Alert and Oriented

Should doctors protect their turf?

Michel AccadApril 26, 2018April 26, 2018Articles, Healthcare economics, Healthcare policyLeave a comment

It’s been a little over a 100 years since medical licensing laws were introduced in the US. If people doubt that slippery slopes are real, they should reflect on that history.

In our latest video, Anish Koka and I discuss a “white paper” jointly written by Jeffrey Flier, former dean at Harvard Medical School, and Jared Rhoads from the Dartmouth Institute, calling for some deregulation of the apparatus that rules the supply of physicians and their scope of work. The paper gives an exhaustive account of the bureaucratic mess and offers some possible remedies.

Anish and I a fun conversation, although we barely scratched the surface of this important topic. Anish is concerned that opening the flood gates willy-nilly without addressing other aspects of the healthcare boondoggle will mainly decrease the quality of care and do little to reduce costs. I feel that Flier and Rhoads are way too timid in their proposals and could at least call for competition among regulatory and accrediting bodies.

We touch on the question of safety, patient sovereignty, alternatives to licensing, and whether protectionism is ever a legitimate option. I’m sure we’ll have occasion to revisit this question. By the way, the can subscribe to the YouTube channel…

Let’s take the BM out of EBM

Michel AccadApril 23, 2018April 23, 2018Articles, Medical scienceLeave a comment

I had a fun chat with Professor Darrel Francis on Evidence-Based Medicine. Here are some of the highlights:

1:18 – I throw down the gauntlet on EBM.

4:01 – Dr. Francis proposes the analogy of the chocolate-made washing machine spinner.

6:15 – My come back: overuse is not due to a lack of RCTs but improper incentives. Dr. Francis on the reception of ORBITA in the UK versus the US: “They don’t get angry!” EBM as tool for rationing.

11:20 – Dr. Francis: “How is it possible for there to be a single number that God has implanted in the coronary artery and revealed it to Nico Pijls…that tells us the risk/benefit ratio of stenting that patient?”

18:00 EBM and the placebo effect.

24:-30:00 – “Shared-decision making” is a sham.

31:00 – On the harm to clinical judgment: “I don’t mind the E, but I don’t want the BM in my practice!”

33:00 – Dr. Francis on “Bogle’s Demon” and “A vulnerable plaque is a plaque that has a stent in it.”

Confessions of a pharma-fed doctor

Michel AccadApril 18, 2018April 18, 2018Articles, Ethics, Healthcare economicsLeave a comment

In our latest video, Dr. Koka and I discuss a recent paper in JAMA that starts with the following opening paragraph.

Physicians and teaching hospitals in the United States receive approximately $7 billion from the pharmaceutical industry annually. These payments have been associated with higher-cost, brand-name pharmaceutical prescribing. Whether industry payments are associated with physician treatment choice in oncology is uncertain. We examined the association between oncologists’ receipt of payments from pharmaceutical manufacturers and drug selection in 2 situations where there are multiple treatment options.

Payments to doctors by the pharmaceutical industry are problematic, even if they amount to literally peanuts. But let’s not get distracted by the much greater and more pervasive conflicts of interest that affect implicate everyone in the health care system.

At the end of the clip, I offer my version of the kind of opening paragraph I would love to read in the medical literature (but never do):

Physicians in the United States receive approximately $700 billion from the government and insurance industry annually. These payments have been associated with higher-costs, over-utilization, over-treatment, and decreased quality. Whether government and insurance industry payments are associated with physician treatment choice is uncertain. We examined the association between physicians’ receipt of payments from the government and insurance industry with duration of office visits, quality of care as perceived by the patient, and with utilization of health care resources. The control group was composed of patients who do not accept government and insurance payment for services.

Here’s the clip.

RCTs are ineffective in the treatment of refractory uncertainty

Michel AccadApril 15, 2018April 15, 2018Articles, Medical scienceLeave a comment

In our latest vlog, Anish and I discuss a thoughtful and well documented post by John Mandrola in which John rebukes the practice of using thrombolytic agents in acute stroke (“The Case Against Thrombolytic Therapy in Stroke.“). John’s post was itself prompted by a piece in the New York Times that is favorable to the use of the “clot-busting” treatment.

After posting our video, I was made aware of another post by an ER doc who, like John, is underwhelmed by the evidence in favor of thrombolytic therapy and, reflecting on the fact that numerous trials have tried to provide answers about the value of the treatment, asks “Why after 23 years do we still not know the answer?”

Of course, as readers of this blog know, my position is that RCTs are incapable of providing the answers that doctors seek (see, e.g., “The Devolution of Evidence-Based Medicine“).

Having expressed that opinion repeatedly here and on social media, I have been challenged by Professor Darrell Francis, professor of medicine at the UK’s National Heart and Lung Institute, and faculty at the Imperial College in London, to a debate (or, at least, a spirited discussion) that we will record and post on the channel.

This will happen in next week and should be really fun. Francis is a firebrand in the EBM movement, and has been principal investigator of several “game-changing” clinical trials.

Stay tuned, but meanwhile below is my discussion with Anish.

The real replication crisis

Michel AccadApril 9, 2018Articles, Medical scienceLeave a comment

I am pleased to announce that Anish Koka and I will start a regular program on YouTube (and possibly later as a podcast) in which we cover topics of mutual interest in medicine and healthcare policy, including the latest scientific or policy brouhahas.

In our first episode, we discussed a recent editorial by John Ioannidis in which he considers the pros-and-cons of lowering the P-value threshold for statistical significance from the currently commonly accepted 0.05 to a lower threshold of 0.005. Bizarrely, Ioannidis thinks this could be a good idea (at least, that’s my interpretation of the paper. Anish gives him the benefit of the doubt).

Ioannidis, of course, made a big splash in 2005 with a paper entitled “Why most published research findings are false,” subsequent to which he rose to prominence beyond academia. (He was featured in a front-cover article in The Atlantic and in The Economist, and now leads the impressive-sounding Meta-Research Innovation Center at Stanford (METRICS). Here is his Wikipedia entry.) The meaning of false in that paper was not reproducible, so the paper marked a milestone in what is now commonly known as the “replication crisis.”

In the course of my conversation with Anish, I mentioned that the real crisis may very well be that the idea of “replication” as a standard of truth is not as sound as it may seem. In particular, I mentioned a recent editorial by Ioannidis and colleagues Goodman and Fanelli in which the authors acknowledge that replication can refer to different things, including replication of methods, replication of results, and—get this—replication of interpretation!

They give replication of interpretation the more technical sounding name of inferential reproducibility, which they define as “drawing out qualitatively similar conclusions from either an independent replication of a study or a reanalysis of the original study.” To Ioannidis et al., the lack of inferential reproducibility may be the “most important” and “under-recognized” dimension of the reproducibility crisis.

I’ll let you draw your own conclusions as to the significance of that definition, but if you want to hear our take on it, here it is:

How to stem the incipient epidemic of hypertension

Michel AccadNovember 16, 2017March 20, 2018Articles, Medical practice, Medical science2 Comments

On November 13, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans. The epicenter of the outbreak was traced back to the halls of the Anaheim, CA, convention center where the annual meeting of the American Heart Association was taking place.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.” The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press. Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic. Everyone is advised not to click on any document or any link connected to this virus. Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.Continue reading “How to stem the incipient epidemic of hypertension”

You eat as you are

Michel AccadOctober 21, 2017October 21, 2017Articles, Medical practiceLeave a comment

Here’s the typical story we come across every day:

Jack was overweight and had a terrible cardio-metabolic profile. Jack changed his diet: he eliminated X, Y, Z and added more A, B, and C. He’s now lost 30 pounds and he feels fantastic. His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range.

Todd was overweight and had a terrible metabolic profile. Todd changed his diet but he did not eliminate X, Y, or Z. In fact, he did the opposite. He increased his intake of X, Y, and Z but eliminated A, B, and C. He’s now lost 30 pounds and he feels fantastic. His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range. Continue reading “You eat as you are”

I refuse to tell you what to eat

Michel AccadSeptember 30, 2017September 10, 2021Articles, Medical practice5 Comments

A recent tweet from JAMA, the journal of the American Medical Association, urged me and other doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk. I will not do it. I simply will not. I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!” I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted? After all, the recommendations themselves seem sensible enough: Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables. What’s not to like?

Unhealthy guidelines

I don’t know. Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid. But what have they got to show for? The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.Continue reading “I refuse to tell you what to eat”

Charlie Gard, disproportionate care, and assisted suicide

Michel AccadJuly 22, 2017September 23, 2017EthicsLeave a comment

Kevin Malik writes in the New York Times in support of Charlie Gard’s parents, presenting a secular, utilitarian argument for the continuation of the child’s treatment.

In the article, Malik draws attention to a contradiction between the State’s position regarding Gard and its position regarding the wishes of a patient with a terminal neurological condition who wishes for assisted suicide.

The practice of withdrawal of care is often invoked in the debate over assisted suicide. Proponents of assisted suicide frequently make an “equal protection” argument: since we allow the death of patients by withdrawing intensive care, shouldn’t we also allow patients to commit assisted suicide?

A few years ago, Neil Garsuch wrote an excellent book examining the legal and moral arguments that bear on the question of assisted suicide. He discussed at length and with meticulous detail the question of withdrawal of care as it might relate to assisted suicide.

Opponents of assisted suicide sometimes argue that withdrawing care is not the same as assisting someone’s suicide because the former is an omission, while the latter is an “action.” Gorsuch explains that that argument is unsatisfactory.Continue reading “Charlie Gard, disproportionate care, and assisted suicide”

Health insurance is not insurance

Michel AccadJune 15, 2017June 17, 2017Articles, Healthcare economics, Healthcare policy16 Comments

Is health insurance a plan to help healthy people mitigate against an unexpected illness, or an income subsidy to help the sick pay for medical care?

Conservatives ought to have a clear answer to that question. Congressman Morris Brooks from Alabama did not and found himself on the receiving end of liberal ridicule.

By suggesting that those who take better care of themselves should pay lower health insurance premiums, Brooks implied that health insurance is indeed a type of insurance arrangement. After all, the risk adjustment of premiums is a practice proper to all other kinds of insurance services: A prudent driver pays less for auto insurance than one with a pre-existing driving record. A home owner pays more for home insurance if the property is on muddy terrain rather than on sturdy ground. A smoker pays more for life insurance than a non-smoker, as does anyone whose risk of dying prematurely is high, even if that predisposition is inherited genetically.

Brooks’ conception of health insurance, however, intuitive as it may be, is wrong.Continue reading “Health insurance is not insurance”