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COVID herd immunity: At hand or forever elusive?

By MICHEL ACCAD, MD

With cases of COVID-19 either disappeared or rapidly diminishing from places like Wuhan, Italy, New York, and Sweden, many voices are speculating that herd immunity may have been reached in those areas and that it may be at hand in the remaining parts of the world that are still struggling with the pandemic.  Lockdowns should end—or may not have been needed to begin with, they conclude. Adding plausibility to their speculation is the discovery of biological evidence suggesting that prior exposure to other coronaviruses may confer some degree of immunity against SARS-CoV2, an immunity not apparent on the basis of antibody seroprevalence studies.

Opposing those viewpoints are those who dismiss the recent immunological claims and insist that rates of infections are far below those expected to confer immunity on a community. They believe that the main reason for the declining numbers are the behavioral changes that have occurred either under force of government edict or, in the case of Sweden, more voluntarily. What’s more, they remind us that the Spanish flu pandemic of 1918-1919 occurred in 3 distinct waves. In the summer of 1918 influenza seemed overcome until a second wave hit in the fall. Herd immunity could not possibly have accounted for the end of the first wave.

The alarmists may have a point.  However, recent history offers a more instructive example.

Until early 2015, epidemiologists considered Mongolia to be exemplary in how it kept measles under control. In the mid-1990s, the country instituted a robust vaccination program with low incidences of outbreaks, even by the standards of developed countries. In the early 2000s, it adopted a 2-step MMR immunization schedule and, after 2005, its vaccination rates were upwards of 95%. From 2011 through 2014, not a single case of the virus was recorded, leading the WHO to declare measles “eradicated” from Mongolia in November 2014.  

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Equipoise and Its Problems

By MICHEL ACCAD, MD

I recently participated in a debate opposing me to Professor Adam Cifu on the topic of “Evidence-based medicine in the age of COVID.” The debate took place on an episode of Dr. Chadi Nabhan’s Outspoken Oncology podcast. Dr. Saurabh Jha was the moderator and he did a great job keeping us on point and asking for important clarifications when needed. It was a fun and cordial moment and I found it intellectually fruitful. You can listen to it here or on any podcast platform. The discussion strengthened my conviction that the central issue about EBM is the conflation of the role of the physician with that of the clinical scientist.

That conflation was quite apparent in a recent online editorial published by Robert Yeh and colleagues on the topic of equipoise during the COVID-19 pandemic. Yeh at al. are accomplished academic cardiologists and outcomes researchers (Yeh was a guest on The Accad and Koka Report a couple of years ago).

I’ll get to their editorial in a moment, but equipoise is a term that I became aware of only in the last few years, mainly from mentions on MedTwitter. From those mentions I developed an intuitive sense of what equipoise must mean: a mental state of uncertainty about a treatment that prompts the medical community to seek a more definitive answer by way of a randomized controlled trial. For example, one might say “I’m not sure if hydroxychloroquine works to prevent or treat COVID-19.  Based on the existing collective experience, there is equipoise about it.  We need a clinical trial.”

That seems reasonably straightforward, but the editorial by Yeh et al. piqued my curiosity so I decided to look into the origin of the term and its introduction in the medical literature.

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What’s a diagnosis about? COVID-19 and beyond

By MICHEL ACCAD

Last month marked the 400th anniversary of the birth of John Graunt, commonly regarded as the father of epidemiology.  His major published work, Natural and Political Observations Made upon the Bills of Mortality, called attention to the death statistics published weekly in London beginning in the late 16th century.  Graunt was skeptical of how causes of death were ascribed, especially in times of plagues.  Evidently, 400 years of scientific advances have done little to lessen his doubts! 

A few days ago, Fox News reported that Colorado governor Jared Polis had “pushed back against recent coronavirus death counts, including those conducted by the Centers for Disease Control and Prevention.”  The Centennial State had previously reported a COVID death count of 1,150 but then revised that number down to 878.  That is but one of many reports raising questions about what counts as a COVID case or a COVID death.  Beyond the raw numbers, many controversies also rage about derivative statistics such as “case fatality rates” and “infection fatality rates,” not just among the general public but between academics as well.  

Of course, a large part of the wrangling is due not only to our unfamiliarity with this new disease but also to profound disagreements about how epidemics should be confronted.  I don’t want to get into the weeds of those disputes here.  Instead, I’d like to call attention to another problem, namely, the somewhat confused way in which we think about medical diagnosis in general, not just COVID diagnoses.

The way I see it, there are two concepts at play in how physicians view diagnoses and think about them in relation to medical practice.  These two concepts—one more in line with the traditional role of the physician, the other adapted to modern healthcare demands—are at odds with one another even though they both shape the cognitive framework of doctors.  

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It’s Not About Tradeoffs

By MICHEL ACCAD

It is tempting to oppose the harmful effects of COVID-related lockdown orders with arguments couched in terms of trade-offs. 

We may contend that when public authorities promote the benefits of “flattening the curve,” they fail to properly take into account the actual costs of imposing business closures and of forced social distancing: The coming economic depression will lead to mass unemployment, rising poverty, suicides, domestic abuse, alcoholism, and myriad other potential causes of death and suffering which could be considerably worse than the harms of the pandemic itself, especially if we consider the spontaneous mitigation that people normally apply under the circumstances.

While I have no doubt that lockdown policies can and will have very serious negative consequences, I believe that the emphasis on trade-offs is misguided and counterproductive.  It immediately invites a utilitarian calculus: How many deaths and how much suffering will be caused by lockdowns?  How many deaths and how much suffering will occur without the lockdowns? How exactly are we to measure the total harm?  What time frame should we consider when we ponder the costs of one option versus the other?

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Neither Expert nor Businessman: The Physician as Friend

Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

“With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!

Perhaps sensing the difficulty of their position, Sullivan and Ellner conclude the article on a more sober note:

If we believe that relationships are key to value, how should we be measuring them? The good news is that we have role models: Some practices are already doing this. The bad news is that each one is different, specific to its patients’ and community’s needs. But maybe that’s not so bad. After all, every relationship is different.

Yes, “every relationship is different,” and for the most part, healthcare economists and policy makers have paid scant attention to the doctor-patient relationship except in two opposing respects.

On the one hand, Nobel Prize winner Kenneth Arrow and his followers have emphasized the “asymmetry of information” between doctor and patient. According to them, the lopsidedness between the knowledge of doctors and the ignorance of patients is so great as to render patients helpless. Government must intervene in the healthcare market to redress the imbalance of power.

On the other hand, and against the paternalism of Arrow’s view, a “consumer-driven healthcare” movement has emerged according to which patients should have more choice in the kind of care they receive. This choice will occur if patients manifest greater financial responsibility in their medical care through the use of health-savings accounts and high-deductible health insurance. With such measures, it is argued, healthcare would behave more like a free market, costs would decrease, and quality would improve.

While both models seem at odds with one another, both commit the same conceptual error of considering that the primary function of the doctor is to supply an objective service. Hence, neither school has any qualms with identifying the doctor as a “provider.”

But to limit medical care as a “provision” of services greatly misunderstands the complex reality of the therapeutic relationship.

Almost 60 years ago, Szasz and Hollender pointed out that there are three aspects to the doctor patient-relationship: activity-passivity (doctor does “something” to patients); guidance-cooperation (doctor tells patients what to do); mutual participation (doctor helps patients help themselves).

All three aspects are operative, but one may dominate the others depending on the particular circumstances at a given time.

Accordingly, a cardiologist may be “doing” a coronary stent at one point, yet for months prior to that she may have been—perhaps begrudgingly—cooperating with the patient’s desire to avoid taking a statin. And she may spend the next years coaching the patient on best ways to cope with statin-induced muscle pains and to adjust to difficult dietary restrictions.

Of course, all these aspects of care are rendered with great uncertainty as to the particular patient’s ultimate outcome, and parsing the importance of each aspect of care in relation to an uncertain outcome is anyone’s guess.

The first aspect of the doctor-patient relationship (the “activity-passivity” mode) is the only one that policy makers and health economists typically consider, precisely because it involves a “something” that doctors do to patients. That something can (theoretically) be objectively observed, analyzed—and measured by third parties. But in ignoring the other two aspects of the relationship, one inevitably distorts the whole picture of what healthcare is about.

And Szazs and Hollender’s account of the therapeutic relationship may even be too simplistic. Yes, doctors do things to patients, guide them, or help them help themselves. But they may also humor them, scold them, or ignore them altogether, and each action may be appropriate in its own context.

And conversely, patients act on doctors. They can show gratitude (in a variety of ways), and thus enrich them on a personal level. But they can also question them, challenge them, refuse their advice, and keep them on the straight-and-narrow, all-the-while remaining committed to that relationship despite any limitation they may perceive about the care they are receiving.

In truth, a good therapeutic relationship is precisely undergirded by this mutual commitment, where the one will not abandon the other for failing to follow through with the prescribe course of action, and the other will not ditch the one for failing to “deliver” outcomes everyone knows are unpredictable.

Relationships based on commitment are neither captured by the expert-subject model, which primarily focuses on the skills and science of the all-knowing physician, nor by the businessman-customer model, which focuses on how physicians can aim to please patients.

No, the committed therapeutic relationship is truly one of friendship. And any person, entity, or policy that overlooks the friendship aspect of medicine is sure to inhibit, if not altogether destroy, the essence of what good medical care is all about.

Will outcome enthusiasts take stock of the likely outcome of their own enterprise?

Michel Accad is a cardiologist based in San Francisco.

The Great American Hypertension Epidemic of 2017

On November 15, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the meeting of the American Heart Association in Anaheim, CA.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

Only a strong dose of common sense packed in a few lines of text can possibly save us from an otherwise lethal epidemic of nonsense.  Please save the following text on your EHR cloud or hard-drive, commit it to memory or to a dot phrase, and copy and paste it on all relevant quality and pay-for-performance reports you are asked to submit.

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A Health Plan CEO Daydreams

Jim was at his desk, looking weary.

The last few weeks had been brutal.  Despite working twelve-hour days, he felt that he had little to show for it.  His annual board meeting was to take place the next day, and he expected it to be tense.

With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious.  The board members had asked him to present a contingency plan, in case things in DC didn’t go well.

As CEO of a major health insurance company, Jim was well aware that business as usual had become unsustainable in his line of work.  No matter what insurers had tried to do in the last few years—imposing onerous rules, setting high deductibles, pushing for government subsidies—prices had been going up and up.

Premiums, of course, had had to do the same but, evidently, the limit had now been reached.  The horror stories being told at town hall meetings across the country were all too real.  People were fed up, and politicians were feeling the heat.

Something needed to be done to change course, but what?  He did not have any good plan to propose to the board.

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A Guide to Top Medical Journals: A Primer For Journalists

Charles Ornstein is an award-winning healthcare journalist who recently wrote an article in the Boston Globe about an ongoing controversy regarding a top medical publication. Yet Ornstein still wonders about the current status of medical journals:

To help answer Mr. Ornstein’s query, I have asked the editors of top medical journals to submit responses to a simple questionnaire. Here are their answers.

BMJ

What would an alternative title to your journal be? The Journal of Transparent Research

What is your tag line? “Leading the charge against conflicts of interest

What happened at your most recent editorial staff meeting? We discussed possible strategic partnerships with healthcare journalists to get Freedom-of-Information-Act orders. Independent observers should be able to get patient-level research data released from the clutches of industry and their puppet scientists and journals.Continue reading…

The Paradox of Evidence-based Medicine

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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, an alert clinician would make advances using her powers of observation, her five senses (as well as the common one) and, most importantly, her clinical judgment. He would produce a case series of his experiences, and others could try to replicate the findings and judge for themselves.

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Quality v. Quantity

A few weeks 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. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”

Indeed, we all deserve uniform quality measures. Equality in quality!

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