    Bottom line, don't go looking for trouble like this unless you have a reason to do so. If your heart is racing, get it checked out. If you feel dizzy or weak, get it checked out. Don't buy a toy to try to self diagnose. As Bruce pointed out, an incorrect diagnosis can affect your ability to fly. Disproving the incorrect diagnosis is expensive and may not be possible.
     
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  33. bflynn

    bflynn Final Approach

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    I disagree.

    The FAA shouldn’t be using a guess in a doctor’s record to establish legal proof of a condition which must then be disproved. That is an abuse of HIPPA and a flagrant disregard for process.

    This is one of the things wrong with FAA medicals. Technically, if the airman did not report on the 8500-1 and the AME found something counter, the airman should be flayed alive for lying in the 8500. If the FAA isn’t ready to go that route, they should not be using speculation to ground an airman.

    IMO, the OP’s AME committed libel.
     
    Last edited: Jan 12, 2021
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  34. bbchien

    bbchien Touchdown! Greaser!

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    Yes....the claim of the adjunct diagnostic “power” of the device....33% is worse than a coin toss last I looked. Everyone know that nobody not even the OP’s doc, Reads the fine print.

    Sort of “Flying 2.0, your personal airliner”.
     
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  35. PeterNSteinmetz

    PeterNSteinmetz Pattern Altitude PoA Supporter

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    Given the apparent low rate of such alarms, apparently the positive predictive value wasn’t so bad. From the second study provided:

    “Among participants who were notified of an irregular pulse, the positive predictive value was 0.84 (95% CI, 0.76 to 0.92) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular pulse notification and 0.71 (97.5% CI, 0.69 to 0.74) for observing atrial fibrillation on the ECG simultaneously with a subsequent irregular tachogram.”

    For a test like this, one really needs to consider all possible test outcomes to estimate utility.

    Agree with others here that of course neither the PCP nor the AME should consider that performance accurate enough to be making clinical decisions. Just an indicator that perhaps it is something to look into.
     
  36. Lindberg

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    Only if the actual prevalence of afib in the population was higher than 33%. According to Google, estimates are around 3%. That would make 33% significantly better than chance. Certainly not valid for diagnostic purposes, since you're still more likely to not have it than have it, but seems valid for screening purposes.
     
  37. bbchien

    bbchien Touchdown! Greaser!

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    And the prevalance of afib in the population with a racing heart and shortness of breath?

    Sigh.
     
  38. Lindberg

    Lindberg En-Route

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    I don't understand the relevance.
     
  39. PeterNSteinmetz

    PeterNSteinmetz Pattern Altitude PoA Supporter

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