Why Are 12-Leads Not Required For School Physicals

[18G]

The difference is that you're now trying to support this statements with peer-reviewed research.

I think usafmedic sometimes comes across as a little abrasive. I'm not sure if he's aware of this, or if he cares if he is. But what he was asking isn't unreasonable, even if his frustration was clear from some of his posts. Perhaps he could have been gentler.

Personally, I've got some reading to do before I have an opinion on this area. So far, I'm more convinced by the information that usafmedic has put forward, because his arguments have been supported by an evaluation of peer-reviewed research, which he and other people have linked to. But I'm keeping an open mind, and interested in seeing other data.

I think key points that have been made here include:

* Any diagnostic test carries a certain false-negative and false-positive rate. When considering the benefit of a given test, this has to be balanced against the potential cost / risk / negatives of both false-positives and false-negatives.

* The ECG is less sensitive and specific than the echocardiogram for identifying cardiac hypertrophy. (Although, I think the sensitivity improves dramatically if we have voltage criteria + signs of LV strain).

* Any time you have a rare condition (i.e. low prevalence), any test with a low specificity will throw a lot of false-positives. This can result in unnecessary expense, alarm for the patient, and exposure to potentially dangerous medical treatments for healthy patients that would never had been exposed to this risk had they not been tested.

* Peer-reviewed research trumps anecdote. What a particular cardiologist, tree surgeon or supermarket cashier "thinks", is not that interesting. Obviously we should listen first to the cardiologist, but this remains "expert opinion" at best. What we should do, is demand research, and demand real data.

I hope this can remain a productive discussion.

Cardiologists at Stanford University School of Medicine did perform research that was published in the Annuals of Internal Medicine. It showed cost effectiveness and benefits which include saving lives.

Why is this research being dismissed and the research USAF provided being upheld? The Italian study I've read reveals a decreased death rate of 90% andwith screening programs in the US using the data from the Italian study as a model.

So I'm not even sure what research people are referring to that USAF provided that say's ECG screening is absolutely a waste.

Because what I've read is multiple studies and professional opinion thatsay either 1) ECG screening is beneficial and saves lives, 2) Not enough data exists to say either way, 3) ECG screening does not help save lives.

There is no absolute as USAF is portraying.

 

[Aidey]

The decrease of 90% was TO the level that US deaths are already at. They also state that the subjects in the Italy was made up of a higher % of males and older males, who are a higher risk group. The US has a larger % of younger and female athletes.

No one is saying it is a total waste, just that automatically screening 25,000,000 athletes a year in order to detect a handful of at-risk people and causing several thousand false positives may not be a very efficient way of going about things. Especially because screening is not going to catch everyone and there will always be deaths from SCA.

 

[18G]

So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?

 

[terrible one]

18g with all due respect you are the one that is out of line here. USAF, while his tactics and upfront attitude may be a little brash, all he has asked for is statistical peer-reviewed research to support your claim that 12-leads should be mandated in high schools.
You have responded emotionally and without proper documentation to all of USAF's responses. There are several reasons why this practice isn't utilized all of which USAF has stated, yet you continue to ignore many of them and repeat your opinion, not facts on the subject.
It's great that you are highly motivated to protect and initialize prevention for our youth, something highly lacking in the paramedic culture, however, continuing down the path of "what if it was your kid" is not the correct way to go about it.
Do not take this as an attack against you, I admire anyone that takes interest in furthing medical care, I am simply an outsider looking in.

 

[usafmedic45]

I think usafmedic sometimes comes across as a little abrasive. I'm not sure if he's aware of this, or if he cares if he is. But what he was asking isn't unreasonable, even if his frustration was clear from some of his posts. Perhaps he could have been gentler.

I could also offer the benefit of a reacharound. Alas, I don't. No offense intended though if I was kind of excessively harsh.

So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?

Screening is worthwhile, if it has a demonstrated and positive impact. Crude analysis and assumptions are not sufficient to say "This works". That's why people are not so eagerly supporting your idea. I actually think screening should be mandatory (and used to volunteer doing echos on cases where it was clinically indicated) but also realize the shortcomings of the technology and the fact that you're not going to eliminate most of these cases simply because they don't show up on affordable screening tests until they present as a fatal occurrence.

The decrease of 90% was TO the level that US deaths are already at. They also state that the subjects in the Italy was made up of a higher % of males and older males, who are a higher risk group. The US has a larger % of younger and female athletes.

Bingo. You can't compare non-alike populations without recognizing those limitations and differences.

So I'm not even sure what research people are referring to that USAF provided that say's ECG screening is absolutely a waste.

Go back up and read the post where I cited the study from either early this year or late last year. 2 cases out of 950 or so screened were picked up by combined echo and EKG. Not exactly a significant rate.

Because what I've read is multiple studies and professional opinion thatsay either 1) ECG screening is beneficial and saves lives, 2) Not enough data exists to say either way, 3) ECG screening does not help save lives.

Likely because you're looking at wildly varying study populations with the inherent variability in risk factors. Most of the studies in the US (which is the population we are concerning ourselves with) show no appreciable benefit because of an already freakishly low rate of SCA in student athletes.

There is no absolute as USAF is portraying.

When did I say it was an absolute? I simply stated that there is no evidence that it works as well as you are hoping in the population you are concerning yourself with. Even if we TEE, treadmill stress test and angio every last kid who sets foot on the field, we're still going to miss some. That is the only absolute in this discussion.

 

[18G]

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?

 

[JPINFV]

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?

Anything from Stanford isn't worth the Redwood it's written on. Stanford, the only school with a mascot more hideous than the banana slug.

 

[Tigger]

Part of my job at school is to assist with the rather overwhelming process of ensuring that every collegiate varsity athlete has his or her medical history reviewed. We start the process with a three page health history questionnaire that covers both orthopedic and general health issues. If an athlete answers "yes" to any of the questions, he will see one of our staff Family Practice/Sports Medicine certified physicians or staff orthopedists, depending on the history. Depending upon the doctors examination, the athlete can be referred to a specialist (free of charge) for further follow up. Anyone with a significant cardiac history (murmur, high/low BP, arrhythmia, significant family history) will see a cardiologist, and he will make the decision on what sort of additional diagnostic testing is needed.

Also note that every freshman must have a full physical performed by their own physician/pediatrician, meaning that we are usually aware of those that need an additional cardiac workup prior to them even arriving on campus.

I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes. Good medicine is targeted medicine. We at Sports Medicine do not mandate physicals for every athlete every season if they have a "clean" history. Is it possible that something drastic has changed in their medical history? I guess, but at this point we are willing to accept that infinitesimal degree of risk.

 

[18G]

Anything from Stanford isn't worth the Redwood it's written on. Stanford, the only school with a mascot more hideous than the banana slug.

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?

 

[18G]

I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes

You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument.

When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong.

It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.

 

[JPINFV]

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?

I think that went over your head...

 

[Smash]

Where does it end? If we start doing an ECG on every school athlete in the offchance that it may pick up an abnormality and that it's not a false positive and that it actually has any positive result anyway, do we extend that?

Do we start doing a CTA on every student to make sure they don't have an AVM, which tend to kill people in their teens and can be triggered by increased shear forces that we get when people exercise? After all, if we can save one life it must be worth it right?

 

[Akulahawk]

Anything from Stanford isn't worth the Redwood it's written on. Stanford, the only school with a mascot more hideous than the banana slug.

Again, what is to be made out of the research at Stanford? Is the Annuals of Internal Medicine not peer-reviewed?

I think that went over your head...

JP: I think you're correct. Right over the head...

Part of my job at school is to assist with the rather overwhelming process of ensuring that every collegiate varsity athlete has his or her medical history reviewed. We start the process with a three page health history questionnaire that covers both orthopedic and general health issues. If an athlete answers "yes" to any of the questions, he will see one of our staff Family Practice/Sports Medicine certified physicians or staff orthopedists, depending on the history. Depending upon the doctors examination, the athlete can be referred to a specialist (free of charge) for further follow up. Anyone with a significant cardiac history (murmur, high/low BP, arrhythmia, significant family history) will see a cardiologist, and he will make the decision on what sort of additional diagnostic testing is needed.

Also note that every freshman must have a full physical performed by their own physician/pediatrician, meaning that we are usually aware of those that need an additional cardiac workup prior to them even arriving on campus.

I just don't see it as logistically possible nor cost efficient to mandate 12 leads for all athletes. Good medicine is targeted medicine. We at Sports Medicine do not mandate physicals for every athlete every season if they have a "clean" history. Is it possible that something drastic has changed in their medical history? I guess, but at this point we are willing to accept that infinitesimal degree of risk.

Funny how I've been saying something pretty similar...

You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument.

When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong.

It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.

18G - we're talking about apples and avocados here. Generally speaking, athletes are quite healthy and don't have lots of events of VF or VT. The same can not be said of the general population. Although I don't have the numbers in front of me, I would expect that the incidence of those kinds of SCA is higher (if not far) in the general population than it would be/is in the athletic populations. Because of the higher incidence, it makes excellent sense to put AED units where lots of people congregate and/or on Police units because they usually have faster response times than ambulance units...

Also, something else to consider: it was stated above that a 12-lead and echo followup would cost $88? AED units can be purchased for the equivalent of a dozen of those checkups. One question that remains outstanding is where will the 12-lead machine come from? I doubt that a physician is going to want to bring it from his/her office and therefore deny it's use by other providers in the office, I doubt that EMS providers will lend use of one of their machines for the same reason... so what remains is: who is going to purchase the unit? I'd expect that a good AED unit would be less expensive than a 12-lead monitor.... To me, it just makes better sense to screen initially, send any suspect cases out, and buy AED units for use at school events. Long-term, that's probably the best answer for the athletic population in the US.

 

[18G]

JP: I think you're correct. Right over the head...


Funny how I've been saying something pretty similar...


18G - we're talking about apples and avocados here. Generally speaking, athletes are quite healthy and don't have lots of events of VF or VT. The same can not be said of the general population. Although I don't have the numbers in front of me, I would expect that the incidence of those kinds of SCA is higher (if not far) in the general population than it would be/is in the athletic populations. Because of the higher incidence, it makes excellent sense to put AED units where lots of people congregate and/or on Police units because they usually have faster response times than ambulance units...

Also, something else to consider: it was stated above that a 12-lead and echo followup would cost $88? AED units can be purchased for the equivalent of a dozen of those checkups. One question that remains outstanding is where will the 12-lead machine come from? I doubt that a physician is going to want to bring it from his/her office and therefore deny it's use by other providers in the office, I doubt that EMS providers will lend use of one of their machines for the same reason... so what remains is: who is going to purchase the unit? I'd expect that a good AED unit would be less expensive than a 12-lead monitor.... To me, it just makes better sense to screen initially, send any suspect cases out, and buy AED units for use at school events. Long-term, that's probably the best answer for the athletic population in the US.

This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times.

The AED mention was simply to point out the position of many people during the early days of the public access concept. Many people thought a defibrillator would never hang on the wall outside of a mall but they were wrong.

For the last time:

1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2. However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.

2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.

3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care.

4) I am well aware of the limitations of 12-lead screening. I know they will not catch everything. I am well aware some students will still slip through. I am well aware a 12-lead will NOT end student athlete deaths but it CAN identify some at risk and save lives.

5) Based on current data, research, and cardiologists opinion, it is NOT unreasonable for a person to be willing to further explore these programs and support their implementation in their own community until more conclusive data says otherwise.

I know in my area, the local hospital has an annual health fair where they offer free diagnostic testing at the local high school. They offer free ECG's, echo's, and lab work. Why is that? Because benefit does exist in routine diagnostic testing and it's important to establish a baseline to identify changes later on in life. These tests are performed as an endeavor to improve community health. But according to you all, the hospital should have big studies to justify the testing performed at the health fair. Without a study its just a waste of time to try to make a difference, right? Why waste time screening people in the community with an echo who are asymptomatic, right? The thought of picking up on something insidious is like finding a million dollars tonight, right?

Just because a patient is not symptomatic or rise to the level of suspicion for a physician to order a test, doesn't mean a problem isn't in the making.

I agree with routine diagnostic testing during certain times and events. It can be truly life saving.

Continue to think what you want. It's cool. I'm not going to criticize anyone for it. It's very reasonable to be against the 12-lead testing at this point in time. I see both sides. I just choose to err on the side of benefit and saving lives even if that is only 50 a year.

 

[Tigger]

You know they're was a time when people said the same thing about AED's and their widespread deployment? Cost vs benefit was once an early argument.

When AED's first hit the scene I don't think anyone imagined AED's would be found in malls, schools, police cars, and office buildings, due to perceived logistical concerns with liability, purchasing, and training. But they were wrong.

It has been shown that an ECG can be performed along with follow-up care including an echo for as low as $88.

Yes there was. But that's an entirely different comparison. The reoccurring cost to the organization is quite low with the AED once its been purchased. The same is not true for getting 12 leads for every freshmen.

This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times.

The AED mention was simply to point out the position of many people during the early days of the public access concept. Many people thought a defibrillator would never hang on the wall outside of a mall but they were wrong.

For the last time:

1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2. However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.

2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.

No doubt that testing can save a life. There are lots of other tests that can do the same, where do we draw the line, especially when faced with inconclusive evidence on EKG's effectiveness? Sorry, but I don't buy the "if it saves one life it was worth it" line of thinking.

3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care.

Have these practices been implemented in sustainable ways? Just because an organization is getting a good deal now on bulk testing does not mean that continues, schools lose their staff physicians and associated perks fairly frequently. Also, the $88 statistic for testing sounds nice, but completely fails to address the logistical hurdle of having to test 100+ athletes annually. There is no possible way that we could conceivably test these athletes before the season starts, there isn't the time, space, or staff available.

 

[Aidey]

One of the studies approximated there were 25,000,000 student athletes in the US. If just a 12 lead costs $30 that is 750 million dollars. If 50 lives are "saved" that comes out to 15 million per life saved just for the 12 lead costs.

I'm pretty sure that is waaaaay outside NICE's criteria for a cost effective tool.*

I put saved in quotes because the people may still die even if they don't play sports.

That is a lot of money. Where is it going to come from? A lot of kids are on some sort of public insurance, and states like California and New Jersey do not have the money to pay for 12 leads for all of them.

* I know NICE is a UK agency, but they put out good information and it would be a good idea to pay attention to what they're doing.

 

[Aerin-Sol]

Why don't you just change your screen name to Jenny McCarthy because you have about the same burden of proof standards as she does.

That is a wonderful insult.

 

[systemet]

So what is the threshold? How many kids a year need to die before we deem screening a worthwhile endeavor?

This is a call to pathos.

It's easy to say "you can't put a value on a human life", but we do this on a daily basis. We often make the judgement that a given life-saving intervention is not justified based on cost.

For example, we could:

* Lower the BAC to 0.02 or lower to reduce the number of DUIs and highway fatalities (this has been done with positive results in many European countries).

* Lower highway speed limits

* Increase driver training standards, etc.

All of these things would results in lives saved, including the lives of children. Much as the current discussion about ECG screening is motivated to do. But for whatever reason, many societies have decided the cost is not worth it.

That kids are precious, is definitely an argument that we should devote resources to them. But when are resources are finite, it doesn't logically follow that we should (i) devote all our resources towards children, or (ii) devote a large percentage of the available resources to a given intervention without critically examining whether that money could be better spent elsewhere.

 

[systemet]

This is the main problem with this discussion. People misconstrue what I am saying even though I have repeated it several times.

This seems to happen a lot in the forums. I would assume that most people are not deliberately twisting your words, or trying to set up strawmen. Perhaps if you feel you're being misconstrued you can restate your position?

1) There IS evidence that shows ECG screening in athletes IS a HELPFUL screening tool and HAS been shown to reduce deaths. I AM WELL AWARE THIS IS NOT CONCLUSIVE EVIDENCE - see #2.

I don't think anyone is arguing that ECG screening can identify patients at risk for hypertrophic cardiomyopathy or ARVD, LQTS, etc. I think that's common ground.

I think we also have a general consensus that the ECG is not a particularly sensitive or specific means of evaluating hypertrophy. But that it is much more pratical than echocardiography.

However, several studies do support screening programs and these programs ALREADY exist with GOOD results - several students ended up on medication and several were identified as needing surgery as a result of this routine screening.

I'm not sure that you've adequately supported this statement. One paper you linked [1] evaluated 1,424 students, found ECG changes worthy of restricting activity in 12 patients, who were then subsequently cleared to return to exercise following echo.

It's probably likely that these patients may receive further follow up testing, and be aware of the potential for future problems to develop. If followed up long enough, it's possible that one of these students might have a syncopal episode, that someone might attribute to electrocardiographic abnormalities identified in this study. It might be beneficial in this instance. But this study failed to demonstrate a benefit.

The second study you presented [2] uses the Italian data, and attempts to extrapolate it to the US population and present a model of the theoretical economic benefits. It's not without merit -- but it's not a report of an existing screening program. It could be used to make inferences about the likely cost or benefit of such a program once it was introduced in the US, but this is still quite aleap.

2) There is NO evidence that say's ABSOLUTELY without a doubt that ECG screening is not useful and life saving. Evidence exists that says screenings make no difference or more so, makes so little difference that cost is not warranted.

And that seems to be the issue here. Is whether it's worth the cost. The study that attempts to address this, is available free here, for anyone who wants to read it:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873148/?tool=pubmed

At $89/test, with 25 million student athletes, it could become very costly.

They're projecting a cost of $21,200-71,300/ year of useful life saved, and assuming a post-testing life expectancy of 60 years for all identified patients (which may not be a valid assumption). If we define a "life saved", it looks to me like there's a cost of $1.2-4.2 million / life saved. But that might not be a valid inference from the text.

3) It HAS been found that the logistics that many people cite as a roadblock can be overcome and these screenings can be cost effective - including the ECG, echo, and follow-up care.

I don't think that the data you've presented supports that statement. They've reported cost-effectiveness numbers, but whether this intervention can be considered cost-effective probably depends on what other avenues for healthcare dollars are available and the relative merits of increasing funding in those areas.

4) I am well aware of the limitations of 12-lead screening. I know they will not catch everything. I am well aware some students will still slip through. I am well aware a 12-lead will NOT end student athlete deaths but it CAN identify some at risk and save lives.

I don't think this is being disputed, is it?

What I don't think is being discussed enough is the burden of a false-positive. The ECG and echocardiogram themselves are pretty benign. But what's the cost to the student athlete who's told they can't compete until follow-up has been performed, and loses a half-season, or a place on a team? What's the dollar value of having some sort of minor-normal variant identified on your ECG and spending the rest of your life worrying about your CVD risk?

I appreciate these things are hard to quantify, but they're worth mentioning.

5) Based on current data, research, and cardiologists opinion, it is NOT unreasonable for a person to be willing to further explore these programs and support their implementation in their own community until more conclusive data says otherwise.

I'm not sure I agree with this either. Is it worth introducing this if the benefit is small, and the cost high?

I mean, I don't mind paying taxes. I'm pretty left wing. I like supporting the health care system. I think it's fantastic. But I'm not convinced that this is the best area for my tax dollars to be spent in.

It might be interesting to see some sort of study performed to compare a screening program with ECG to a screening program without. But this might also be very expensive.

To make a (non-evidence based, and completely anecdotal) EMS comparison -- if I have a patient who's overdosed on INH, I'd love to have a bucket load of pyridoxine (B6) on the ambulance. It would be potentially life-saving. But I've seen this once. The crew that had the patient gave massive amounts of benzodiazepine and ran to the first ER we could find that actually had pyridoxine on hand. I can motivate the cost of putting the B6 on the trucks by the potential that it might save lives, but if we throw it out every couple of months, and the system sees this sort of call every couple of years, is it going to be worth it?

I know in my area, the local hospital has an annual health fair where they offer free diagnostic testing at the local high school. They offer free ECG's, echo's, and lab work. Why is that? Because benefit does exist in routine diagnostic testing and it's important to establish a baseline to identify changes later on in life. These tests are performed as an endeavor to improve community health.

Are they trying to improve community health? Or is it an attempt to advertise service and provide PR? Educate the students about health? Promote health care careers?

If the benefit is there, why hasn't it been shown in the peer-reviewed literature? And if it has, why not link to it here?

But according to you all, the hospital should have big studies to justify the testing performed at the health fair.

I know this isn't directed at me personally, but yes. They should.

If we're going to spend finite resources doing something, we should demonstrate that what we are doing is worthwhile. Otherwise we should direct those finite resources elsewhere.

Without a study its just a waste of time to try to make a difference, right?

No. It's not a waste of time to try and make a difference. But we might be wasting our time because we're not making a difference. There's an important distinction there.

Why waste time screening people in the community with an echo who are asymptomatic, right? The thought of picking up on something insidious is like finding a million dollars tonight, right?

Well, this is the question? Are we spending 10 million dollars that could be spent in an area where there's demonstrable benefit to save a million dollars elsewhere?

Just because a patient is not symptomatic or rise to the level of suspicion for a physician to order a test, doesn't mean a problem isn't in the making.

I don't think anyone is arguing against this point.

Continue to think what you want. It's cool. I'm not going to criticize anyone for it. It's very reasonable to be against the 12-lead testing at this point in time. I see both sides. I just choose to err on the side of benefit and saving lives even if that is only 50 a year.

You're entitled to your opinion. Just as other people are entitled to disagree with you.

But at the same time, if you can't justify that opinion in the basis of peer-reviewed research, you are going to have difficulty convincing people with an academic background to side with you.

It's been fun discussing this, though. I hope there's no hard feelings.


[1]Lacorte MA, Boxer RA, Gottesfeld IB, Singh S, Strong M, Mandell L. EKG Screening Program for School Athletes Clin. Cardiol. 12, 42-44 (1989)

[2]Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA.
Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010 Mar 2;152(5):276-86.

 

[18G]

I'm curious... if your taking your child for a sports physical and knowing its possible that an ECG could be life saving, would you personally ask for a 12 lead or would you be willing to assume the risk of death and not want the extra level of screening for your son or daughter?

This is a general question to all.