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Pills Still Matter

May 15, 2012• 5

By David Shaywitz, MD

Reviewing “The Myth of The Paperless Office” for the New Yorker in 2002, Malcolm Gladwell argued that if the computer had come first, and paper didn’t exist, someone would have had to invent it. Paper, it turns out, is a lot more useful than we typically appreciate.

It occurred to me that perhaps the same might be said of another product we seem to take for granted in the digital age – medicines. (Disclosure: I work at a company that makes them.)

Medicines – you know, those little white pills that everyone loves to critique – are in many cases remarkably effective solutions to very difficult problems; it’s actually kind of amazing how useful some of these products can be. What an incredibly powerful idea – addressing a difficult and complex health problem with a simple pill you can pop before breakfast.

I read a tweet recently asserting that physicians may soon prescribe health apps as an alternative to medications; my initial reaction: good luck with that one. It’s certainly easy enough to envision how magical thinking about the power of health apps will soon be replaced by disappointment as app developers realize something drug makers have known for years: it’s hard to improve health, and it can be very difficult to get patients to stick with a treatment long enough to make a difference.

Red or Blue Pill for Payment Reform? Both Won’t Work

May 14, 2012

By JOSHUA ARCHAMBAULT

Are the House and Senate giving us a false choice for how to control health care costs in Massachusetts? Aren’t there other options?

A few major themes have emerged from the two payment reform proposals and highlight the fact that they fail to align incentives for patients to be more involved in the purchase of their health insurance and their health care.

For example, even with full transparency of cost and quality (which is a huge lift on its own) for many patients, high-cost still correlates with higher quality in medicine. A recent report from Attorney General Coakley proved this theory wrong, but simply providing patients with cost data without placing the right incentives in their health plan to choose the low-cost high-quality provider will result in many selecting the most expensive care. As a result, these proposals will fall short of sustainably bending the cost curve.

Activist Seeds – The Latest, Subtle Trend in Seed Investing

May 14, 2012• 5

By Jeff Bussgang

When I entered the VC business 10 years ago, I tried to keep thinking about venture capital as a business, where the key focus area was on meeting the needs of our target customers — entrepreneurs and limited partner investors.

In the case of entrepreneurs, those needs have changed radically in these last 10 years. The surge in seed investing over the last few years has been well-reported and analyzed. With advances in cloud computing, open source infrastructure, development tools and general “Lean Start-Up” techniques, entrepreneurs need less capital than ever before. And when entrepreneurs’ needs change (i.e., requiring less capital), smart investors adjust to meet those new needs. Hence, the rise of angels, super-angels, incubators, accelerators, micro-VCs and VC-led seed programs.

But as the “Great Seed Experiment” (as my partner, Michael Greeley, calls it) matures, a new trend is emerging. Entrepreneurs are beginning to learn the difference between what I’ll call Passive Seeds and Activist Seeds. And entrepreneurs are learning that the difference between the two, although somewhat subtle, matters greatly.

Passive Seeds are when a VC invests a small amount of money (for a $200-500M mid-sized fund, typically $250k or less, for a large $1B fund, perhaps $500k or less), to achieve a very small amount of ownership (typically less than 5%) to simply create an option to participate as a more meaningful investor in the future. Passive seed programs get most of the press attention because of their sheer volume.

Fast Science: The Uncertainty Paradox

May 13, 2012• 9

By Marya Zilberberg, MD

Reading Barbara Ehrenreich’s “Bright-Sided” has been liberating in that is has given me permission to let my pessimistic nature out of the closet.

Well, it’s not exactly that I am pessimistic, but certainly I am not given over to brightness and cheer all the time. My poison is worry. Yes, I am a worrier, in case you had not noticed. So, imagine how satisfying it is for me to find new things to worry about. As if climate change were not enough, lately I started to worry about science.

No, my anxiety about how we do clinical science overall is not new; this blog is overrun with it. However, the new branch of that anxiety relates to something I have termed “fast science.” Like fast food it fills us up, but the calories are at best empty and at worst detrimental. What I mean is that science is a process more than it is a result, and this process cannot and should not be microwaved. Don’t believe me? Let me give you a couple of instances where slow science may be the answer to our woes.

1. Lies and damned lies

Remember this story in the Atlantic that rattled us with its incendiary message? Researcher John Ioannidis has been making headlines with his assertion that most, if not all, of what we know in medicine is in doubt, given how we do and publish research. And how we do and publish research has everything to do with the speed of “progress.” Academic careers are made with positive results, to sell news the media demand positive results, and to respond to this demand academic journals prefer only to publish positive results (this last phenomenon is referred to as “publication bias,” and is something Ben Goldacre rails against at length). A further manifestation of this fast science is that “no replicators need apply.” I am, of course, referring to an extension of the publications bias, whereby journals are not interested in publishing even a positive study that replicates a previous finding — this is simply not sexy. Thus, results have to be quick and positive to grab a share of our attention and sell academic prestige, journals and news.Continue reading…

Don’t Bypass Physicians

May 13, 2012• 3

By Peter W. Carmel

As physicians, our primary concern is ensuring the health and safety of our patients. The Food and Drug Administration has offered a new concept to make more prescription drugs available over the counter (OTC). Proponents claim it could improve patient health and outcomes, reduce patient costs and promote proper medication use. We are skeptical that it would achieve any of these goals.

The American Medical Association is concerned about patients taking certain drugs without physician involvement — especially patients with chronic diseases. No evidence has been offered that the innovative technologies underpinning this concept would actually allow patients with high blood pressure, high cholesterol, asthma or migraine headaches to self-diagnose and manage these serious chronic medical conditions safely on their own.

As a chronic condition evolves, treatment changes are often needed from a physician. Without physician involvement, patients might take the wrong medication or dose for their needs, potentially causing harm. Self-diagnosis and treatment conflict with the care coordination and disease management that new health care payment and delivery models are trying to achieve.

Making Privacy Policies Not Suck

May 12, 2012• 7

By Aza Raskin

Privacy policies are long legalese documents that obfuscate meaning. Nobody reads them because they are indecipherable and obtuse. Yet, these are the documents that tell you what’s going on with your data — how, when, and by whom your information will used. To put it another way, the privacy policy lets you know if some company can make money from information (like selling you email to a spammer).

Creative Commons did an amazing thing for copyright law. It made it understandable.

Creative commons reduced the complexity of letting others use your work with a set of combinable, modular icons.

In order for privacy policies to have meaning for actual people, we need to follow in Creative Commons footsteps. We need to reduce the complexity of privacy policies to an indicator scannable in seconds. At the same time, we need a visual language for delving deeper into how our data is used—a set of icons may not be enough to paint the rich picture of where you data is going.

DSM 5 Finally Begins Its Belated and Necessary Retreat

May 11, 2012• 6

By Allen Frances

Sigh of relief. The DSM 5 website announced recently that two of its most controversial proposals have finally been dropped. We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression. Both are now definitively rejected as official DSM 5 diagnoses and instead are being exiled to the appendix. And one other piece of good news-the criteria set for Attention Deficit/Hyperactivity Disorder has been tightened (not enough, but every little bit helps).

The world is a safer place now that ‘Psychosis Risk’ will not be in DSM 5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM 5 proposal—we should all be grateful that DSM 5 has finally come to its senses in dropping it.

Drug Data Shouldn’t Be Secret

May 11, 2012• 9

By Peter Doshi and Tom Jefferson

In the fall of 2009, at the height of fears over swine flu, our research group discovered that a majority of clinical trial data for the anti-influenza drug Tamiflu ― data that proved, according to its manufacturer, that the drug reduced the risk of hospitalization, serious complications and transmission ― were missing, unpublished and inaccessible to the research community. From what we could tell from the limited clinical data that had been published in medical journals, the country’s most widely used and heavily stockpiled influenza drug appeared no more effective than aspirin.

After we published this finding in the British Medical Journal at the end of that year, Tamiflu’s manufacturer, Roche, announced that it would release internal reports to back up its claims that the drug was effective in reducing the complications of influenza. Roche promised access to data from 10 clinical trials, 8 of which had not been published a decade after completion, representing more than 4,000 patients from every continent except Antarctica. Independent verification of the data seemed imminent. But more than two years later, and despite repeated requests, we have yet to receive even a single full trial report. Instead, the manufacturer released portions of the reports, most likely a very small percentage of the total pages. (One of us, Tom Jefferson, has been retained as an expert witness in a lawsuit relating to some of these issues.)

Slow Medicine

May 11, 2012• 5

By Danielle Ofri

I can’t tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren’t sure of the difference between the two, then “God’s Hotel” is the book for you. It’s an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco’s Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, “slow medicine,” as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Should Your Boss Encourage You to Take Drugs?

May 10, 2012• 6

By Michael Schrage

A top executive I know recently decided to take Inderal before making high-pressure/high-anxiety presentations. The impact was immediate. She felt more relaxed, confident and effective. Her people agreed.

Would she encourage a comparably anxious subordinate to take the drug? No. But if that employee’s anxiety really undermined his or her effectiveness, she’d share her story and make them aware of the Inderal option. She certainly wouldn’t disapprove of an employee seeking prescription help to become more productive.

No one in America thinks twice anymore if a colleague takes Prozac. (Roughly 10% of workers in Europe and the U.K. use antidepressants, as well). Caffeine has clearly become the (legal) stimulant of business choice and Starbucks its most profitable global pusher (two shots of espresso, please).

Increasingly, prescription ADHD drugs like Adderall, dedicated to improving attention deficits, are finding their way into gray market use by students looking for a cognitive edge. When one looks at existing and in-the-pipeline drugs for Alzheimer’s and other neurophysiological therapies for aging OECD populations with retirements delayed, the odds are that far more employees are going to be taking more drugs to get more work done better.

Performance-enhancing (or degraded performance-delaying) drugs will become as common as that revitalizing cup of afternoon coffee.

Should that be encouraged? Or should management pretend those options don’t exist?

Most managers would believe they’re doing a good thing if they encouraged a hard-of-hearing employee to explore a hearing aid or a visually-impaired colleague to consider glasses. By contrast, encouraging an under-performing subordinate to lose 25 pounds, get a hair transplant or contact-lenses would likely inspire a formal complaint to Human Resources and/or a possible lawsuit. Ironically, the money isn’t the issue here; the business norms associated with perceived cosmetic and aesthetic concerns are radically different from those attached to job performance and productivity.Continue reading…