An introduction to praxeology and Austrian school economics

A primer for physicians and healthcare professionals

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A couple of weeks ago, I presented a paper about health and medical care at the 2016 Austrian Economics Research Conference, which was held at the Mises Institute.  I will be sharing the content of the talk in the next few posts, but given that I use some terms and concepts borrowed from that school of thought (e.g., “praxeology”), I thought that I would first take the opportunity to give a brief introduction to Austrian economics for those unfamiliar with it.

Brief history

Austrian school economics refers to a school of economic thought whose adherents generally share similar views on methodology.  The originators of that school were mid-to-late nineteenth century Austrian scholars whose economic ideas were in opposition to the ones dominant in Germany at that time.   The term “Austrian school,” given in disparagement by members of the German Historical School, stuck.  The German school has disappeared, but the Austrian school remains vibrant today.

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Podcast interview: Mendelspod

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A couple of weeks ago, Theral Timpson kindly interviewed me for his Mendelspod science podcast (an excellent show, especially for those interested in cutting edge biotech matters).  We talked about philosophy of science and medicine.  I really enjoyed the conversation, and I hope you will too.  The link is here.

The machine metaphor in medicine

Further cogitations on health

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In the first part of a paper I will present at the Austrian Economics Research Conference next week, I talk about the healthcare system’s elephant in the room: how an activity that occupies 18 percent of GDP is doing so without any precise definition of health.

The lack of definition does not mean that there aren’t any prevailing notions about health.  In fact, there is one particular concept that is clearly dominant, however implicit or covert it may be: it’s the notion of health that emerges if one adopts the “machine metaphor” for the body, a metaphor that is as pervasive as could be, given that it seems to have no viable counterpart (see, for example, here).

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That most nagging question in health care

A challenge to medical school deans

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As I mentioned a couple of days ago, Jeffrey Flier, Dean of Harvard Medical School, wrote an Op Ed in the WSJ in which he makes some cogent proposals to medical journal editors about how to minimize the irreproducibility of clinical science.  He even proposed to hold a symposium to discuss the topic.

Now, that is all well and good, as far as the problems of science are concerned, but I wish that deans of medical schools thought about another problem that’s closer to home, and more directly relevant to the medical profession. Isn’t it time the medical community confronted the fact that we don’t have a cogent definition of health?

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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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Why I don’t “believe in science”

A response to John Mandrola, with reactions to the SPRINT trial as a case in point

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A few days ago, cardiologist and master blogger John Mandrola wrote a piece that caught my attention. More precisely, it was the title of his blog post that grabbed me: “To Believe in Science Is To Believe in Data Sharing.”

Mandrola wrote about a proposal drafted by the International Committee of Medical Journal Editors (ICMJE) that would require authors of clinical research manuscripts to share patient-level data as a condition for publication. The data would be made available to other researchers who could then perform their own analyses, publish their own papers, etc.

The ICMJE proposal is obviously controversial, raising thorny questions about whether “data” are the kinds of things that can be subject to ownership and, if so, whether there are sufficient ethical or utilitarian grounds to demand that data be “forked over,” so to speak, for others to review and analyze.

Now all of that is of great interest, but I’d like to focus attention on the idea that conditions Mandrola’s endorsement of data sharing. And the question I have is this: Should we believe in science?

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Taking stock of our existence

Gawande versus Frankl on the meaningful life

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My last post was prompted by a reader’s comment where Victor Frankl’s Man’s Search for Meaning and Atul Gawande’s Being Mortal were juxtaposed.  Since receiving that message, I have had occasion to notice that others also associate these two books.

For example, both are mentioned positively in this moving article by Dr. Clare Luz about a friend’s suicide, and in these tweets from Dr. Paddy Barrett’s podcast program:

Friends and patients of mine have likewise mentioned these two works to me, expressing praise and testifying to the deep impact the books have had on them.

I suspect that many readers of this blog will at least be familiar with these two books.  If not, summaries are here (Frankl) and here (Gawande).

I read the books in succession and found the difference between the two striking.  Frankl and Gawande seem to be at polar opposites on the question of life and death.  In this post, I will explore this difference, starting with Gawande’s point of departure.

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Good medicine starts with friendship

Advice from the ancients

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Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?!

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

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How to safeguard your career in a treacherous healthcare environment.

Economics, ethics, and philosophy for medical students

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the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

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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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