Alert and Oriented

Against surgical excellence

Michel AccadMay 19, 2016December 13, 2016Healthcare policy, Medical sciencemedical decision-making2 Comments

A Vox.com piece about decision-making caught my attention this morning.

The story was compelling. A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain. A first neurosurgeon would not operate and recommended radiation therapy instead. The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken. The second surgeon surgeon was undeniably right. The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good? Not so, according to Vox. That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why? Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off. Variability in judgment, as always, is the enemy.Continue reading “Against surgical excellence”

A free market repudiation of evidence-based medicine

Michel AccadMay 13, 2016December 13, 2016Healthcare economics, Healthcare policy, Medical scienceevidence-based medicine6 Comments

In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.” I am grateful for his interest in my work and for the the kind compliment that he extended in his article. Having also become familiar with his fine writing, I return it with all sincerity. I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices: “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.” Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.Continue reading “A free market repudiation of evidence-based medicine”

Book review: How Doctors Think

Michel AccadMay 4, 2016December 13, 2016Medical practice, Medical science, Philosophymedical decision-makingLeave a comment

Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis. Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine. Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.Continue reading “Book review: How Doctors Think”

The war on the NEJM

Michel AccadApril 30, 2016December 13, 2016Healthcare policy, Medical scienceconflict of interest1 Comment

The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe. The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.” Their ideological alliance is with the BMJ.

A users guide to key differences between @bmj_latest and @NEJM pic.twitter.com/vXZElda4wD

— Vinay Prasad (@VinayPrasad82) April 21, 2016

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”

Bottom line: lots of trialists don’t want to share their data. Not really a surprise. But a shame IMHO. https://t.co/9PcScwpLur #openscience

— Harlan Krumholz (@hmkyale) April 29, 2016

The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein. Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!Continue reading “The war on the NEJM”

Flexner versus Osler

Michel AccadApril 26, 2016December 13, 2016Healthcare policy, Medical science, Philosophymedical education5 Comments

In the introduction to a talk I gave at the Mises Institute this year, I noted how, in the early part of the twentieth century, a convergence of interests between social progressivists and ideological empiricists led to the publication of the Flexner report and the subsequent enactment of licensing laws.

That historical context is further treated in an outstanding article by Alfred Tauber, who was professor of medicine and philosophy at Boston University School of Medicine.

In “The two faces of medical education: Flexner and Osler revisited,” Tauber contrasts the radically different views these two men held about the ethos of medicine and the proper approach to medical education. It is ironic that the victorious position would be the one pushed by Flexner who, as Murray Rothbard put it, was “an unemployed former owner of a prep school in Kentucky…sporting neither a medical degree nor any other advanced degree.”Continue reading “Flexner versus Osler”

From reacting machine to acting person – part 2

Michel AccadApril 22, 2016September 10, 2021Medical science, Philosophy2 Comments

[This is part 2 of my paper presentation at AERC 2016 at the Mises Institute. Find part 1 here and the audio here.]

I would therefore like to entertain an interpretation of health rooted in the view that human beings are persons acting purposely, persons who select means to achieve chosen ends, which is the framework of praxeology.

Under a praxeological framework, I would distinguish external means such as land, labor, and capital, which are generally the concern of economic theory, from internal means, such as the physical and mental conditions of the person that allow him or her to pursue chosen ends.

Health, then, may be defined as the state that is present when a person’s physical and mental conditions allow the pursuit of his or her chosen ends. Disease, then, is the absence of health.Continue reading “From reacting machine to acting person – part 2”

From reacting machine to acting person – part 1

Michel AccadApril 22, 2016September 10, 2021Medical science, Philosophy2 Comments

[This is the transcript of a paper I presented at the Austrian Economics Research Conference at the Mises Institute. I have included the slides below and you can hear the audio here. The title of the paper is “From reacting machine to acting person: a praxeological interpretation of the patient, his health, and his medical care.” For more info on praxeology, see my previous article here. I have split the presentation into two parts. This is a very condensed talk, covering a lot of ground, but I will elaborate on various points I make in the paper in the ‘progress notes’ section of this website over the next few days and weeks. Thank you for reading and for any feedback you might have.]

The elephant in the room in healthcare is that there is no precise definition of health. I believe that this ambiguity plays a major role in our perennial healthcare crises, and I am hopeful that Austrian insights can be helpful.

Here is the outline of my talk.

I will first identify the two dominant modes of thinking about health in modern Western societies. I will show that those conceptual modes are counterproductive to fostering health, both economically and medically. I will then propose a praxeological interpretation of health, and sketch the possible benefits and ramifications of that interpretation.

The dominant mode of thinking about health in Western societies owes its origins to René Descartes who, at the beginning of the scientific revolution, proposed the machine concept of the organism. Descartes’ proposal was a radical departure from pre-existing notions which were rooted in the idea that organisms have essences and natures. Instead, he proposed that every material body is an assemblage of tiny particles moving mechanically according to physical laws. In the case of plants and animals, God directs the laws and the motions. In the case of humans, the mechanical bodies are under the control of a separate human soul acting like a “ghost in the machine.”Continue reading “From reacting machine to acting person – part 1”

An introduction to praxeology and Austrian school economics

Michel AccadApril 13, 2016December 13, 2016Healthcare economics, Medical science, Philosophy4 Comments

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.Continue reading “An introduction to praxeology and Austrian school economics”

A guide to top medical journals

Michel AccadApril 6, 2016December 13, 2016Medical science7 Comments

Charles Ornstein is an award-winning healthcare journalist who recently wrote an article in the Boston Globe about an ongoing controversy regarding a top medical publication. Yet Ornstein still wonders about the current status of medical journals:

Which medical journal do you believe is best adapting to the realities of medical research today? @jflier @VinayPrasad82

— Charles Ornstein (@charlesornstein) April 5, 2016

To help answer Mr. Ornstein’s query, I have asked the editors of top medical journals to submit responses to a simple questionnaire. Here are their answers.Continue reading “A guide to top medical journals”

The machine metaphor in medicine

Michel AccadMarch 25, 2016August 31, 2020Medical science, Philosophydisease definition, health definitionLeave a comment

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).Continue reading “The machine metaphor in medicine”