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Saturday, February 26, 2011

Sound Bite Medicine

Peggy Noonan wrote an interesting column in the WSJ this morning ( entitled "The internet helps us get serious". The basic premise of this piece is the internet has again changed how information is presented and appears to be capable of rescuing us from the sound bite mentality.  As she summarizes:
In the past quarter-century or so, the speech as a vehicle of sustained political argument was killed by television and radio. Rhetoric was reduced to the TV producer's 10-second soundbite, the correspondent's eight-second insert. The makers of speeches (even the ones capable of sustained argument) saw what was happening and promptly gave up. Why give your brain and soul to a serious, substantive statement when it will all be reduced to a snip of sound? They turned their speeches into soundbite after soundbite, applause line after applause line, and a great political tradition was traduced. 
But the Internet is changing all that. It is restoring rhetoric as a force. When Gov. Mitch Daniels made his big speech—a serious, substantive one—two weeks ago, Drudge had the transcript and video up in a few hours. Gov. Chris Christie's big speech was quickly on the net in its entirety. All the CPAC speeches were up. TED conference speeches are all over the net, as are people making speeches at town-hall meetings. I get links to full speeches every day in my inbox and you probably do too. 
The reason that TV moved to the sound bite was time pressure. The time real estate associated with news  programming became so precious that no one could devote sufficient time to fully explore an idea or point of view. What the internet is doing is moving information exchange from one way to two way and while there are time constraints, they are simply less constraining. People are abandoning broadcast in droves.

So, what does this have to do with medicine? Reading this article made me realize that we practice sound bite medicine for many of the same reasons that conventional news organizations practice sound bite news. Our information exchanges with patients occur in remarkably time constrained circumstances and the results are predictable. We simplify the messages so that they can be conveyed in the few moments we have with patients and are framed to virtually guarantee what decision will be made. Here, get this blood test to screen for prostate cancer. We will discuss the results later. You need to get your mammogram and if something is identified as worrisome by the radiologist, we will send you to the surgeon or radiologist to have something else done. You need to be on this statin to prevent heart attacks.

Who is going to question these recommendations presented as they are? Who wants to have cancer or heart attacks?  However, the usefulness to any given patient is not so overwhelmingly certain. How many patients are in a position to ask questions such as ..Do I really want this test or drug? How likely will it be that I actually benefit from this? What is the likelihood of harm? No many given how fast the throughput that is needed to feed the machine. Can there actually be any discussion?  Not really since the waiting room is full of patients waiting to get their sound bites.

Granted there are many people who are the equivalent of politically agnostic. They do not really appear to care even though they have a dog in the hunt. However, there are many who will be willing partners in shared decision making but the architecture of present encounters allows them only time sufficient to exchange sound bites with their caring physicians.  These patients have great value since they are the ones who force health care providers to reflect upon what they are doing and make sure we do not simply default to believing all of our sound bites.

I often hear my colleagues ridiculing the health information posted on the net but I would argue that the those who seek information there are infinitely better informed than those who rely on their physicians. This is true not because their physicians are generally uninformed but because they are unwilling or more  likely unable to devote the time required to go beyond simply sound bites.

The internet has the potential to create really valuable  tools which can both provide much enhanced educational and disease management tools for patients that go beyond platitudes and sound bites. There is risk involved but the risk is probably greatest to the relative monopoly of the conventional health care industry. The internet has disrupted the print and broadcast journalism industry and while those displaced lament the changes, the public now has access to information which they could have only dreamed up a generation ago. Journalism is alive and well. Similarly, changes in information flow in health care are almost certainly going to disrupt the historical doctor-patient relationship. As the decisions get more complicated and the goals for individual patients more nuanced, the sound bite approach won't cut it. Patients deserve and will demand better and if we do not deliver it, they will get want they want from other quarters.

Sunday, February 20, 2011

What is the right answer? Framing and medical decision making

In the Sunday NYT, Denise Grady reports the results of a study out of the University of Florida where they have determined that open breast biopsies appear to be vastly over utilized. They reviewed a Florida database and found that the open biopsy rate was approximately 30% while there is a consensus among experts that the rates should be closer to 10% (

What I though was the most intriguing part of this report is the fact that we are now setting up quality standards which are measured not by the fact that we get our patients to do any one  thing, but that we now appear to be targeting some degree of variability (or diversity) in decisions that are the result of our actions. As noted in the article:
She said that when she asked surgeons in the study why they were doing open biopsies, many said patients wanted them. “My comeback was, ‘Do you think you had an inherent bias in the way you explained it?’ ” In the past seven years, she said she had only one patient choose an open biopsy over a needle biopsy.
In the book "Nudge" Cass Sunstein uses (?coins) the term choice architect. We are choice architects having what could be characterized as an unhealthy influence over our patient's decisions. I would venture to suggest that there are very few situations where our we should consider it desirable if our patients followed our recommendations all of the time, particularly when we are dealing with some issue in an asymptomatic person who by all other measures is without disease. 

What this article talks about is the possible driver of the discrepancy between the ideal and real rates of open biopsy, that being the reticence of surgeons to refer to radiologists to do needle biopsies because of the loss of business. Before radiologists rejoice in their new found income stream, it might behoove us to look and an earlier choice also shaped by other choice architects, that being the choice to do mammography, on whom, starting when, and how often. These same issues arose when the US Preventative Services Task Force looked at breast cancer and found that screening mammography impact  was marginal at best in a number of subgroups and its impact so modest that it seemed reasonable that at least some women (and perhaps many women) should be forgoing screening if the data were presented in a balanced way.

While the current article presents the figures as being very black and white, the reality is almost certainly more nuanced. Needle biopsies are very small and although I am not a pathologist, I suspect that the risk of sampling error is much greater than an excisional biopsy. Not all cases are optimal for needle biopsy and depending upon the individual and their preferences, some circumstances warrant the more aggressive diagnostic approach. The question becomes if there is no one right answer and the "ideal" is for the doctor patient discussion to yield a variety of decisions, how you define where the target should be?

Furthermore, how will this translate into other metrics? Should the targets for blood pressure control or  HA1c be different for different patients? Of course they should but how do quality metrics account for this? We also must ask the question as to whether we should be held accountable to individual patient vs. an aggregate goal. If a given patient, after being explained the pluses and minuses of needle or open biopsy, wants an open biopsy because of concerns about sampling error, should we accommodate them or tell them the open biopsy is simply not a choice for them?

Now that the overwhelming majority of encounters in health care occur outside of an urgent setting, where decisions revolve around acting now in some way to prevent some low frequency event which may happen in the future (often way in the future), this is what physicians and patients will face. Physicians need to understand that what they have come to believe is true and base their recommendations to patients will change over time. Patients also need to understand that if they are not engaged in the decision making process, the end result is not likely to reflect their desires. Finally, all parties need to understand that we have wandered into a realm where the results of our decisions will almost never be clearly linked to a given outcome in a given patient. This may be the hardest pill to swallow since both patients and physicians desire the control associated with targeted actions which purportedly save lives. The truth is not so clear.

Saturday, February 19, 2011

What is more important - Money or Lives?

I am reading a very entertaining book, "Packing for Mars" by Mary Roach. It touches upon a host of issues impacting space travel and the ongoing efforts to simulate in flight scenarios on earth. It contains a great mix of fascinating scientific observations and bathroom humor.

The chapter I am reading now is focused upon the development of escape technologies to facilitate survival of space travelers in the event of catastrophic capsule breakup either on the way up or the way down. It never occurred to me prior to reading this chapter but the issues being addressed by NASA regarding the space shuttle (and future space vehicles), are not unique. If we are going to spend large sums of money to engineer escape technology for a vehicle that flies only rarely, why not invest comparable or larger sums to deploy the similar technologies to protect the hundred of thousands of airline travelers who occupy our skies every single day?

Granted there are serious engineering challenges to creating separate and distinct deployable oxygen sources for each seat on an aircraft which will need to be also equipped with an ejection device and a parachute. These challenges are substantially less than what will be required to provide protection for travelers on a vehicle entering or leaving space. Why don't we have the technology built into aircraft that will guarantee my survival if something happens to the plane at 30,000 feet?

The answer is actually very simple. It's all about the money. While technically possible, it is financially impossible. Does that mean we value money more than lives? Of course not. If we were to mandate such technology, it would simply have the effect to make airline travel unavailable, shunting people to other forms of transportation that are slower and more dangerous.

I think the lesson from this is not that we need to look at decisions using the filter of lives or money, but the perspective of lives and money. Short term perspectives create a false choice. Money is a proxy for resources which can be deployed to improve the human condition. Fewer resources means tougher choices as to where to deploy them and likely lives lost. The most publicly visible product of the engine which creates resources to better human conditions on earth is wealth, which for a number of reasons has been colored with an unflattering brush.

However, to me it is clear. Wealth means additional resources which are deployed to make lives better and to save lives via a myriad of mechanisms. For those who are fixed in the mindset that the world is a zero sum game, that anyone's gain must be linked to someone else's losses this is a hard concept to grasp. Paul Rubin has written about this in his paper on "Folk Economics"  (

Decisions are made every day regarding deployment of scarce resources which impact the lives of people. We do not deploy survival systems on airplanes and because of this people do die. However, scarce resources which might have been less usefully deployed to create safer airline travel are deployed elsewhere which greater overall impact on human life.. or at least we hope.

In medicine, we really have not come to grips with this concept. No intervention, no matter how expensive, no matter how futile, can be withheld when the primary justification is cost. Even if we bankrupt the system for future generations by unwise deployment in the present at the potential cost of thousands if not millions of lives, that appears of little immediate concern. Potential impact on lives now trumps availability of resources for future generations. However, we can basically be certain that fewer resources and less wealth means more lives lost.

As I have written before, a major reason for this quandary is the architecture of resource pooling. Using our own resources, we make trade offs every day. You might purchase the used car without the side impact air bags or the subcompact which save gas but provides less protection in an accident. Not everyone pays the Whole Foods premium for organically grown food. Many of us travel faster than the speed recommended for safest travel in our autos, but we value the time saved and enjoy the thrill of higher speed travel. I could go on and on (but I won't). These are all personal choices made with individual resources.

This simplicity comes to complete halt when resources are commonized and what was once simple becomes difficult bordering on impossible. Increasingly common resources appears to drive their deployment to marginally less and less useful use and that waste means that lives will be lost. It is not about money or lives, it is money and lives. Sticking to rules which create more wealth and resources means saving lives.

Sunday, February 13, 2011

On being an outlier

I saw an interesting piece in the New York Times today regarding psychologist Jonathan Haidt.
It was identified by Jonathan Haidt, a social psychologist at the University of Virginia who studies the intuitive foundations of morality and ideology. He polled his audience at the San Antonio Convention Center, starting by asking how many considered themselves politically liberal. A sea of hands appeared, and Dr. Haidt estimated that liberals made up 80 percent of the 1,000 psychologists in the ballroom. When he asked for centrists and libertarians, he spotted fewer than three dozen hands. And then, when he asked for conservatives, he counted a grand total of three.
“This is a statistically impossible lack of diversity,” Dr. Haidt concluded, noting polls showing that 40 percent of Americans are conservative and 20 percent are liberal. In his speech and in an interview, Dr. Haidt argued that social psychologists are a “tribal-moral community” united by “sacred values” that hinder research and damage their credibility — and blind them to the hostile climate they’ve created for non-liberals.
This article led me to his TED talk at It is well worth listening to. The message he sends is that there are innate moral circuits in our brains and that liberals and conservative cultivate differently. What is common to both groups is that they firmly believe in the same thing; that they are right and that this certainty actually hinders their efforts to get to the "truth".

I have long since realized that my views are outlier views in my environment, an academic medical center and university. I must say that it is healthy to have one's views constantly challenged. I have an open mind and when I am wrong, I find it easy to separate my ideas from my ego. When wrong, admit it and move on. I am used to this given that I am surrounded by people who hold many views to the contrary. It forces me to re-examine what I think and why I think the way I do. It is something akin to intellectual weight lifting, with a toning effect on my intellectual fitness.

I was amazed last week when I met with close friends who have a different political bent and they remarked they listen to Glenn Beck and Rush Limbaugh. Perhaps they were simply tired of hearing many of their friends and colleagues simply parrot when they already believe? It is unfortunate that they need to listen to entertainers to get a conservative spin. The university should be a place a real intellectual melting pot, where diversity is more than a marketing slogan.

Saturday, February 12, 2011

Biomedical research and entitlements

During my professional lifetime I have seen the ebb and flow of funding for biomedical research. I have been involved in this world, being supported by Federal grants and mentoring younger physician scientists. I remember watching the pay lines in the mid-90's drifting down briefly into single digits, driving many young researchers into private industry or some non-research career. The economy recovered, federal tax receipts soared, and funding for the NIH essentially doubled (although not in inflation adjusted dollars). 
While everything looked rosy for almost a decade, the underlying trends in the growth of entitlement programs were slowly but inexorably crowding out discretionary spending, including spending on biomedical research. 

A series of economic and political bumps distracted us from the entitlement time bomb. We balanced our federal budgets in late 1990's, although this was partly due to the dot-com bubble which collapsed at the end of the decade.  The global war on terror served as a major distraction starting in 2001, and siphoned off money into defense spending. Any concern regarding entitlement growth during this time of the Bush presidency was deftly deflected by assumptions that all could be made well by simply paring defense expenditures. despite the general long term trend toward decreasing defense spending. 

In the mid 2000's the economy grew rapidly rapidly, much like Bernie Madoff's investment scheme, both based upon faulty fundamentals. However, when the real estate bubble burst, the day of reckoning grew nearer.  Tax receipts plummeted and federal spending exploded. Furthermore, the prolonged recession exposed profound weaknesses in state and local government finance, also saddled with exploding entitlement and pension costs. 

The obvious truth is that the Federal government cannot be all things to all people, despite the desire of politicians to wish it so. Entitlement programs such as Medicare and Social Security served as excellent mechanisms for politicians to purchase votes in current elections while deferring the actual costs to future times. However, the future is arriving with a vengeance. 

We can disagree whether investment on biomedical research is an appropriate use of Federal tax dollars. I think it has proven to be a good investment both in terms of the impact of the discoveries on care and in terms of creating robust sources of new tax revenues. Similarly, basic and applied programs such as the space program spun off a host of innovations which fundamentally changed our world. Some may argue that all of these investments would be better coming from the private sector. I may be biased but I look at the explosion of biomedical research driven by the NIH in the latter part of the 20th century was unlike anything in history.  

What is not contestable is that we will have no reason to have these discussions in the future when the entirety of discretionary spending has been swallowed up by the growth of entitlement spending. Defense spending can basically disappear entirely and do nothing but defer the day of reckoning by less than a decade.  We can raise our tax rates to near 100%. Historical data has shown that this does not result in major changes in collections as a percentage of GDP. All our passionate pleas on Capital Hill for commitment of more resources to noble endeavors such as biomedical research will fall upon deaf ears when the tax receipts are not there and whatever that is collected is already committed before the budgeting process has begun. 

We simply cannot have both robust discretionary spending needed to support our NIH model of biomedical research and uncontrolled growth in entitlement spending. If we want to be advocates of Federal investment in biomedical research, we have to be harshly critical of the out of control entitlement programs which are completely consuming the pool monies which have historically supported these activities . 

Accountable Care Organizations: Another exercise in triangulation

We are at a cross road. We cannot continue to travel down the road we have been traveling. We are bleeding and going deeper and deeper in debt. Even the most optimistic actuarial projections do not contest this. The only point of contention is when the day of reckoning will occur.

Our ability to respond rationally and effectively is limited since so much of our resource allocation machinery in health care has been moved into the political realm and not surprisingly, there is not sufficient political will to make impossible political decisions. Anyone within the political realm who attempts to explicitly acknowledge that scarcity matters will never be elected or at least re-elected. You cannot say no to the electorate and because of those constraints, we are virtually guaranteed to spend more than we should and allocate resources inefficiently when they are moved into the political realm. It has become a political hot potato to actually admit that there are limits to what can be done. From yesterday's WSJ:

Indiana Gov. Mitch Daniels, who is considering a run for the 2012 Republican presidential nomination, veered from his party’s orthodoxy on end-of-life care Friday, suggesting the nation cannot afford to provide every treatment and technology available for every single dying patient.
“We all want to live forever. We want everything done to help us,” he told health care reporters during a discussion of Medicare and its financial pressures. “And we cannot, no one can, do absolutely everything that modern technology makes possible for absolutely everyone ’til absolutely the very last day, the very last resort.”
He added that he understands the urge by families to push for what may be futile care. “It’s the most human thing in the world,” he said. “Your loved one is in desperate shape.” He said “we can try this thing that has almost no chance of working” but questioned whether it is worth it, especially given that “it’s going to cost an incredible amount of money.”
Many health care experts have voiced similar views, saying doctors and families need to do a better job at making choices at the end of life, but the subject has been politically taboo.

Politicians simply cannot make these decisions with "commonized" resources. In addition, private insurers may be equally bad at this. Out of the wilderness comes the ACO to the rescue. From obscurity no more than five years ago the ACO has moved to the centerpiece of the most ambitious piece of legislation of my lifetime. It is a brilliant political move which has played upon physician egos to move making the tough (if not impossible) decisions from the insurance companies and state bureaucrats to physicians. However, we are going to find ourselves in the unenviable position of which party we will need to team up with to achieve our goals of both saving money and improving quality of care. 

That is the problem with triangles or financial arrangements where it is not clear who the buyers and sellers might be, and a clear understanding of who  is paying the bills. There is no limit to the appetite of patients for consuming health care when consumption is unlinked to their individual resources. In the realm of little or no addition cost for any service rendered, it is essentially impossible to define value or lack thereof.  If physicians team up with patients we cannot control costs. Make efforts to control costs and we are forced to team up with payers to beat up on patients, particularly if the model is based upon gain sharing from cost savings that derive from stinting on care. 

The retort is that it is both savings and quality which matter. However, the only real hard measures revolve around dollars and cents. We have many systems that are very good at counting money. On the other hand, quality measurement in health care is in an infantile state and is for the most part unmeasurable and infinitely open to gaming. 

The actual consumers of health care need to wake up and understand that their needs are best served when they directly control the resources needed to purchase the health services they desire and need. When the first financial transactions involved are to take all the resources away from them and shunt them to other parties, they have lost almost all leverage. As structured now, responsiveness to patient needs become blunted by the creation of very long and inconsistent feedback loops, either through the electoral process or through annual benefit selection activities, neither of which are particularly robust.  It has taken over 50 years to show that the third party payment model for healthcare has spawned a system which both costs too much and delivers too little of what people actually need and want.