An FH clinical scoring system, as if sufficient, is an applied selection bias. So ironically, the cause of underdiagnosis is the recommended selection bias: a clinical scoring system such as the Dutch Lipid Clinic Network criteria (“DLCN”). Most FH mutation carriers score below clinical detection. Therefore, underdiagnosis is as certain as the deception that clinical testing can be sufficient to determine FH. On the other hand, clinical testing includes non-mutation carriers in high percentages. The gap between these two exclusive groups reveals the mechanical switch that is thrown by Pharma when we move from the alarming genetic message to the actual front-line clinical diagnosis, a selection bias in vivo. These easy-to-find non-mutation carriers and the real mutation carriers are swapped.
Let genetic proof shout a true alarm of a danger that one’s own recommended diagnostic procedure has actually contributed to and then let the fear herd all through the only available exit, that which guarantees the persistence of the danger. Genetic testing proves “underdiagnosis!” and then the recommended and culturally prevailingclinical scoring system guarantees it.
“Don’t eat the Potato Salad”
Here’s an analogy of passing the “baton” from the message to the selection strategy.Imagine there is a doctor who treats food poisoning and his office is just outside a large conference room where attendees are breaking for lunch. On the left side of the room there is a large dish of potato salad, and on the right, there is another large dish of potato salad. It is learned by the doctor that the potato salad on the left is perfectly fine, but the dish on the right has spoiled and those who have ingested that potato salad will certainly have food poisoning. The doctor of course makes a profit in proportion to the number of patients he serves, not to the degree of health he restores or complications he prevents.
He can make two possible announcements, both of which will be true, sort of.
- “All those who have eaten the potato salad on the right have a high chance of food poisoning. If you’ve eaten the potato salad on the left, however, you shouldn’t be alarmed. It’s OK. I have an office next door and will provide a remedy to those who ate the potato salad on the right. The remedy may be unpleasant and, to be honest, it’s a little risky, but it is better than doing nothing.”
- “Attention. The potato salad has a strong chance of giving you severe food poisoning. We’ve found samples of dangerous bacteria and this could be very serious. I have an office next door and will provide a remedy, which may be unpleasant but it is better than doing nothing.”
Or to put it differently ….
- Making an adequate distinction between those poisoned and those not poisoned is the best health strategy. Why subject those who were not poisoned to a risky treatment?
- Making an inadequate distinction between those vulnerable to the poison and those vulnerable to one’s best financial strategy is, well, the best financial strategy.
If an inadequate clinical scoring system is the inherited cultural assumption and academicstudies continue to reinforce that assumption by actually recommending it, while shouting the alarming molecular fact of “Underdiagnosis!” where will all these targets be sent?
- Making an inadequate distinctionbetween those vulnerable to FH and those vulnerable to one’s best financial strategy is the best financial strategy.
- Making a competent distinction between those with and those without the FH mutation is the best health strategy.