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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How doctors became subcontractors

In our healthcare system, the "middleman" is not who you think

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During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients.  In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980s, the process by which healthcare business was conducted did not seem to change in any visible way.

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Neither expert nor businessman: the physician as friend.

Arguments against the outcomes movement

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In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes!

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Prohibition: Then and now

Arguments against banning or taxing our way to health

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The following editorial was first published in September 2014 on the blog of the San Francisco Medical Society. At the time, a ‘soda tax’ was on the ballot for voters to consider. The measure was defeated but the debate continues, as seen in these recent BMJ editorials. Note: the version below is slightly modified from the original.

Nearly one hundred years ago, the eighteenth amendment to the United States Constitution made it illegal to produce, transport, or sell alcoholic drinks. The prohibition was the culminating action of a “temperance movement,” a century-long grassroots effort aimed at curbing the consumption of alcohol. The movement arose in response to an epidemic of alcoholism and was guided by the compelling argument that alcohol is toxic and that alcoholism brings along serious social evils: chronic unemployment and family neglect or abuse.

Today, a similar movement is taking shape in response to the obesity epidemic. Excessive consumption of sucrose and fructose in ubiquitous “sugary” drinks has been identified as a main cause and found to be responsible for the high prevalence of diabetes and its associated health and socioeconomic complications: cardiovascular and renal disease, blindness, premature death, and exploding health care costs. The new temperance movement decries the excessive use of sweet beverages and calls for restricting their sale. These restrictions can come in the form of taxes or outright bans.

But is resorting to taxation and to the strong arm of government always a wise move? I propose some arguments to ponder:

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