Alert and Oriented

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”

Reasons to MOC®: Board certification revisited

Michel AccadJuly 2, 2015December 13, 2016Healthcare policy, Medical practicecertification, licensing7 Comments

Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.

These allegations, however, are not the only questions board organizations may need to confront. Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.Continue reading “Reasons to MOC®: Board certification revisited”

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”

Blood pressure and the conundrum of medical numerology

Michel AccadJune 25, 2015December 13, 2016Medical scienceLeave a comment

As part of a series on heart disease, Gina Kolata of the New York Times is calling attention to Blood Pressure, The Mystery Number.

And what a mystery it is! Reading Kolata’s piece, one gets a sense that hypertension researchers are chasing after the optimal blood pressure the way Pythagoreans of old sought numeric answers for the riddles of the universe.

Kolata relates:

What about a patient like Glenn Lorenzen, 67, whose systolic pressure was a frightening 220 in October? On a chilly day in December…he had received the good news that drugs and weight loss had lowered his reading to 124. Should he be happy? Should he aim to be below 120? Or should he ease up on the medications a bit and let his pressure drift toward 140 or even 150?

Unfortunately, with Lorenzen’s happiness hanging in the balance, doctors must make decisions “in a fog of uncertainty.”Continue reading “Blood pressure and the conundrum of medical numerology”

Will a single-payer system cure the administrative bloat?

Michel AccadJune 22, 2015September 10, 2021Healthcare economics4 Comments

[UPDATE: This article was cross-posted on the Ludwig von Mises Institute website. It also prompted a rebuttal at the Progressive Physician website, to which I made a brief reply in a more recent post contrasting the Canadian and American health care systems.]

In contrast to the expected shortage of tens of thousands of physicians, there appears to be an abundance of health care administrators, at least judging by the following graph:

The originators of the graph—economists and physician-activists at Physicians for a National Health Program (PNHP)—invoke the administrative bloat as reason to promote a single payer system. With a single payer, they argue, complexity will be greatly reduced, the administrative burden wiped out, and costs brought under control.

For those who contend that administrative positions consist chiefly of make-work jobs soaking up a glut of workers otherwise destined to swell the ranks of the unemployed, this outcome could indeed be welcome. Unfortunately, if PNHP gets its wish, we may all discover that gluts and shortages are enhanced, not avoided, by the central planning process that would necessarily accompany the establishment of this program.Continue reading “Will a single-payer system cure the administrative bloat?”

How Western medicine lost its soul

Michel AccadJune 18, 2015September 10, 2021Philosophy22 Comments

[This article is now published by Taylor & Francis in The Linacre Quarterly under the same title and available online. It remains posted here with the publisher’s permission]

A few decades ago, the idea of medicine presented no difficulty. A patient who fell ill would go to the doctor to get treated. He might get better or he might not, but there was no need for him to consider at the outset what type of medical care he should choose for his ailment.

Today, someone who needs attention for a health matter can seek conventional “Western” medicine or opt to receive a “holistic” treatment from the realm of so-called alternative medicine. For most people, there is a clear distinction between the two. Sure, some licensed physicians claim to provide holistic care, but this usually means that they might add an alternative form of therapy to standard treatment, or perhaps that they strive to be exceptionally considerate. The holistic character of the care rarely, if ever, comes from Western medicine per se.Continue reading “How Western medicine lost its soul”