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

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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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The war on the NEJM

Under attack by the red brigades of transparency

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The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe.  The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.”   Their ideological alliance is with the BMJ.

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”


The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein.  Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!

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Flexner versus Osler

Medical education suffers to this day

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In the introduction to a talk I gave at the Mises Institute this year, I noted how, in the early part of the twentieth century, a convergence of interests between social progressivists and ideological empiricists led to the publication of the Flexner report and the subsequent enactment of licensing laws.

That historical context is further treated in an outstanding article by Alfred Tauber, who was professor of medicine and philosophy at Boston University School of Medicine.

In “The two faces of medical education: Flexner and Osler revisited,” Tauber contrasts the radically different views these two men held about the ethos of medicine and the proper approach to medical education.  It is ironic that the victorious position would be the one pushed by Flexner who, as Murray Rothbard put it, was “an unemployed former owner of a prep school in Kentucky…sporting neither a medical degree nor any other advanced degree.”

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Thoughts on the trustworthiness of the healthcare system

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The media periodically report tragic stories of parents who, for one reason or another, shun the medical system and, as a result, allow their children to either die or endure severe complications.

One such story came out yesterday regarding young parents whose toddler became sick.  Instead of seeking medical attention, they took the advice of a naturopath over the phone.  The child was misdiagnosed and treated with so-called natural remedies despite showing signs of deterioration and lethargy, although at times he appeared to get better.

After a two week period of persistent symptoms, the toddler took a turn for the worse.  By the time the parents brought him to the hospital he had sustained profound, diffuse brain damage.  There is no detail on what his exact diagnosis was, but it stands to reason that the child would have been better off if brought to the hospital or to medical attention much sooner.  The parents are facing criminal charges. (more…)

Peer-review and science’s funding problem

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I enjoyed listening to Theral Timpson’s podcast interview of Jason Hoyt yesterday.

Hoyt is the co-founder of Peer J, an open access publisher that is also encouraging biologists to post pre-prints.  Peer J offer pre-print hosting for free and is one of those entrepreneurial companies that is trying to find a remedy for the widely perceived science publishing gridlock.  Hoyt gives good insights about some of the challenges present in that world.

A couple of years ago, Hoyt also co-wrote an article for Scientific American in which he traces back the history and evolution of science publishing.  Amazingly, peer-review of papers was not mandated by most journal until the 1970’s. (more…)

Good news about quality measures?

Not everything that counts can be counted

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A few days ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services.  Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers.

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The Swiss healthcare system

A model for the US?

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20151109_Fouradoulas_Marc_002This week’s post is by Dr. Marc Fouradoulas who is a board-certified internist with a subspecialty in psychosomatic medicine. Marc’s ten years of clinical experience include psychiatry and primary care, and he currently works at the University Clinic in Bern, Switzerland.  For the past 3 years, Marc has been studying towards a Master’s degree of advanced studies in managed healthcare and health economics at the Winterthur Institute of Health Economics, School of Management and Law, in Zurich, Switzerland.  You can send him email.

An alternative take on the Swiss health care system

In a recent New England Journal of Medicine editorial, Nikola Biller-Adorno, a German ethicist now based in Switzerland, and Thomas Zeltner, a physician and former Secretary Director of the Swiss National Health Authority, painted a rosy picture of the Swiss health care system, which they qualified as a potential role model for the US.

Given the author’s backgrounds and positions, their viewpoint may not be the most objective. Here, I wish to give readers a more realistic glimpse into this highly complex system from the perspective of a practicing physician.

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Maintenance of board certification

Who is thriving and who is struggling?

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Nov-Dec-15-Web 1This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career.  Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.

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