Alert and Oriented

Good health care news from America

Michel AccadJune 2, 2017September 10, 2021Articles, Healthcare economics, Healthcare policy, Medical practice1 Comment

[I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud. The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.]

Health care in the United States: The surprising good news

On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining. If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”

For a small but growing number of doctors and patients, however, the future is surprisingly hopeful. Continue reading “Good health care news from America”

Does Bergen, Norway, hold the key to the mystery of hypertension?

Michel AccadMay 15, 2017May 18, 2017Articles, Medical science5 Comments

At the beginning of my new book, Socrates engages Geoffrey Rose to discuss one of the most fascinating conceptual questions regarding hypertension.

The question is the following: Compared to normal subjects, do hypertensive patients constitute a distinct population of patients? In other words, if we go out and measure the resting blood pressure of a large swath of the population and plot the numbers as a distribution curve, do we get two separate bell-shaped curves or just one?

The answer to that question was the subject of an intense debate that began in the mid 1950s and lasted a couple of decades until it died down in the 1970s without any settled conclusion. Yet, an answer to that question is of critical importance not just for our understanding of hypertension, but for medical science in general and, by implication, for the direction of our healthcare system.Continue reading “Does Bergen, Norway, hold the key to the mystery of hypertension?”

Compassionate care in 2017

Michel AccadMay 3, 2017May 3, 2017Ethics, Progress notes5 Comments

A 90-year-old mother is in the hospital for a stroke. Her son gave me the following details:

Two months ago, mom was admitted to the hospital for dehydration. At baseline she had mild dementia and chronic atrial fibrillation.

She recovered well. Before discharge, the primary care physician convinced the family to change her status to “hospice,” arguing that she would get better, more appropriate, and more comfortable care. Her blood thinner Eliquis was discontinued for being “too risky.”Continue reading “Compassionate care in 2017”

A health insurance CEO daydreams

Michel AccadApril 4, 2017May 3, 2017Articles, Healthcare economics, Healthcare policy3 Comments

Jim was at his desk, looking weary.

The last few weeks had been brutal. Despite working twelve-hour days, he felt that he had little to show for. His annual board meeting was to take place the next day, and he expected it to be tense.

With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious. The board members had asked him to present a contingency plan, in case things in DC didn’t go well.Continue reading “A health insurance CEO daydreams”

Should we blame technology for increased healthcare spending?

Michel AccadJanuary 31, 2017February 6, 2017Articles, Healthcare economics9 Comments

Should we blame technology for the growth in healthcare spending? Austin Frakt, a healthcare economist who writes for the New York Times, thinks so. Citing several studies conducted over the last several years, he claims that technology could account for up to two-thirds of per capita healthcare spending growth.

In this piece, Frakt contrasts the contribution of technology to that of the ageing of the population. Frakt notes that age per se is a poor marker of costs associated with healthcare utilization. What’s important is the amount of money spent near death. If you’re 80 years old and healthy, your usage of healthcare services won’t be much more than that of a 40-year-old person.

So far, so good. But should we accept the proposition that technology is the culprit for healthcare spending growth?Continue reading “Should we blame technology for increased healthcare spending?”

The body language of assisted suicide

Michel AccadJanuary 2, 2017January 6, 2017Articles, Ethics, Philosophyphysician-assisted suicide3 Comments

Laws that allow assisted suicide restrict the provision of “aid-in-dying” drugs to patients whose mental status is not impaired and who are capable of sound judgment.

Medscape recently featured a video interview of Timothy Quill, the palliative care specialist and long-term assisted suicide activist. He is interviewed by the ethicist Arthur Caplan, and the two discuss the psychological evaluation of terminally ill patients who request physician-assisted suicide (PAS).

Several points made by Quill caught my attention.Continue reading “The body language of assisted suicide”

Evidence that women are better cooks than men

Michel AccadDecember 22, 2016Articles, Medical science3 Comments

I must admit that my initial reaction to the now famous study by Ashish Jha and colleagues—showing that female internists achieve slightly better 30-day inpatient mortality rates than male internists—was one of annoyance. “Here we go again,” I thought. “Data mining at the service of political correctness.” And I was pleased to read David Shaywitz reply to the study with a piece in Forbes aptly titled “When Science Confirms Your Cherished Beliefs—Worry.”

That said, I must give credit to the study authors for generating a lot of interesting discussion and for stimulating Saurabh Jha to write his magnificent commentary “Homme Fatale.”Continue reading “Evidence that women are better cooks than men”

Should assisted suicide be legal in a free society?

Michel AccadOctober 13, 2016December 13, 2016Ethicsphysician-assisted suicide2 Comments

Abigail Hall Blanco, a research fellow at the Independent Institute, recently wrote a piece entitled “Assisted suicide is a personal choice” in which she defends the position that assisted suicide should be legal in a free society.

Before discussing this piece, it is important to clarify what Blanco probably means when she asserts that assisted suicide is a “personal choice.” After all, the statement may seem like a triviality: all humans are persons, and therefore all human choices are personal choices.

I suspect that what Blanco means to say is that assisted suicide should be legal because it is a free choice that only affects the person making it. In that sense, the subject and object of the choice are both the same person: The choice begins with the person and the effect ends in the same person.

Having made that clarification, let’s examine the three arguments Blanco makes to support her position. These arguments are counterpoints to claims allegedly made by opponents of assisted suicide.Continue reading “Should assisted suicide be legal in a free society?”

How I learned to stop worrying and love practicing without EBM

Michel AccadSeptember 30, 2016July 31, 2020Medical scienceevidence-based medicine1 Comment

If you’ve enjoyed my previous take-downs of evidence-based medicine but can’t let go of your attachment to the randomized controlled trial, this post is for you.

My aim is to show you practical ways you can safely and effectively exercise clinical judgment without recourse to “evidence-based” knowledge, provided you follow simple but fundamental principles of clinical care: circumspection, parsimony, and due respect to patient autonomy.

What’s more, I will make my case against RCTs using examples that EBM apologists have precisely identified as paradigmatic of this “single greatest medical advance.”Continue reading “How I learned to stop worrying and love practicing without EBM”

On the deactivation of implantable devices

Michel AccadSeptember 26, 2016December 13, 2016Ethicsphysician-assisted suicideLeave a comment

There is an interesting thread on Twitter generated by a BBC article relating the case of a British patient who was granted the right to have her pacemaker deactivated. Dr. Wes Fisher was interviewed in the article.

The question posed is whether this constitutes assisted suicide or not. Dr. John Mandrola pointed to the position document of the Heart Rhythm Society regarding such cases and seems firm that pacemaker deactivation is not euthanasia.Continue reading “On the deactivation of implantable devices”