Interview on the Wake-Up Call podcast.

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I had the pleasure of being interviewed by Adam Camac and Daniel Laguros, hosts of the Wake-Up Call podcast.  We talked about the history of American healthcare.  The interview was broken down into 2 segmenst.  Here is part 1 and here is part 2.  I highly recommend this podcast.  Adam and Daniel are very good hosts and they have terrific guests, covering a wide range of topics.  You can subscribe on iTunes.

The pharma-fed doctor

And the foundation-fed healthcare journalist

Photo credit: Bobsama - Own work, CC BY 3.0, via Wikimedia
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In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

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In defense of the employed physician

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I wish to make one clarification and one prediction regarding employed physicians.

The clarification is this:  There is a common misconception that if healthcare operated under free market conditions, it would primarily be a cottage industry of solo practices and of small physician-owned hospitals.  Such operations would not develop the capabilities of large healthcare entities that we commonly associate with central planning.

In reality, however, the opposite would be the case.

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Let’s be clear about transparency

And about the obfuscations of healthcare policy interventions

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Note: This article is jointly posted here and on The Health Care Blog.

Transparency—or its absence—continues to fascinate healthcare analysts and healthcare economists.  A study just published in the Annals of Internal Medicine addresses the effects of public reporting of hospital mortality rates on outcomes.  Its senior author, Dr. Ashish Jha, offered his perspective on the study results and on the topic of transparency in The Health Care Blog.

According to the study investigators, mandatory public reporting of hospital mortality is not improving outcomes.  The result of their analysis surprised them because “the notion behind transparency is straightforward” and the “logic [of public reporting] is sound.”  The conclusion, therefore, is to persist in the effort, but to do it better with better metrics, better methods, and better data. 

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Practicing medicine for the common good

Beware of the fallacies of Spaceship Earth ethics

By Forcastro - eigin skrá, Via Wikimedia Commons
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In a recent New England of Medicine article titled Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each which his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of one against those of the other.

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Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)

Against surgical excellence

How inept decision models are targeting surgical practice

By Venkatnathaniel (Own work) via Wikimedia Commons
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A Vox.com piece about decision-making caught my attention this morning.

The story was compelling.  A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain.  A first neurosurgeon would not operate and recommended radiation therapy instead.  The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken.  The second surgeon surgeon was undeniably right.  The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good?  Not so, according to Vox.  That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why?  Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off.  Variability in judgment, as always, is the enemy.

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A free market repudiation of evidence-based medicine

A response to Andrew Foy

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In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.”  I am grateful for his interest in my work and for the the kind compliment that he extended in his article.  Having also become familiar with his fine writing, I return it with all sincerity.  I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices:  “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.”  Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.

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Mukherjee’s error and his critics’

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I can’t help but take a moment to comment on the heated response to Siddharta Mukherjee’s New Yorker piece.  Theral Timpson summarizes the kerfuffle very well, provides the appropriate links, and gives it its needed context.  The two posts by Jerry Coyne are worth reading, if only as a good education about what’s at stake.

The only interjection I will make is to say that neither side is getting it right or can get it right.  This is an example of the inevitable confusion that arises when one adopts the wrong metaphysical framework or, more precisely, when one pretends that metaphysics doesn’t matter because empirical science will tell us all we need to know. (more…)

Book review: How Doctors Think

By Kathryn Montgomery

How Doctors Think with book
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Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis.  Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine.  Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.

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