There was a time when scientists were advocates only of seeking the truth.
Lawrence Solomon: John Maddox, skeptic, 1925-2009
Posted: April 16, 2009, 10:05 AM by Lawrence Solomon
By Lawrence Solomon
Sir John Maddox, the legendary editor of the science journal Nature, died this week at age 83. The obituaries were laudatory, as might be expected given his role, over a 22-year career, in elevating Nature to one of the world's great journals.
But few obituaries referred to Maddox's reputation as a skeptic of doomsaying environmentalism and a skewerer of politically correct science.
In his most famous skewering, Maddox in 1988 first published a paper by French scientist, Jacques Benveniste, that supported theories of homeopathy. The paper described experiments in which substances, diluted in water to such an extent that no molecules of the original material remained, retain their biological activity.
Maddox then went to Paris, two experts in tow, to observe Benveniste's experiments first-hand. One expert, Walter Stewart, was a scientific fraud investigator; the other, James Randi (stage name The Amazing Randi), was a renowned magician. The trio then convincingly debunked the homeopathy claim in an article entitled "High-dilution" experiments a delusion.
Maddox's fame as a skeptic began in 1972 with the publication of The Doomsday Syndrome, a book that attacked predictions of environmental calamity. "Population growth, pollution, overconsumption of resources, genetic engineering, economic growth all, say the doomsayers, spell danger to the human race.... Although these prophecies are founded in science, they are at best pseudoscience. Their most common error is to suppose that the worst will always happen. And to the extent that they are based on assumptions as to how people will behave, they ignore the ways in which social institutions and humane aspirations can conspire to solve the most daunting problems."
And Maddox's finale as a sceptic occurred in 2005, following a London meeting of climate change sceptics. As reported in an article in the Guardian:
"Bob May, the president of the Royal Society, said the sceptics were a ‘denial lobby' similar to those who refused to accept that smoking caused cancer.
"But John Maddox, a former editor of the journal Nature, who attended yesterday's meeting, said the sceptics might have a point.
"He did not dispute that carbon dioxide emissions could drive global warming, but said: ‘The IPCC [Intergovernmental Panel on Climate Change] is monolithic and complacent, and it is conceivable that they are exaggerating the speed of change.'"
By 2005, John Maddox had been retired from Nature for 10 years, and Nature was no longer the truth-seeking journal that was its hallmark under Maddox. On climate change, Nature has become, in fact, monolithic and complacent, just like the IPCC positions it supports. Not surprisingly, Nature's reporting of its illustrious editor's death made no mention of his history of scepticism.
lawrencesolomon@nextcity.com
Lawrence Solomon is executive director of Energy Probe and Urban Renaissance Institute and author of The Deniers.
Monday, September 7, 2009
Saturday, September 5, 2009
Testing vs. Talking
Why do doctors run so many tests? Is this purely a construct of defensive medicine, trying to protect ourselves from a litigious society? I would suggest that concern about being sued is only a small part of the equation. A much larger part is an unintended consequence of how physicians are paid and the time constraints of practice.
Physicians (and other "providers") are evaluated via many different metrics. My favorite one is RVUs per clinical FTE. For those of you who are not familiar with such jargon, this is a measure of how much "work" a given MD is doing per the equivalent of a full time clinical position. It is interesting that actually talking to patients is not really considered work. Thus, the feedback we receive from such metrics is that if we invest our time in talking to patients, we are not really working and thus not really paid to do so.
Why should we think that talking to patients is of any value? Medicine should be practiced one patient at a time. Recommendations for interventions (or the wisdom of no intervention) need to be assessed on a patient by patient basis, since the suitability of any particular decision depends heavily upon patient specific circumstances. Even the most pedestrian of encounters may involve multiple different options where ideally patients should be at least reasonably informed regarding their options.
Unfortunately this is very difficult to undertake in our present ambulatory practice environment. As medicine becomes more factory like, the resource which is most short supply is time. Patients are stacked up like jet planes waiting to land at O'Hare. The way to deal with time and throughput pressures is to create a one sized fits all certainty to our encounters. Ordering tests are great for this. Whether it be biopsies, tests for Lupus, allergies, there is a false finality and certainty of a test. It also serves as a great way to force an end to the face to face encounter, thus freeing up the runway for the next plane to land.
Thus, while a CAT scan for a headache may not put money directly in the pocket of the evaluating provider, it spares them the need to discuss the uncertainty of the clinical evaluation of headaches, an activity which can be viewed through the lens of the payment system as not actually being work and thus monetarily almost useless. When faced with uncertainty and a choice to discuss this uncertainty with the patient vs ordering additional tests (even ones we do not directly benefit from financially), testing will always win hands down.
Physicians (and other "providers") are evaluated via many different metrics. My favorite one is RVUs per clinical FTE. For those of you who are not familiar with such jargon, this is a measure of how much "work" a given MD is doing per the equivalent of a full time clinical position. It is interesting that actually talking to patients is not really considered work. Thus, the feedback we receive from such metrics is that if we invest our time in talking to patients, we are not really working and thus not really paid to do so.
Why should we think that talking to patients is of any value? Medicine should be practiced one patient at a time. Recommendations for interventions (or the wisdom of no intervention) need to be assessed on a patient by patient basis, since the suitability of any particular decision depends heavily upon patient specific circumstances. Even the most pedestrian of encounters may involve multiple different options where ideally patients should be at least reasonably informed regarding their options.
Unfortunately this is very difficult to undertake in our present ambulatory practice environment. As medicine becomes more factory like, the resource which is most short supply is time. Patients are stacked up like jet planes waiting to land at O'Hare. The way to deal with time and throughput pressures is to create a one sized fits all certainty to our encounters. Ordering tests are great for this. Whether it be biopsies, tests for Lupus, allergies, there is a false finality and certainty of a test. It also serves as a great way to force an end to the face to face encounter, thus freeing up the runway for the next plane to land.
Thus, while a CAT scan for a headache may not put money directly in the pocket of the evaluating provider, it spares them the need to discuss the uncertainty of the clinical evaluation of headaches, an activity which can be viewed through the lens of the payment system as not actually being work and thus monetarily almost useless. When faced with uncertainty and a choice to discuss this uncertainty with the patient vs ordering additional tests (even ones we do not directly benefit from financially), testing will always win hands down.
Fundamentals of the health care wicked problem
The public conversation regarding the myriad of problems associated with delivery of health care boils down to three basic themes. First there is the theme of fairness and entitlement; we have unfairly excluded significant segments of the population of access to services they should be entitled to. Second, we are going to go broke unless we change how health care is paid for. Lastly, health care as it is presently delivered fails to respond to patient wants and needs, even fully insured and financially well off clients.
Viewing the debate within framework the analysis and potential solutions become both clearer and more murky. Fixing one of the two imperatives automatically makes the other more difficult to address. Scaling back on spending likely aggravates the third imperative.
This raises the obvious question, what is the priority? The answer to that question really depends upon who you might ask and is at the heart of the gridlock we have faced for over 20 years. Any broad reaching federal solution likely will impose the priorities of one group (and likely a minority group) on the remainder of the population. How can one reform health care while maintaining sufficient flexibility to ensure the needs and wants of diverse populations (with different needs and wants) will be met into the indefinite future without bankrupting our children?
Viewing the debate within framework the analysis and potential solutions become both clearer and more murky. Fixing one of the two imperatives automatically makes the other more difficult to address. Scaling back on spending likely aggravates the third imperative.
This raises the obvious question, what is the priority? The answer to that question really depends upon who you might ask and is at the heart of the gridlock we have faced for over 20 years. Any broad reaching federal solution likely will impose the priorities of one group (and likely a minority group) on the remainder of the population. How can one reform health care while maintaining sufficient flexibility to ensure the needs and wants of diverse populations (with different needs and wants) will be met into the indefinite future without bankrupting our children?
Tuesday, August 25, 2009
How American Health Care Killed My Father - The Atlantic (September 2009)
How American Health Care Killed My Father - The Atlantic (September 2009)
Shared via AddThis
This article really hits the nail on the head. It takes a sharp mind and an innovative thinker from OUTSIDE of medicine to have this perspective. This is a must read.
Shared via AddThis
This article really hits the nail on the head. It takes a sharp mind and an innovative thinker from OUTSIDE of medicine to have this perspective. This is a must read.
Saturday, August 22, 2009
Value based Medicine; Paradigm Shift or Marketing Ploy
Value is the buzz word in medicine this year. I must agree that it sounds great but I think we need to step back and make sure that everyone using the term has a common understanding of the term. Value can only really be understood within the terms of exchange and is commonly converted to monetary units because of the almost universal acceptance of these units. Value in the business world is relatively straight forward to define and understand because the architecture involved in exchanges. There is usually a buyer and a seller and the value of the product or service exchanged is defined by a voluntary exchange between the two parties. Each party ultimately receives value from the exchange or the exchange does not happen barring fraud or coercion.
Medical exchanges insert a whole new series of complications into the value equation. Because of insurance, at least one third party is injected into the equation which often results in the the purchaser of the service not being the recipient of the service. This aspect of value in medicine is virtually always glossed over. However, how can one begin to assess the value of any given transaction within the health care realm which has this exchange architecture?
The question becomes value to who? For transactions from which the patient incurs virtually no cost, almost any intervention which does not harm the patient is of value. Physicians as choice architects can generally sway patients to acquiesce to blatantly non-harmful interventions which may be financially beneficial to their practices. However, these transactions may not be of any value to the payer. In fact, virtually no transactions are of value to he payers.
In conventional two way exchanges, either party has veto power. In three way exchanges, it gets much more complex. What should be the rules? Who can and should have veto power? In reality, physicians always have veto power. They essentially cannot be compelled to treat a patient with a given treatment. In addition, patients should always have veto power. They may be ill suited to exercise this because of problems with information deficits. In an insured world where they are heavily insulated from costs, financial considerations are less likely to be a reason for saying no. Whether they decide to agree to a given intervention will be based upon whether they perceive they will be better off, independent of cost.
That ultimately leaves the payer with the most relevant veto. Should it be that majority rules and that the provider and patient can trump any payer veto? If the patient believes the intervention is of value to them, should the payer's vote count for anything?
Assuming the answer to this question is yes, the follow up question becomes on what basis should the payers be able to veto payment for services?
Presumably the answer to this question should be - if the intervention is of any real value, the third party should pay for it. The question then becomes value to who? Which value are we talking about? Is it value to a given patient, the average value to populations of patients, or the value to payers which is the determining factor?
It reminds me a hearing Ralph Nader speak many years ago about the deceptive practice of advertisers who would make all sorts of claims of the nature of "50% stronger" or "last 30% longer" but failed to define stronger or longer than what. The point is that value based medicine is a meaningless term unless it is defined within the context of value to who. This sort of ambiguity relegates the term of value based medicine to a marketing slogan as opposed to any real idea as a driver of health care reform.
Once we as physicians more into the realm of treating populations, as opposed to individual patients or become agents of third parties, we have gone down a dangerous path. I am not ready to face patients and tell them, although you have come to me for managing your health issues, I do not primarily represent your interests. I treat and represent the interests of individual patients. They should decide if there is value in what I offer. No third party who enters into the equation will ever be in a position to place a given patient's interest over their own financial interests.
Medical exchanges insert a whole new series of complications into the value equation. Because of insurance, at least one third party is injected into the equation which often results in the the purchaser of the service not being the recipient of the service. This aspect of value in medicine is virtually always glossed over. However, how can one begin to assess the value of any given transaction within the health care realm which has this exchange architecture?
The question becomes value to who? For transactions from which the patient incurs virtually no cost, almost any intervention which does not harm the patient is of value. Physicians as choice architects can generally sway patients to acquiesce to blatantly non-harmful interventions which may be financially beneficial to their practices. However, these transactions may not be of any value to the payer. In fact, virtually no transactions are of value to he payers.
In conventional two way exchanges, either party has veto power. In three way exchanges, it gets much more complex. What should be the rules? Who can and should have veto power? In reality, physicians always have veto power. They essentially cannot be compelled to treat a patient with a given treatment. In addition, patients should always have veto power. They may be ill suited to exercise this because of problems with information deficits. In an insured world where they are heavily insulated from costs, financial considerations are less likely to be a reason for saying no. Whether they decide to agree to a given intervention will be based upon whether they perceive they will be better off, independent of cost.
That ultimately leaves the payer with the most relevant veto. Should it be that majority rules and that the provider and patient can trump any payer veto? If the patient believes the intervention is of value to them, should the payer's vote count for anything?
Assuming the answer to this question is yes, the follow up question becomes on what basis should the payers be able to veto payment for services?
Presumably the answer to this question should be - if the intervention is of any real value, the third party should pay for it. The question then becomes value to who? Which value are we talking about? Is it value to a given patient, the average value to populations of patients, or the value to payers which is the determining factor?
It reminds me a hearing Ralph Nader speak many years ago about the deceptive practice of advertisers who would make all sorts of claims of the nature of "50% stronger" or "last 30% longer" but failed to define stronger or longer than what. The point is that value based medicine is a meaningless term unless it is defined within the context of value to who. This sort of ambiguity relegates the term of value based medicine to a marketing slogan as opposed to any real idea as a driver of health care reform.
Once we as physicians more into the realm of treating populations, as opposed to individual patients or become agents of third parties, we have gone down a dangerous path. I am not ready to face patients and tell them, although you have come to me for managing your health issues, I do not primarily represent your interests. I treat and represent the interests of individual patients. They should decide if there is value in what I offer. No third party who enters into the equation will ever be in a position to place a given patient's interest over their own financial interests.
Saturday, August 1, 2009
Why things thrive
One of my favorite books I have read in recent years is a book written by the economist Paul Omerod which is entitled "Why things fail". It is a fascinating study of failure of a variety of things ranging from fortune 500 companies, animal species, and civilizations. Its observations have implications in virtually all realms of human activity.
The take home message is that you can predict that things will fail but you cannot consistently predict what will fail, when it will fail, and what will trigger failure. Sometimes stressing an entity or system with a major stress will result in nothing while a small perturbation may result in cataclysmic effects.
The companion question which Omerod does not address directly is how do robust complex entities develop and persist? However, one can infer this from his observations, from the study of human history, and from study of biological systems. I maintain that complex systems, whether human systems or biological systems, have much in common and principles derived from one can be useful in understanding the other. This truism is not newly observed. Charles Darwin was heavily influenced by the preceding work of Adam Smith and David Ricardo in the realm of political economy when he conceived his work on the theory of evolution.
How do complex systems come to exist? There appears to be a tendency for humans to look for some sort of master designer, based upon the belief that complexi systems cannot come into being through self organization. Furthermore, it also appears that humans crave to be able to take on the master designer role, believing that is is possible for humans to take on God-like qualities.
Evolutionary theory and copious supporting observations point to complexity in biological systems developing in a bottum up fashion. Even the most complex systems can develop given sufficient time, feedback loops, and mechanisms supporting diversity. However, for every successful iteration there are likley many failures. Furthermore, the certainty of changing environments means that todays successful iteration will likley be tommorrow's failure.
While we humans desire to create and control complex social systems, I believe we delude ourselves if we think conceive the optimal structure of these systems. Best practices in social systems have developed in an ad hoc way in different places in different times. Many diverse human populations have tried many approaches to human organization and the extraordinary improvements in human existence over the past 400 years are the unintended products of legal and social constructs put in place for other reasons. Good tools do what they are designed to do. Great tools do much much more. Robust social systems adapt like biological systems. Over time adaptable and diverse social systems can respond to and thrive in changing and stressful environments.
What does this all mean? The only thing that never changes is that everything changes. For anything to thrive and survive long term, it must change and adapt and ultimately evolve into something else. The desire to plan and control works well as long as one realizes that for all the planning we do there is a limited realm where we have control.
The take home message is that you can predict that things will fail but you cannot consistently predict what will fail, when it will fail, and what will trigger failure. Sometimes stressing an entity or system with a major stress will result in nothing while a small perturbation may result in cataclysmic effects.
The companion question which Omerod does not address directly is how do robust complex entities develop and persist? However, one can infer this from his observations, from the study of human history, and from study of biological systems. I maintain that complex systems, whether human systems or biological systems, have much in common and principles derived from one can be useful in understanding the other. This truism is not newly observed. Charles Darwin was heavily influenced by the preceding work of Adam Smith and David Ricardo in the realm of political economy when he conceived his work on the theory of evolution.
How do complex systems come to exist? There appears to be a tendency for humans to look for some sort of master designer, based upon the belief that complexi systems cannot come into being through self organization. Furthermore, it also appears that humans crave to be able to take on the master designer role, believing that is is possible for humans to take on God-like qualities.
Evolutionary theory and copious supporting observations point to complexity in biological systems developing in a bottum up fashion. Even the most complex systems can develop given sufficient time, feedback loops, and mechanisms supporting diversity. However, for every successful iteration there are likley many failures. Furthermore, the certainty of changing environments means that todays successful iteration will likley be tommorrow's failure.
While we humans desire to create and control complex social systems, I believe we delude ourselves if we think conceive the optimal structure of these systems. Best practices in social systems have developed in an ad hoc way in different places in different times. Many diverse human populations have tried many approaches to human organization and the extraordinary improvements in human existence over the past 400 years are the unintended products of legal and social constructs put in place for other reasons. Good tools do what they are designed to do. Great tools do much much more. Robust social systems adapt like biological systems. Over time adaptable and diverse social systems can respond to and thrive in changing and stressful environments.
What does this all mean? The only thing that never changes is that everything changes. For anything to thrive and survive long term, it must change and adapt and ultimately evolve into something else. The desire to plan and control works well as long as one realizes that for all the planning we do there is a limited realm where we have control.
Professionalism
I read a review of Paul Starr's 1982 book The Social Transformation of American Medicine and a retrospective of this work published in the Journal of Health Policy, Politics, and Law in 2004. The journal published a condensed version of the original work which has prompted me to order the book. Perhaps the work may be a bit dated given it was published almost 30 years ago, but I was struck by two things. First, present events can be viewed with greater insight given the historical background provided by Starr and in addition, Starr was remarkably prescient in predicting future events.
Starr's analysis of professionalism and power in medicine is enlightening and provided me with a better understanding of the role of claims of professionalism in various political positions of organized medicine. The series of events which occurred and allowed medicine to attain power, status, and money during the 20th century were unique and perhaps not sustainable.
A number of changes have occurred in the health care environment have eroded physician autonomy and status. At the same time concerns have been raised regarding the loss of professionalism among physicians and medical practice in general. My own experience in dealing trainees in general suggests that the elevation of medicine into a high income field has fundamentally changed the types of candidates who we attract to the field. Because medicine is so lucrative, we now attract smart people who place a higher priority on income generation. When medicine was not so lucrative, individuals with primary financial motivations steered clear.
An obvious solution to this problem is to decrease physician compensation to attract people with the right motivations to the profession. However, that might solve one problem and replace it with a less desirable state. What is the goal of providing any reward whatsoever? Ultimately what is the purpose of having physicians and what is the advantage of a professional class vs. someone who we employ or contract with to provide services?
Whether we like it or not in the modern world we must rely on other people to provide us with both things we want and things we need. The spectrum of virtues and faults displayed by those who provide our needs is extensive. You can be assured than none are perfect and it is a reasonable assumption that most operate with their self interest in mind. Even if the health care profession is not driven strictly by self-interest, it will be a rare exception who does not suffer from pressures from constituencies other than patients they serve (family, colleagues, employees).
What we want from our physicians is that they fix our problems. If they get rich honestly by doing so, so be it. Cultivating a virtuous but inept workforce creates more losers than winners.
More money less professionalism
Starr's analysis of professionalism and power in medicine is enlightening and provided me with a better understanding of the role of claims of professionalism in various political positions of organized medicine. The series of events which occurred and allowed medicine to attain power, status, and money during the 20th century were unique and perhaps not sustainable.
A number of changes have occurred in the health care environment have eroded physician autonomy and status. At the same time concerns have been raised regarding the loss of professionalism among physicians and medical practice in general. My own experience in dealing trainees in general suggests that the elevation of medicine into a high income field has fundamentally changed the types of candidates who we attract to the field. Because medicine is so lucrative, we now attract smart people who place a higher priority on income generation. When medicine was not so lucrative, individuals with primary financial motivations steered clear.
An obvious solution to this problem is to decrease physician compensation to attract people with the right motivations to the profession. However, that might solve one problem and replace it with a less desirable state. What is the goal of providing any reward whatsoever? Ultimately what is the purpose of having physicians and what is the advantage of a professional class vs. someone who we employ or contract with to provide services?
Whether we like it or not in the modern world we must rely on other people to provide us with both things we want and things we need. The spectrum of virtues and faults displayed by those who provide our needs is extensive. You can be assured than none are perfect and it is a reasonable assumption that most operate with their self interest in mind. Even if the health care profession is not driven strictly by self-interest, it will be a rare exception who does not suffer from pressures from constituencies other than patients they serve (family, colleagues, employees).
What we want from our physicians is that they fix our problems. If they get rich honestly by doing so, so be it. Cultivating a virtuous but inept workforce creates more losers than winners.
More money less professionalism
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