Medical science Archives - Page 5 of 8

How to safeguard your career in a treacherous healthcare environment.

Michel AccadNovember 13, 2015September 10, 2021Ethics, Healthcare economics, Medical practice, Medical science, Philosophy7 Comments

[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.Continue reading “How to safeguard your career in a treacherous healthcare environment.”

Phronesis

Michel AccadAugust 13, 2015December 13, 2016Ethics, Medical practice, Medical science, Philosophymedical decision-making3 Comments

I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.

In “The Paternalism Preference — Choosing Unshared Decision Making,” Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.

The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician. She remarks:

But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?

The answer to that question has to do with our understanding of what constitutes good medical decision-making. Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”Continue reading “Phronesis”

Evidence-based mania: an intoxication of the intellect

Michel AccadAugust 10, 2015December 13, 2016Medical science, Philosophyempiricism6 Comments

For many years, thoughtful commentators have highlighted the shortcomings of evidence-based medicine (EBM). Among them was Alvan Feinstein, one of the great pioneers and theoreticians of clinical research, and arguably one of the founders of the EBM movement.¹ But despite the increasing discontent with this mode of thinking, EBM remains an extremely prevalent intellectual vice that has captured the mindset of the medical community.

In the last few days, I came across some particularly striking examples of how EBM dominates the medical psyche.Continue reading “Evidence-based mania: an intoxication of the intellect”

From DPC to CPC – part 1

Michel AccadJuly 30, 2015December 13, 2016Medical practice, Medical sciencecase reportLeave a comment

A couple of years ago, as I was trying to determine the best business model for my practice, I offered direct primary care (DPC) services to a few patients. Among them was WW, a then 57-year-old man who was well when I first saw him, but who ended up dying a year later in a very sad and dramatic way from a rare condition.

The extraordinary illness that struck W is worth describing simply on account of its rarity and its highly unusual manifestations. But in addition, it occurred to me that my experience with W may be of particular interest to the growing number of physicians and health care professionals intrigued by, or involved in, DPC as a practice model. This case exemplified the challenges and rewards of taking care of people with no insurance and with limited financial means.

I hope you will find this “clinico-pathological conference” to be of value. Although W’s ultimate outcome would likely have been the same under any circumstance, I’m sure his clinical course may have been tackled differently by another doctor. Continue reading “From DPC to CPC – part 1”

How experts really decide

Michel AccadJuly 20, 2015December 13, 2016Medical practice, Medical science, Philosophymedical decision-making3 Comments

I opened my last post with a question I never came around to really answer: How should doctors make decisions?

That wasn’t an oversight. To try to provide an answer seemed daunting, plus I wouldn’t have resisted the urge to wax philosophical about praxeology or phronesis. And how sexy is that? Surely my Alexa ranking would have suffered!

Perhaps sensing my predicament, Dr. Saurabh Jha tactfully suggested a book which I have since ordered and read. (And what a great call that was. Thank you, @RogueRad!) The book is Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making by Gary Klein.

According to his Wikipedia entry, Klein is a cognitive psychologist credited with pioneering the field of naturalistic decision-making, a research endeavor where people’s decisions are examined in real life setting, not under contrived laboratory experiments.

The book, published in 2011 by The MIT Press, summarizes the fruits of his research. It’s a captivating work.Continue reading “How experts really decide”

Make decisions, not calculations

Michel AccadJuly 16, 2015December 13, 2016Medical practice, Medical sciencemedical decision-makingLeave a comment

How should doctors make decisions?

In the last post, we reviewed the conceptual difficulty of applying risk estimates derived from population studies to individuals, and I proposed that medical decisions should NOT be modeled on the following scheme:

Step 1: weigh the probability of future pluses and minuses.
Step 2: make a decision on the basis of “probability of pluses > probability of minuses.”

Yet that scheme implicitly serves as a rationale for pay-for-performance measures and justifies legal impositions on the content of informed consent procedures (e.g., precise disclosure of risks, probability of benefit, risks of alternative treatments, etc.).

Today, I will add a some perspectives that I think buttress my case.

Disclaimer: This discussion is not meant to entice you to violate the standard of care, to forego the established procedures for informed consent, to incite you into civil disobedience, or to put your medical license at risk!

Let’s start with two anecdotes:

A few years ago, the New York Times detailed the extraordinary story of Michael DeBakey’s aortic repair operation.Continue reading “Make decisions, not calculations”

Risky decisions

Michel AccadJuly 13, 2015December 13, 2016Medical practice, Medical sciencemedical decision-making6 Comments

I had a sort of epiphany about risk and medical decision-making last Thursday evening, even though I was particularly tired and in a state of mental fog.

I had been thinking about two recent articles dealing with risk prediction, but I also was preoccupied with risky career decisions I have made, and how these are affecting me and my family (I am pursuing a quixotic version of the “triple threat:” independent physician, apprentice schoolman, blogger). So risk was very much on my mind.

One of the articles I had read was a recent viewpoint in JAMA by Allan Sniderman, Ralph d’Agostino, and Michael Pencina titled “The role of the physician in the era of predictive analytics.” The other was a response to that article written by Bill Gardner at the Incidental Economist blog.

In their paper, Sniderman et al. discuss an important difficulty in the medical science of risk prediction. The difficulty is apparent when one contrasts the notion of population risk with the notion of individual risk.Continue reading “Risky decisions”

Overdiagnosis: The disease that cannot be diagnosed

Michel AccadJuly 9, 2015October 17, 2021Articles, Healthcare policy, Medical scienceoverdiagnosisLeave a comment

Some say mammograms don’t save lives, and we order too many of them. That may be true, but which ones should we eliminate? The answer is not so easy after all.

Today’s post will deal with overdiagnosis, a concept preoccupying health care analysts, academics, and policy makers, and one whose importance is confirmed by the distinction of having its own dedicated Twitter hashtag.

And if you follow the #overdiagnosis hashtag these days, you will surely encounter the following chart, excerpted from a recent JAMA Internal Medicine paper:Continue reading “Overdiagnosis: The disease that cannot be diagnosed”

A documentary about doctors and widowmakers

Michel AccadJuly 6, 2015September 10, 2021Healthcare policy, Medical practice, Medical science4 Comments

[Note: A slightly modified version of this article was just published in the Feb/Mar 2016 issue of San Francisco Medicine, the magazine of the San Francisco Medical Society (MA 03/23/2016).]

An award-winning documentary entitled The Widowmaker was just released on Netflix. It shouldn’t leave viewers indifferent, and doctors in particular are likely to be thoroughly captivated.

Cardiologists can identify the title as the nickname commonly given to a threatening plaque near the origin of the left anterior descending artery, the major of the coronary arteries of the heart. A clot forming at that site is frequently fatal. Since middle-aged men are more prone to heart attacks than middle-aged women, such a clot often leaves behind a widow and fatherless children, hence the name for the plaque.

Cardiologists who watch this movie will also recognize some familiar figures: Drs. Steve Nissen, Matthew Budoff, Bruce Brundage, Martin Leon, Arthur Agaston, Shamin Sharma, Joseph Loscalzo, Julio Palmaz, Douglas Boyd, Harvey Hecht, and many other high profile clinicians, innovators, and academics are featured in a suspenseful tale of heroes and villains.Continue reading “A documentary about doctors and widowmakers”

Skills, Knowledge, and Prediction

Michel AccadJune 29, 2015September 10, 2021Medical sciencemedical decision-makingLeave a comment

[The following letter to the editor was published in the American Journal of Cardiology in response to an excellent article by George Diamond and Sanjay Kaul who highlighted the limitations of quantitative methods for achieving relevant “risk-stratification” at the individual level. Comments made by these authors prompted me to reflect on the tension between the appeal of quantitative methods and the value of unquantifiable clinical skills. I hope you will find these remarks stimulating.]

In the March 15, 2012, issue of The American Journal of Cardiology, Diamond and Kaul¹ provided an insightful analysis of the complex relation between risk stratification schemes and therapeutic decision making. The investigators clearly identified some of the reasons why predicting response to treatment at the individual level is difficult. However, they conclude their report with a caution against “wholesale abandonment of evidence-based guidelines in favor of idiosyncratic clinical judgment,” which, in their opinion, runs the risk of “intellectual gerrymandering” and “wasteful utilization of high-cost technology.”

Proponents of quantitative methods of clinical assessment frequently portray critics as Luddites ready to “jettison” objective evaluation in favor of personal opinion rooted solely in clinical experience.² This is an unfair characterization.Continue reading “Skills, Knowledge, and Prediction”