Are you familiar with the trolley problem? It is an ethics dilemma first formulated by the great Philippa Foot as a part of a series of such dilemmas. Her formulation goes roughly like this. Imagine there is a tram hurtling down a track. If it keeps going straight, it will hit and kill 5 people who are working on that track. The …
Doctors are shackled by the stigma of ignorance
I love when an article I read first thing in the morning gets me to think about itself all through my morning chores and then erupts into a blog post. So it was with this little gem in the statistical publication Significance. The author suggests making gambling safer by placing realistic odds estimates right on the poker machines in casinos. He even goes through the generation of the odds of …
A radical transformation in healthcare decision making is needed
“Twenty years ago, I helped save a man’s life.”
So begins this New York Times essay by Peter Bach, MD, where he talks about the inadequacy of resource use at the end of life as a policy metric. Now, I am not very fond of policy metrics, as most of you know. So, imagine my surprise when I found myself disagreeing vehemently with Peter’s argument. Well, to be fair, I did …
Turn away from interventions that merely prolong dying
We have known for quite some time now that the patient’s environment in a hospital matters to his/her outcomes. The concept of biophilia was applied by Roger Ulrich back in the 1980s to surgical patients in a series of experiments. Famously, this work showed that looking out your hospital room’s window on a bunch trees is associated with better and less eventful post-operative recovery than staring at a brick wall, …
Private rooms in the ICU can reduce length of stay
I like to poke fun at real estate agents (please, forgive me if you are one, it is all in good fun).
My experience has been that, despite what I describe as my preferences, they always end up showing me what they have, even if it does not bear the remotest resemblance to what I need. This holds true for politicians, with this cardinal rule: always answer the question you want …
How physicians derive evidence for their practices needs to change
One of the top hits that comes up on the Oracle of Googlius for “astroturf” is for the original company, now renamed SYNLawn, but still proudly stating, “We invented synthetic grass,” which is what astroturf is. More recently, this already synthetic term has become a verb, as in “astroturfing.”
My favorite of all credible information sources on the web, Wikipedia, has this to say about it:
Astroturfing denotes political, advertising, or public relations campaigns that are formally …
How astroturfing disease affects patients
You know that joke about the farmer whose cows are not producing enough milk? A university panel gathers under the leadership of a theoretical physicist. They analyze each aspect of the problem thoroughly and carefully, and after much deliberation produce a report, the first line of which is “First, assume a spherical cow in a vacuum.”
This joke has become short-hand for some of the reductionist thinking in theoretical physics, but …
Payment systems must take into account the art of medicine
When I was in training as a resident and a fellow, I remember taking only a couple of sick days over the entire 6-year period.
And I had to stay home because I could not stop praying to the porcelain Goddess during a bout of a particularly nasty flu, despite a vaccination. I actually took pride in my health record, and attributed it directly to being rather sickly as a child. …
Why comparing healthcare access to food is a false analogy
My father passed away about two weeks ago after battling a brain tumor for some time.
Initially diagnosed with an extensive inoperable mass one and one-half years ago, upon presenting with a focal seizure, he did well with only one medication for seizure control for about ten months. Around Christmas of 2009, however, he landed in the hospital in status epilepticus that took three days to control. After these days of …
Marginal treatments at a high emotional cost from families
It is not a secret that large sums of money have passed from the pharmaceutical and device manufacturers into physicians’ hands.
This money has been paid not only for such socially beneficial pursuits as research and consulting, but also for lavish gifts and junkets. And interestingly, despite disingenuous assertions to the contrary by many a stake holder, these gifts generated a return on investment — surprise! It turns out that the …
Gifts and money influence physician prescribing
Our grandparents used to tell us, “if it ain’t broke, don’t fix it”.
Management gurus, in their race to the finish line have turned this sentiment on its head by telling us that, if it ain’t broke now, it will be soon, and if you do not fix it before it breaks, you will be behind the competition. This sentiment drives the annual corporate reorganization at every corporation that I or …
What libraries and community centers have to do with health care
When do tests improve mortality?
This is a question well worth asking, particularly as we argue about the merits of mammography screening. The USPSTF has really stirred up the hornet’s nest with this one, and the politicians cannot help but get on their populist pulpit, ignoring the facts completely.
But the question remains, do screening or diagnostic tests that are more sensitive save lives? We all hear that mortality from many diseases …
Screening studies that blur the mortality and case fatality line
I believe in the peak oil theory.
Think about it, in a closed system nothing is infinite. Since oil is a product of millions of years of decay, unless we use it at the same rate that is it produced, we will run out. I do not have a crystal ball any more than anyone else I know, so I will not hang my hat on when, but will commit to …
How the oil shortage will affect hospitals and healthcare
Much like many other news items, I came upon the one about the proposed name change for Physician Assistants quite by accident: it came to me as an e-mail notification of a new topic being discussed on one of the physician only discussion boards that I am a part of. Apparently, after 40+ years of the profession’s existence, there is a grassroots effort afoot to upgrade the name, and presumably …
Physician assistant name change rubs doctors the wrong way
Now, as you know, I am a big fan of epidemiology. I do not believe that a randomized controlled trial is the be-all-and-end-all in evidence generation, and a well done observational study can add to our reservoir of knowledge much more efficiently. Of course, I, as many others, acknowledge certain limitations of epidemiologic design. However, many of them can be overcome with careful design and analysis.
I have to confess, though, …
Epidemiology and how confounding statistics can confuse
Remember the trial a couple of years ago that showed that group support participation was associated with prolonged survival among women with metastatic breast cancer?
I’ve thought a lot about that over the years. Isn’t it interesting that something as simple as a supportive environment can make a difference in what researchers consider to be the hardest endpoint there is: survival? In our dualistic view of the human organism, we think …
Evidence and the Eastern paradigm of medical treatment
A recent story from the UK reported a school child who developed diarrhea and tested positive for C difficile.
The alarming thing is that there did not seem to be any explicit risk factors for this. The appalling thing is the mis-information by the story that, “children rarely become ill with C diff, which normally strikes elderly people in hospital.”
This is how things used to be, before the BI/NAP1/027 bug evolved …
C Diff and antibiotic resistance in kids
The recent uproar over the new screening mammography recommendations got me thinking about a lot of stuff. One of the lessons cited by some journalists and pundits is on how potentially volatile information should be presented to the public. The USPSTF was excoriated by critics not only for what it said, but how it said it. While the objections over the former can be dismissed as ravings of loud and …
How can medical guidelines be immune from politics?
The costs of healthcare have been rising exponentially, but people’s incomes have not. Despite the biggest economic expansion over the last 50 years, and despite astronomic rise in our productivity, the real wages for the bottom 80% of all earners have not increased one iota since 1975. This means that, while the costs for all products and services have grown at the pace of inflation or more rapidly (as in …
Without controlling costs, health coverage becomes unaffordable
When we talk about efficiency in the business world, we are basically talking about getting as much profit as possible. This profit is wrung out of the system by reducing production costs to the maximum extent possible and by charging the top price that the market allows.
Some of the ways in which the US companies have increased their efficiencies over the last 30 years are, 1) by moving manufacturing to …
Should medicine be efficient in the business sense?
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