“There are some enterprises in which a careful disorderliness is the true method” – Herman Melville, Moby Dick
Asymmetry of Error
During the Ebola epidemic calls to ban flights from Africa from some quarters were met by accusations of racism from other quarters. Experts claimed that Americans were at greater risk of dying from cancer than Ebola, and if they must fret they should fret more about cancer than Ebola. One expert, with a straight Gaussian face, went as far as saying that even hospitals were more dangerous than Ebola. Pop science reached an unprecedented fizz.
Trader and mathematician, Nassim Taleb scoffed at these claims. Comparing the risk of dying from cancer to Ebola was flawed, he said, because the numerator and denominator of cancer don’t change dramatically moment to moment. But if you make an error estimating the risk of Ebola, the error will be exponential, not arithmetic, because once Ebola gets going, the changing numerator and denominator of risk makes a mockery of the original calculations.
The fear of Ebola, claimed Taleb, far from being irrational, was reasonable and it was its comparison to death from cancer and vending machines which was irrational and simplistic. Skepticism of Ebola’s impact in the U.S. was grounded in naïve empiricism – one which pretends that the risk of tail events is computable.
By RICHARD DUSZAK, MD
The online membership forum of the Society of Interventional Radiology (SIR) blew up this week in response to an email announcement by the American Board of Radiology (ABR) that it will effectively be doing away with lifetime diagnostic radiology certificates for interventionalists whose original certificates pre-dated the introduction of time-limited certificates. Interventionalists were given two choices:
1. You can keep your lifetime diagnostic certificate if you give up your (earned) interventional subspecialty certification, or
2. You can keep your interventional certification, if you give up your lifetime diagnostic certification.
Talk about choice.
For American conservatives, Britain’s NHS is an antiquated Orwellian dystopia. For Brits, even those who don’t love the NHS, American conservatives are better suited to spaghetti westerns, such as Fistful of Dollars, than reality.
The twain is unlikely to meet after the recent press surrounding Charlie Gard the infant, now deceased, with a rare, fatal mitochondrial disorder in which mitochondrial DNA is depleted – mitochondrial depletion disorder (MDD). In this condition, the cells lose their power supply and tissues, notably in the brain, die progressively and rapidly.
The courts forbade Charlie’s parents from taking him for a last dash of hope to the United States. This confirmed for many conservatives the perils of a government-run healthcare system, where the state decides who lives and who dies through Death Panels.
Ted and Mike, whose healthcare reform might affect many curable little Charlies, were moved by the plight of an incurable Charlie. No European will understand the science behind their sentiment – if you care so much about a sick incurable baby, why don’t you care about sick, curable babies, they’d ask.
Brits will never get the importance conservatives place on individual choice, even if that choice is forlorn, and of the lure of medical heroism. Conservatives seldom acknowledge that modern medicine reaches its limitations too quickly for Death Panels to be effective. Charlie was given a grim prognosis by doctors at the Great Ormond Street Hospital (GOSH), arguably the finest hospital for sick children in the world.
By SAURABH JHA, MD
An old disagreement between Uwe Reinhardt and Sally Pipes in Forbes is a teachable moment. There’s a dearth of confrontational debates in health policy and education is worse off for it.
Crux of the issue is the more efficient system: employer-sponsored insurance (ESI) or Medicaid. Sally Pipes, president of the market-leaning Pacific Research Institute, believes it is ESI. Employers spend 60% less than the government, per person: $3,430 versus $9,130, per person (according to the American Health Policy Institute). Seems like a no brainer.
Pipes credits “consumerist and market-friendly approaches to health insurance” for the efficiencies. She blames “fraud,” “improper payment,” and “waste” for problems in government-run components of health care.
But Uwe Reinhardt, economist at Princeton, counters that Medicaid appears inefficient because of the risk composition of its enrollees. Put simply, Medicaid recipients are sicker. Sicker patients use more health care resources. Econ 101.
The points of tension in their disagreement are instructive.
Any backpacker travelling on a shoestring budget in Thailand knows not to blow their entire budget on premium whiskey in a premium hotel on the first night in Bangkok. Rather, you need to skip the occasional meal, stay in a cheap dorm with random strangers, and drink cheap beer on Khao San Road if you wish to see the country and return home without having to wash dishes in a restaurant in Bangkok to repay the loans. Both Democrats and Republicans seem impervious to a simple wisdom that I learnt when backpacking – you save money if you go for cheap stuff. The operative word here is “cheap.”
Both the Affordable Care Act (ACA) and the Better Care Reconciliation Act (BCRA) impose cost sharing, such as deductibles. Deductibles lower premiums by cost shifting. Because the sick, for obvious reasons, are more likely to meet their deductibles sooner than the healthy, deductibles shift costs from the healthy to the sick, or are a “tax on the sick.” Deductibles also reduce premiums by reducing the administrative loading of insurance – because insurers have fewer small claims to process, administrative costs reduce.
When I first read about neurosyphilis in medical school, I became convinced that Mrs. Thatcher, who I detested intensely because it was fashionable detesting her, had General Paralysis of the Insane. The condition, marked by episodic bouts of temporary insanity, which indicated that the spirochetes were feasting on expensive real estate in the brain, seemed a plausible explanation why she had introduced the retarded Poll Tax.
A little bit of medical knowledge can lead to tomfoolery by the juvenile. I began diagnosing the powerful with medical conditions. I thought the former leader of the Labour Party, Neil Kinnock, who had an odd affect, was both hyperthyroid and hypothyroid – when he spoke he looked myxedematous and when was silent he looked like he had Grave’s Disease. The tacit, but not silent enough, Prince Charles spoke in a tone that seemed a cry for help for acutely thrombosed piles. I also realized that the Prince of Wales – who is the most compelling evidence for the magical kingdom of elves – wasn’t reducible to a single diagnostic code. Diagnosing Hillary was relatively straightforward. After reading a third of her memoirs, which permanently cured my insomnia, I felt someone had inadvertently given her dextrose without thiamine.
In college, I once marched for the plight of Tibetans. Forty of us marched in Hyde Park, London – after an hour, half retreated to the nearest pub to discuss global injustices. Recently, over a million, including five penguins, marched for science. There were no penguins at our march for Tibetans but our goal, though naïve and unrealistic, was clear – we wanted Tibetan independence from Chinese rule. The goals of March for Science, a worldwide endeavor with marches as far south as Antarctica, were numerous and ambiguous.
If you attended the science march expecting to hear about the theory of ether, the nuances of the Special Theory of Relativity, or Galileo’s brush with the papacy, you’d be disappointed. While it was not clear what the march was about, it was patently evident what the march was not about. The march was not about scientific inquiry or an embracement of the scientific process. The marchers were not protesting their right to think freely without persecution.
Many marchers were protesting their right to the public purse particularly, as President Trump has threatened to slash the budgets of government agencies more mercilessly than parents slash the pocket money of an itinerant teenager. It was like Galileo protesting outside the Vatican, not so that he can experiment in peace, but that the Pope fund his activities.
How did scientists transform from demanding more freedom to demanding more funding? Science, particularly biomedical sciences, has changed, and is now an expensive enterprise with considerable oversight. It is no longer possible for curious clergymen with time on their hand to dabble in science. Science, like art, has become a profession. To be funded is to be free – with some restrictions. The scientist, once stubbornly curious, now curiously adheres to stubborn protocols.
Recently, the Harvard Chan School of Public Health, in their press release, reported about the effect of surgical checklists in South Carolina. The release was titled, “South Carolina hospitals see major drop in post-surgical deaths with nation’s first proven statewide Surgical Safety Checklist Program.”
The Health News Review, for which I review, grades coverage of research in the media. Based on their objective criteria, the Harvard press release would not score highly.
The title exudes certainty – “nation’s first proven.” The study, not being a randomized controlled trial (RCT), though suggests that checklists are effective, far from proves it. At least one study failed to show that surgical checklists improve outcomes.
The press release’s opening line is “South Carolina saw a 22 percent reduction in deaths.” It reports relative risk reduction (RRR). Reporting RRR is now considered a cardinal sin in healthcare journalism, because RRR inflates therapeutic optimism by making the intervention sound more efficacious than it is.
Being a radiologist, I rarely speak to patients, but I was asked to counsel Mrs. Patel (not her real name, so calm down HIPAA totalitarians), who was worried about the risks of radiation from cardiac calcium CT scan. Because of her risk factors for atherosclerosis, her cardiologist wanted her to take statins for primary prevention, but she was reluctant to start statins. They eventually reached a truce. If she had even a speck of calcium in her coronary arteries she would take statins. If her calcium score was zero she wouldn’t. This type of shared decision making is the most frequent reason why cardiologists order calcium scans at my institution.
Many allege that the FIRST trial, which randomized surgical residencies to strict versus flexible adherence to duty hour restrictions, was unethical because patients weren’t consented for the trial and, as this was an experiment, in the true sense of the word, consent was mandatory. The objection is best summarized by an epizeuxis in a Tweet from Alice Dreger, a writer, medical historian, and a courageous and tireless defender of intellectual freedom.
It’s important understanding what the FIRST (Flexibility In duty hour Requirements for Surgical Trainees) trial did and didn’t show. It showed neither that working 120 hours a week has better outcomes than working 80 hours a week, nor the opposite. Neither did the trial, despite being a non-inferiority trial, show that working 100 hours was as safe as working 60 hours a week. The trial showed that violating duty hour restrictions didn’t worsen outcomes. The trial was neither designed nor powered to specify the degree to which the violation of duty hours was safe. This key point can be missed. To be fair, neither the trialists, nor the editorials about the trial, claimed so.