Media

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.

Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

Continue reading “Why You Probably Have a Lot Less to Fear From the Latest Superbug Than You Think”

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On March 20, 2013, the media picked up a story about CVS Caremark’s latest wellness program. In summary, CVS will be requiring all of its employees to complete a health screening in order to qualify for a reduction in their health insurance premium. For those employees who participate, the employee’s screening data goes to a third party, and CVS never sees it.

Such wellness financial incentives are commonplace and have been around a long time. And if that is how the media had described the CVS program, it’s doubtful anyone would have even paid any attention to it. Unfortunately, that’s not how the media ran with the story. Let’s look at how the media sent the wrong message – using ABC News as an example – and why it matters to get the message right.

Sending the Wrong Message

ABC’s Good Morning America segment was emblazoned with the headline, “Who’s Watching Your Weight – CVS Employees Required to Disclose Weight.” Their website ran a similar headline, “CVS Pharmacy Wants Workers’ Health Information, or They’ll Pay a Fine.”

Continue reading “How the Media Portrayed the CVS Wellness Program-and Got It Wrong”

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The coverage of the Japanese reactor situation reminds me of the coverage of many other technical issues when they overlap with serious breaking news stories. I wrote a little on this subject a few years ago, talking about the Merck/Vioxx business, but I wanted to expand on it.

I’m not going to rant on about the popular press not understanding this or that scientific or technical issue. There are more systemic problems with the way that news is reported, and in the way that we take it in. I’m not sure of what to do about them other than to be aware of them, but that’s an important step right there.

The first of these is narrative bias. Reporters like to relay stories (and the rest of us like to hear stories) that have a progression. They have a beginning, a middle, and an end, the way our most popular novels and movies do. Something starts, something happens, something ends. Real life sometimes conforms to this template, but sometimes it doesn’t. For example, some situations don’t start, so much as they suddenly get noticed after they’ve been there all along. And some don’t end, so much as they just stop having attention paid to them.

Another narrative-bias problem is the tendency to assign participants in any event to recognizable categories: good guys and bad guys, for starters. Moving to finer distinctions, there’s Plucky Young X, Suffering Y, Salt-of-the-Earth Z, along with Untrustworthy Spokesman A, Obfuscating B, Crusading C, and the whole crowd. Mentally, we tend to assign people to such categories, especially if we don’t know them personally, and it makes it easier for reporters, too. It’s a team effort. The problem is, of course, that not everyone fits into a recognizable category, and many others overlap in ways that a simple narrative structure won’t accommodate. Most real people are capable (more or less simultaneously) of great and venal actions, of heroism and cowardice, of altuism and selfishness.

Continue reading “Bias And How to Deal With It”

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“Despite their great explanatory powers these laws [such as gravity] do not describe reality. Instead, fundamental laws describe highly idealized objects in models.”

– Nancy Cartwright, “Do the Laws of Physics State the Facts?”

In Part I the limitations of science in helping us make wise choices and decisions about our health were examined.

Because of an inherent difficulty in establishing causation, absolute certainty is unattainable even in science. Medical knowledge follows Karl Popper’s theory of science because the right answer, whether about what causes ulcers or if you should take hormone replacement therapy, keeps changing with the publication of new studies. And most depressingly of all, a respected expert on evidence-based medicine concludes, “The majority of published studies are likely to be wrong.”

Part I ended with some suggestions that seemed to imply that savvy patients should enroll in a graduate level statistics class and understand the subtleties of observational studies, meta analysis, and randomized controlled clinical trials. Being an informed health care consumer is evidently difficult indeed.

Part II explores how we all have to change if we are to live wisely in a time of rapid transformation of the American healthcare system that everyone agrees needs to decrease per-capita cost and increase quality.

PATIENTS

When I talk to physicians about pay for performance programs, I am always asked why should doctors be responsible for patient behavior that they cannot control. Even if we were able to have health care access for all and eliminate every error in medicine, we would only account for 10% of whether an individual stays healthy. Environment and genetics account for about 35%, but the remaining 55% of whether one stays well depends on behavior (exercise, smoking, diet) and social support systems (families, communities, places of worship).

Continue reading “The Difficult Science, Part II”

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“The mind leans over backward to transform a mad world into a sensible one, and the process is so natural and easy we hardly notice that it is taking place.” Jeremy Campbell

On the same day in November, headlines from the Wall Street Journal and the New York Times reported on the same story about a federal panel’s recommendations on consumer intake of vitamin D.

“Triple That Vitamin D Intake, Panel Prescribes” read the WSJ story;

“Extra Vitamin D and Calcium Aren’t Necessary, Report Says” stated the New York Times. (http://ow.ly/3tJMe) Since I had recently started taking vitamin D daily, I was interested in what the experts in Washington, DC were recommending.

How should you decide what advice to follow about the relationship between your diet, lifestyle, medications, health, and wellness?

Is this just another example of how the media does a terrible job? Many of us resonate with the view of media watchdog Steven Brill who said, “When it comes to arrogance, power, and lack of accountability, journalists are probably the only people on the planet who make lawyers look good.” (http://ow.ly/3tKdM)

The media does play a role here and needs to improve, but it turns out that it is really complicated to figure out what the “truth” is about diet, exercise, medicines, and your individual well being. Everybody (journalists, government panel members, scientists, patients, physicians, and nurse practitioners) needs to change.

Continue reading “The Difficult Science”

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BrianLambBy BRIAN LAMB

Dear Speaker Pelosi:

As your respective chambers work to reconcile the differences between the House and Senate health care bills, C-SPAN requests that you open all important negotiations, including any conference committee meetings, to electronic media coverage.

The C-SPAN networks will commit the necessary resources to covering all of these sessions LIVE and in their entirety. We will also, as we willingly do each day, provide C-SPAN’s multi-camera coverage to any interested member of the Capitol Hill broadcast pool. Continue reading “An Open Letter to Speaker Pelosi from C-SPAN Founder Brian Lamb”

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Ariana Huffington recently anointed diet-and-exercise guru Dean Ornish as her chief medical correspondent. With all the guff her site had taken from the science-based medicine crowd for giving free rein to anti-vaccinists, faith healers and the no-evidence-needed alternative medicine freaks, I thought it was a smart move — a tack toward the responsible center, if you will.But in a post this week, Ornish recounted his 14-year-battle to get Medicare to pay for a pilot project to test lifestyle intervention as a cure for heart disease (which wouldn’t save Medicare money, but would save more lives for the same money expended as, say, giving those people cholesterol-lowering medication). What he drew from his saga was that the government can’t be trusted to run health care, and that health care reformers needed to rise above the right-left divide and unite around reimbursing physicians for keeping people well.It was a classic case of crunchy granola versus the class warriors. The comments section was overwhelmed with hostile attacks on Ornish’s above-the-fray moralizing. The commentators defended single-payer, pointed out the indiscriminate nature of many diseases, articulated the special needs of the poor whose stress and multiple jobs make them especially prone to disease, etc. etc. What was striking was how thoughtful and well-reasoned many of the comments were, a far cry from conspiracy-minded rants of that usually dominate the comments space.

Continue reading “Ornish Alienates HuffPo’s Class Warriors”

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GooznerEmory University psychologist and political consultant Drew Westen in the weekend Washington Post offers a troubling view of the public’s role in health care reform. While reform’s reality involves complicated technical issues like insurance exchanges, public plan governance, physician and hospital payments and who will pay higher taxes, the public’s understanding of these issues is virtually non-existent, Westen assumes.

Continue reading “The Message Is The Medium”

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Stephen Colbert’s Republican Health Care Infomercial. Quite wonderful. Can’t get it to embed but here’s the link

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Joseph Stalin

Princeton ethicist Peter Singer’s article in this week’s NY Times Sunday Magazine is creating lots of buzz. It is a classic utilitarian description of the case for rationing – QALYs and all – and a plea for a mature national dialogue about the dreaded R-word.Don’t hold your breath. To understand why, remember the words of Joseph Stalin: “A single death is a tragedy, a million deaths is a statistic.”

A society of grown-ups would read Singer’s article and say,

“Gosh, he’s absolutely right. If we don’t make some hard choices about whether to cover $50,000 palliative chemotherapy to extend a life of an 80-year-old by a few months, then we are choosing not to have enough money to provide universal health insurance, or to ensure that everybody has their pap smears and generic Lipitor (or, while we’re at it, to house the homeless, provide decent public education, or have viable auto companies).”
Rationing is inevitable – as I recently mentioned, talking about whether we should ration is like talking about whether we should obey the laws of gravity. The only question is how we do it. And what better time than now to have this difficult national conversation, being that we’re in the middle of retooling our entire healthcare economy, the fundamental obstacle is finding the money to pay the bill, and we have a president who truly understands the dilemma and is smart and mature enough to lead the discussion.

Yet rationing remains a political Third Rail, the Lord Voldemort of the healthcare policy debate.

The issue is not new, nor are its political trappings. It’s worth understanding a bit of this history to frame today’s debate – and lack thereof.

In 1984, Colorado Governor Richard Lamm famously opined that the elderly had a “duty to die” in order to free up resources for the young. He was vilified.

In 1987, Oregon stepped into the mess that is healthcare rationing, and spent much of the next decade scraping off its metaphorical shoe. In the face of exploding Medicaid costs, the state legislature decided not to fund transplants (including bone marrow transplants) in order to preserve limited funds to cover other services.

This was in the early years of bone marrow transplant, when BMT had a 50-50 success rate for certain types of childhood leukemias (it’s better now), and cost about $100,000. The state did the math, and found that for the same $100K, several lives could be saved by plowing the money into other healthcare needs, including prenatal care. And so BMT became an uncovered service. A perfectly rational decision if you live in Utilitarian, Most-Good-for-the-Most-People, World.

But that’s not the world we live in.

What happened next was utterly predictable. A 7-year-old boy named Coby Howard developed acute leukemia, Oregon denied his BMT coverage under Medicaid, and his mom went ballistic (any parent, including this one, would have done precisely the same thing). The only question was which megaphone she would grab first to make her case: the media, her local congressman, or a lawyer (ultimately, of course, she used all three). Here’s how it sounded on ABC’s Nightline:

[Ted Koppel] began the program with footage of Coby Howard and said: “When the State of Oregon decided to stop funding organ transplants, it allowed this boy to die.” Koppel later asked: “Is the cost of modern medical technology forcing public officials to play God?”

In the end, Coby received his BMT, paid for by private donations, but sadly died later that year. Under the leadership of state senate president (later governor) John Kitzhaber, a former ER doc, and in the face of withering post-Coby criticism, Oregon developed a more explicit rationing plan – of course, it covered BMT. Kitzhaber and his staff later described the pressures they felt after they took on healthcare rationing,

“Our detractors consist mainly of uninformed members of threatened interest groups who delight in comparing the Oregon plan to a perfect world.”

Stalin could have predicted this, of course. The Oregon rationing plan (both the ad hoc decision to deny BMTs and the more explicit “prioritized list” that followed) depended on a hard-boiled tradeoff between a single identifiable life – in this case, a cute child with a determined mother – and many unidentified lives. We’ll never know which kids were saved by better prenatal care, or whose strokes were averted by primary care and hypertension control. These statistical lives make for a pretty dull interview on Nightline – and they don’t blog.

Where do docs fit into all of this? Our ethical model is to do everything we can for the patient in front of us – we are socialized from the first day of med school to believe that the single death is indeed a tragedy (the late Norman Levinsky made this point in a wonderful piece in the NEJM called “The Doctor’s Master”). Although as responsible citizens, we care about society and the unidentified lives outside our office or our ICU, it is not our job to weigh the impact of our choices on them. And, of course, we won’t be sued by society for plundering its resources, but might well be sued by the family of an individual patient who feels that we didn’t do everything possible to save their loved one.

I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” As I wrote last year, there are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure.

Is there anything we can do? The favored solution, a board resembling the UK’s National Institute for Health and Clinical Excellence (NICE) with the teeth to limit certain new drugs and technologies, is hard enough. But even if we were able to get a NICE-like organization in place (doubtful), that doesn’t really address the brutally tough issue: is our ethical model one in which we do everything possible, irrespective of cost, for every patient when there is any chance of benefit, or one in which we place limits on what we’ll do in order to do the most good for the most people. An American “NICE” isn’t going to limit ICU care for 80-year-olds with metastatic cancer. That will require a much broader public discussion, and even harder choices – since they will need to be made at the bedside.

As Singer notes, every society that rations provides a safety valve for the wealthy disaffected. In the UK, you can buy private insurance that allows you to jump the queue for your hip replacement. Canada’s safety valve is called the Cleveland Clinic. We don’t talk about the percent of our GNP we are spending on Starbucks lattes, or on iPods, or on vacations. People pay for these things out of pocket, and receive no tax advantages when doing so. Given the American ethos of self-determination and consumerism, any rationing plan will need to allow people who can afford care that isn’t covered by standard insurance to buy it with their own money (with absolutely no tax advantage). Two-tiered medicine, sure, but I see little problem with this as long as we are using the money in the communal pool to provide a reasonable set of benefits to the entire population.

How might a thoughtful structure to support rationing be organized in the U.S.? When considering new technologies and drugs, it will probably entail an independent board empowered to make coverage recommendations based on cost-effectiveness, just as NICE has done in the UK. But just as importantly, at the level of individual hospitals or healthcare organizations, there will need to be committees of providers, administrators, and patient advocates that can set and defend limits on care. Such decisions would not automatically mean that grandpa can’t stay on the ventilator, but would mean that ongoing care would no longer be fully covered by insurance. Of course, these decisions would have to be all-but-immune from litigation threat.

Will this happen? Probably not. Twenty years ago, the great Princeton healthcare economist Uwe Reinhardt observed that there are two kinds of rationing: “civics lesson rationing” and “muddling through elegantly.” In the former, a NICE-like federal board, or local panels such as the one I’ve described above, weighs the evidence and makes these tough rationing decisions algorithmically and prospectively. The muddling through option, which Reinhardt felt was far more likely, involves limiting the resources available – the number of ICU beds, or MRI scanners, or CT surgeons – and allowing docs, patients and administrators to duke it out at the bedside. The evidence is that they do a decent job at triaging to provide the most good for the most people.

Of course, these limits are naturally present when resources are truly scarce – like livers for transplantation – and in these circumstances we have developed thoughtful rationing approaches. The point is that health care dollars increasingly resemble livers.

I’m pleased Peter Singer and others have dared to speak of the R-word in public, because it is so central to today’s healthcare policy debate. But will the society that brings you Rush Limbaugh and Glenn Beck (or, I’m beginning to think, some of our Democratic representatives) deal with it in an effective, mature way? I truly doubt it.

Why not?

Joseph Stalin would know.

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