I've been stewing on this for a few years now (maybe more) without having a clearer picture of what I was feeling/thinking, and I would like to read some reactions/challenges to this framing - genuinely.
Heart disease is the number 1 killer of people in the U.S. The science today says that death due to poorly controlled ASCVD/CAD is largely avoidable (as I understand it). My question is what people think about the explanation below being the primary reason in the U.S. (not the only reason) why this disease continues to kill so many people?
I've framed this as an inquiry as to why most doctors (GPs/internists) do not order fasting insulin alongside fasting glucose, as a standard practice. As many likely know fasting insulin starts to move years before fasting glucose and HbA1C, and is needed to calculate HOMA-IR, which is where it relates more directly to CAD, in this framing...
1 - The "Trajectory as Persuasion" Asset
The core of the argument - that a three-year trajectory of rising fasting insulin is more persuasive than a single high value - moves the clinical conversation from reactive to predictive.
The "Generic Advice" Problem: Most patients tune out "eat less, move more" because it feels like a moral judgment or a boilerplate script.
The Trajectory Solution: When a clinician can point to a trend line, they shift the burden of proof. It’s no longer the doctor’s opinion; it’s the patient's own biology providing a "warning shot." This creates a "compounding asset" because each data point increases the patient's buy-in (agency) and the doctor's leverage.
2 - The Medicolegal Trap
In a litigious environment, knowledge equals liability - the "perverse incentive".
The Paper Trail: If a physician documents a metabolic decline (hyperinsulinemia) but adheres to the standard of care (which often dictates waiting until HbA1c hits 5.7% or 6.5% before aggressive intervention), they are technically "ignoring" data.
Strategic Ignorance: To a risk-management department, a test not ordered is a liability not created. If the trajectory isn't in the chart, the "failure to diagnose" clock hasn't started ticking yet. This is why many clinicians stick strictly to the "legal floor" of the standard of care. It is the safest place to stand, even if it’s the worst place for the patient’s long-term health.
3 - The "Standard of Care" vs. "Better Medicine"
"Standard of Care" is a legal term, not a scientific one... it represents the consensus of what a "reasonable" doctor would do, which is often a lagging indicator of science.
| Metric | Purpose | Outcome for Physician |
|---|---|---|
| Standard of Care | Minimize liability / Ensure baseline safety. | High legal protection; moderate patient outcomes. |
| Early Surveillance | Maximize prevention / Upstream intervention. | Higher legal exposure; potentially superior patient outcomes. |
4 - The Moral Hazard of "Wait and See"
In this framing, the doctor practicing "better medicine" is taking on more risk seems like a cynical but meaningful takeaway. By collecting upstream data (like fasting insulin) that isn't yet mandated by major guidelines (like the ADA), the physician is operating in a "gray zone."
If they use that data to persuade a patient over three years, they are effectively betting on the patient's ability to change. If the patient fails to change and develops disease, the doctor is left holding a chart that proves they knew the house was smoldering but didn't call the fire department because the "standard" says you wait for open flames.
Is this one of the primary drivers of system-incentive mismatch, or is this one of many noisy elements in a crowded and noisy system, and has little singular bearing on quality of outcomes related to T2D and/or CAD?