You’ve probably seen this story at some point. A 32-year-old male without any medical history saw an interesting twitter thread and got a full body MRI which found a suspicious nodule in his liver. The nodule was worked up and turned out to be an early stage cancer. Because it was found early, the surgeons were able to intervene and excise the tumor before it spread elsewhere. Cancer found, cancer taken care of. The conclusion: everyone should get full body MRI screenings.

Or should they?

There have been so many takes on full body MRIs lately. Proponents say it’s about giving the data to the patient. It’s their body and they should have as much information about it as possible. Stop the medical paternalism.

Critics argue that doctors know best and getting full body scans without any indication is a recipe for disaster, leading to patient anxiety, increased follow ups, and chasing down incidentalomas.

We’ve seen this issue debated before. If you want to see pros and cons and even experiences of people who got full body scans, you can go here, here, or here.

I want to take a step back and focus on the bigger issue: are full body MRIs ethical in a system with limited resources that need to be distributed equitably?

The Business of Full Body MRIs

There are two major players in the full body MRI space: Ezra and Prenuvo. We won’t go into the details of comparing the two but the premise is the same. They are both cash pay (i.e no insurance, though there are some work arounds with HSAs or FSAs), cost around $2000-$2500 for a full scan, and from what I’ve seen create a great user experience. If you’d like to see a video experience, here is a great one by Shervin Shares on YouTube.

The business model is simple - they operate imaging centers with a good user experience and charge out of pocket so there is no need to work with insurance or play within the healthcare system. The scan is usually recommended annually, creating a pseudo subscription model, and people are likely to do it if it means taking care of their health (and they have the means to pay for it).

The flip side is hiring the staff to run the imaging centers and of course the radiologists to read the images. I initially thought they probably contract with radiology groups but couldn’t actually find any information on this. However, there are job listings online that look like this:

Not a bad chunk of change for something that can be full teleradiology and promotes volume-based compensation. The more you output, the more money you make. It’s never been a better time to be a radiologist.

Systemic Impacts of Full Body MRIs

So far, this all seems positive. Patients get access to more information about their bodies. Full body MRI companies make money from this model and don’t have to deal with the intricacies and inefficiencies of the healthcare system. Radiologists can even get in on it and have a job that pays well and lets them do what they love to do - sit at home in their PJs with dual monitors reading images (joking, I love my rads friends).

But there are costs to this model. And they come up when you realize that healthcare is a finite good.

Healthcare isn’t the same as an expensive new laptop or a brand new car. When you buy a luxury car, like a Porsche, it doesn’t typically impact the ability of others to purchase more affordable vehicles like Toyotas or Hondas. The car market, while not infinite, has a much more flexible supply chain that can adapt to various levels of demand across different price points.

Healthcare isn’t like this. Sure you may have the disposable income to buy a Prenuvo scan. But when you buy a scan, what you’re also buying is the radiologist’s time to read that scan. If your scan has an incidental finding, you may require a biopsy (which is not a risk free procedure). In order to do that biopsy, you need a surgeon or maybe an interventional radiologist.

There aren’t infinite radiologists or proceduralists to do biopsies in our healthcare system. Some super techies say that AI should just be able to read and interpret scans. Maybe that’s the future but we’re not there yet. Right now, we are working in a system with limited resources. Getting routine full body MRIs for prevention puts stressors on this system and ultimately takes away resources from everyone and moves them to private companies like Prenuvo and Ezra. I wouldn’t be surprised if at some point these companies also hired interventional radiologists or surgeons to do the biopsies as well, essentially owning the whole stack of imaging and follow-up.

In fact, we’ve already seen this happening in areas of mental health where companies like Lyra provide services to large employers (tech companies like Google). They have a network of mental health care providers who work for them and because of this aren’t available to the general public. Lyra has essentially depleted the supply of mental health care workers by providing better compensation and consistency because they can get paid by tech companies to provide services. Mental health workers don’t have to deal with the system and can just work through Lyra and have a more steady income. The losers are those who don’t have access to mental health because they don’t have jobs at these companies and now have to work with a more limited supply of providers to choose from. Again, Lyra is playing by the rules in a broken system but its focus is to make a business that makes money rather than solve the systemic issue.

Is this fair?

In our capitalistic society, thinking about others before making a personal decision may not resonate with everyone. You may think “I earned this money so I should be able to spend it how I want and make sure my body is ok.” This is how literally every other part of our society works. However, in healthcare this becomes a philosophical question of how to utilize a finite set of resources. There are parts of the world that believe that healthcare should be a universal basic right and design their healthcare systems to reflect this belief. In our country, unfortunately, if you’ve got the dollars, you can usually get what you want, and if you don’t, you’re sometimes out of luck.

There’s a counter to all of this though that we often see in technology. Right now, companies like Ezra and Prenuvo target people with disposable income to spend on these scans. Many times, we see new tech adopted by those with money and once it’s validated and becomes mainstream it may be covered for the masses, bringing down the cost to the end user. This is what people are pushing for in the GLP-1 space for instance. Maybe one day insurance companies will cover full body MRIs?

This still doesn’t solve the supply problem of limited radiologists and proceduralists. One solution is AI reading images, which scales the supply of radiologists. Again, I don’t think we are there yet and probably won’t be for a while. There will always be a need for human involvement to confirm the AI findings before giving news to a patient about their body. This is more a legal issue than a tech one.

Another way to increase the supply of these types of providers is to lower the barrier to entry. Just like we’ve seen the rise of mid-level providers in other areas of medicine, there could be training programs that let you become a radiologist much faster or specific programs for those who just want to do specific types of biopsies. None of these exist yet (to my knowledge) but if these companies keep blowing up, I’d imagine they’d want to advocate for these types of programs in order to catch up to their demand. This isn’t easy, and the worry is that these companies may just dip into the current pool of doctors and incentivize them with higher salaries to take them away from where they are now, effectively decreasing the supply for everyone else who doesn’t use their services.

Some Parting Thoughts

My goal with this essay wasn’t to come across as an anti-tech doctor. I like tech and hope it can improve our healthcare system. However, tech often overlooks the downstream systemic impacts of direct actions. One MRI with interesting data is a net positive for a patient, but it can take away resources from others who may need them more. Unfortunately, healthcare isn’t an infinite resource game. Everything we do means taking from somewhere else and those with more financial means tend to benefit at the cost of those who don’t have the same resources. This is exactly what is happening with full body MRIs.

I’m not saying companies shouldn’t innovate. Trying new things pushes us forward. There should just be more focus on how something new impacts the system at large and how we can manage a system with limited resources in an equitable way.

Additional Questions

Since I’m sure they will come up, here is a short list of FAQs about the full body MRI debate:

• I don’t agree with medical paternalism or the idea that “doctor knows best.” Patients understand their bodies and social circumstances better than any doctor, though doctors may understand the pathophysiology better due to their training. Patient autonomy is central to good medical care and the ultimate decision should be in the hands of the patient. The patient anxiety argument is also overdone. If someone wants to know information about their body, they should be entitled to.
• Right now there is no data showing the benefits of full body MRIs. This doesn’t mean they aren’t beneficial, just that they haven’t been studied enough. It’s a classic chicken or the egg problem in healthcare. I’m acknowledging this to say that I truly don’t know if full body MRIs can change outcomes. The larger question of “shouldn’t we have them then so we can get the data?” is a valid one but one that we still need to think through in a limited resource system.
• Last point I’ll make here is that I’m not trying to be an anti-tech doc. If anything, I’ve always been excited about how technology can improve healthcare. I do at times think that tech companies prioritize the quick buck (I get it businesses have to make money) and place less emphasis on longer term outcomes for people and the system. This varies by company, founder, and of course investors, but overall something that should be considered more deeply.

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Thank you to Pranay Sharma for editing versions of this essay.