The medical fortunetellers

Posted byMichel AccadPosted inMedical scienceTags:2 Comments on The medical fortunetellers
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[I’m preparing my paper for the AERC 2016 and have less time for original content, so I thought I would bring to your attention this editorial I wrote a few years ago. I hope you enjoy it. Figure 1 in this article is my most important contribution to empirical science to date!]

There was a time when the foretelling of future events was an undertaking of prophets, palm-readers, and weathermen. In recent years, however, the medical profession seems to have embraced this activity with a great deal of enthusiasm. A prime example is the use of the term “predicts” in the titles of journal articles dealing with human subjects. According to a search of the MEDLINE® database, “predicts” appeared a total of only 13 times before 1980.1 Since then, however, the occurrence of the term in citation titles has increased dramatically. Expressed as a percentage of the annual number of MEDLINE publications, the trend follows a curve that could be described as hyperbolic (Fig. 1).

Fig. 1. Percentage of MEDLINE® publications on human subjects with the term “predicts” in the title.
Fig. 1. Percentage of MEDLINE® publications on human subjects with the term “predicts” in the title.

[Read the rest here]

The devolution of evidence-based medicine

Posted byMichel AccadPosted inMedical scienceTags:, 11 Comments on The devolution of evidence-based medicine
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Anish Koka recently wrote a great piece entitled “In Defense of Small Data” that was published on The Health Care Blog.

While many doctors remain enamored with the promise of Big Data or hold their breath in anticipation of the next mega clinical trial, Koka skillfully puts the vagaries of medical progress in their right perspective.  More often than not, Koka notes, big changes come from astute observations by little guys with small data sets.

In times past, alert clinicians would make advances using their powers of observation, their five senses (as well as the common one) and, most importantly, their clinical judgment.  They would produce a case series describing their experience so others could try to replicate the findings and judge for themselves.

Today, this is no longer the case.  We live in the era of “evidence-based medicine,” or EBM, which began about fifty years ago.  Reflecting on the scientific standards that the medical field has progressively imposed on itself over the last few decades, I can make out that demands for better scientific methodology have ratcheted up four levels:Continue reading “The devolution of evidence-based medicine”

That most nagging question in health care

Posted byMichel AccadPosted inPhilosophy6 Comments on That most nagging question in health care
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As I mentioned a couple of days ago, Jeffrey Flier, Dean of Harvard Medical School, wrote an Op Ed in the WSJ in which he makes some cogent proposals to medical journal editors about how to minimize the irreproducibility of clinical science.  He even proposed to hold a symposium to discuss the topic.

Now, that is all well and good, as far as the problems of science are concerned, but I wish that deans of medical schools thought about another problem that’s closer to home, and more directly relevant to the medical profession. Isn’t it time the medical community confronted the fact that we don’t have a cogent definition of health?Continue reading “That most nagging question in health care”

Good news about quality measures?

Posted byMichel AccadPosted inHealthcare policy, Philosophy7 Comments on Good news about quality measures?
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A few days ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services.  Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers.Continue reading “Good news about quality measures?”

The Swiss healthcare system

Posted byMarc FouradoulasPosted inHealthcare economics, Healthcare policy10 Comments on The Swiss healthcare system
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[This week’s post is by Dr. Marc Fouradoulas who is a board-certified internist with a subspecialty in psychosomatic medicine. Marc’s ten years of clinical experience include psychiatry and primary care, and he currently works at the University Clinic in Bern, Switzerland.  For the past 3 years, Marc has been studying towards a Master’s degree of advanced studies in managed healthcare and health economics at the Winterthur Institute of Health Economics, School of Management and Law, in Zurich, Switzerland.  You can send him email.]

An alternative take on the Swiss health care system

In a recent New England Journal of Medicine editorial, Nikola Biller-Adorno, a German ethicist now based in Switzerland, and Thomas Zeltner, a physician and former Secretary Director of the Swiss National Health Authority, painted a rosy picture of the Swiss health care system, which they qualified as a potential role model for the US.

Given the author’s backgrounds and positions, their viewpoint may not be the most objective. Here, I wish to give readers a more realistic glimpse into this highly complex system from the perspective of a practicing physician.Continue reading “The Swiss healthcare system”

Why I don’t believe in science

Posted byMichel AccadPosted inMedical science, PhilosophyTags:, 10 Comments on Why I don’t believe in science
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A few days ago, cardiologist and master blogger John Mandrola wrote a piece that caught my attention. More precisely, it was the title of his blog post that grabbed me: “To Believe in Science Is To Believe in Data Sharing.”

Mandrola wrote about a proposal drafted by the International Committee of Medical Journal Editors (ICMJE) that would require authors of clinical research manuscripts to share patient-level data as a condition for publication. The data would be made available to other researchers who could then perform their own analyses, publish their own papers, etc.

The ICMJE proposal is obviously controversial, raising thorny questions about whether “data” are the kinds of things that can be subject to ownership and, if so, whether there are sufficient ethical or utilitarian grounds to demand that data be “forked over,” so to speak, for others to review and analyze.

Now all of that is of great interest, but I’d like to focus attention on the idea that conditions Mandrola’s endorsement of data sharing. And the question I have is this: Should we believe in science?Continue reading “Why I don’t believe in science”

Maintenance of board certification

Posted byMichel AccadPosted inHealthcare policy, Medical practiceTags:7 Comments on Maintenance of board certification
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[This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.]

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career.  Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.Continue reading “Maintenance of board certification”

Taking stock of our existence

Posted byMichel AccadPosted inEthics, PhilosophyTags:, , 6 Comments on Taking stock of our existence
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My last post was prompted by a reader’s comment where Victor Frankl’s Man’s Search for Meaning and Atul Gawande’s Being Mortal were juxtaposed.  Since receiving that message, I have had occasion to notice that others also associate these two books.

For example, both are mentioned positively in this moving article by Dr. Clare Luz about a friend’s suicide, and in these tweets from Dr. Paddy Barrett’s podcast program:

Friends and patients of mine have likewise mentioned these two works to me, expressing praise and testifying to the deep impact the books have had on them.

I suspect that many readers of this blog will at least be familiar with these two books.  If not, summaries are here (Frankl) and here (Gawande).

I read the books in succession and found the difference between the two striking.  Frankl and Gawande seem to be at polar opposites on the question of life and death.  In this post, I will explore this difference, starting with Gawande’s point of departure.Continue reading “Taking stock of our existence”

Medical friendship at the end of life

Posted byMichel AccadPosted inMedical practiceTags:1 Comment on Medical friendship at the end of life
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Pat, a non-physician reader, writes:

I read your two articles on friendship for more explicit clues on how to deliver very bad news, and wondered if you would consider publishing something on this topic as part 3 of this series. My prompt is a close friend with cancer, and she’s not getting better. At her last visit, the message she took home was: “there’s not much more we can do for you other than more chemotherapy, and we’re not even sure that it will do any good.”   This was a complete and sudden loss of hope.

Two thoughts come to mind.

The first is from Viktor Frankl. In Man’s Search for Meaning he says: “Those who know how close the connection between the state of mind of a man – his courage and hope, or lack of them – and the state of immunity of his body will understand that the sudden loss of hope and courage can have a deadly effect.”

The second is from Atul Gawande’s book, On Being Mortal. He describes two approaches to giving bad news. Dr. Informative supplies hard cognitive information: cold facts, descriptions, outcome possibilities, statistics. A doctor’s other approach might be to look for an opportunity to start the conversation with “I’m worried” and then continue with the patient in an “ask, tell, ask” process. In this approach, the direction of travel becomes clear more gently and perhaps gives the patient a little more time to walk into the possibility than being crashed into it.

…I would be especially interested to read your views from the doctor’s side in the context of your two blogs on the friendship dimension in the doctor-patient relationship.

Continue reading “Medical friendship at the end of life”

The physician as entrepreneur

Posted byMichel AccadPosted inHealthcare economics, Medical practice, Medical scienceTags:, Leave a comment on The physician as entrepreneur
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Frank Knight, risk and uncertainty

In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.

Knight was an influential American economist.  He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:Continue reading “The physician as entrepreneur”