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Archive for October, 2013

Thursday, October 31st 2013

A Medical Education Bubble

There’s a nice, brief editorial ahead of publication in the New England Journal of Medicine. Everyone needs to consider this when discussing American physician earnings; especially as compared to the rest of the world.

[I]f we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

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Thursday, October 31st 2013

The Falliability of Memory

I am fascinated by the faliability of memory. Especially episodic memory.

You and I really don’t remember what we think we remember. It is rarely accurate and yet people are utterly convinced of that their memory is accurate. There are obviously huge implications. Think criminal or civil law.

[Dr. Elizabeth] Loftus discovered that she could modify memories with startling ease. After showing a film of a crash, Loftus asked some volunteers if they “saw a broken headlight” and others if they “saw the broken headlight.” Those who got the latter question were twice as likely to say yes – though, in fact, the film showed no broken headlights.

Loftus was fascinated, and she soon turned her attention to criminal trials. Suspicious of the accuracy of eyewitness identifications, Loftus conducted an experiment in which volunteers looked at photographs of six faces while listening to a story of a crime.

One face was identified as the criminal, five as innocents. Three days later, Loftus showed the volunteers four photographs: one of an innocent character from the crime story, and three of new people. Sixty percent of volunteers identified the innocent character as the perpetrator from the story. They recognized a familiar face but muddled their associations with it.

[...]

One study in particular bolstered Loftus’ belief that much memory is malleable. In a now-famous experiment, Loftus told a volunteer that she had spoken with his mother and learned four things that happened to him as a 6-year-old.

She then ran through three real memories and one fake one. The volunteer sometimes claimed to remember the fake memory, which involved getting lost in a shopping mall then getting rescued by an elderly stranger. (Planting a more traumatic memory would be even more illuminating for psychologists, but researchers try to avoid permanently scarring their volunteers.)

Even odder, the volunteer would usually be happy to elaborate on this implanted memory. His panic, his confusion, his relief; it was all there, hidden away in his memory. Except that it wasn’t—it was all in his imagination. With just a small bit of coaxing, Loftus could insert this memory even into the most skeptical minds.

Or psychiatric illnesses.

Psychologists Miriam Lommen and colleagues studied 249 Dutch soldiers were deployed for a four month tour of duty in Afghanistan. As part of a study into PTSD, they were given an interview at the end of the deployment asking them about their exposure to various stressful events that had occurred. However, one of the things discussed was made up – a missile attack on their base on New Year’s Eve.

[...]

Eight of the soldiers reported remembering this event right there in the interview. The other 241 correctly said they didn’t recall it, but seven months later, when they did a follow-up questionnaire about their experiences in the field, 26% said they did remember the non-existent New Year’s Eve bombardment (this question had been added to an existing PTSD scale.)

Susceptibility to the misinformation was correlated with having a lower IQ, and with PTSD symptom severity.

I think this is one of the most fascinating parts of not just cognitive study but all of neuroscience.

Functional neurosurgery may hold promises to improve memory, not just in pathology (such as dementia), but in normal individuals. Initial studies show poor episodic improvement, but who knows what the future holds. And I wonder the implications of that for these “false” memories.

Wednesday, October 30th 2013

Big Data & Insurance

I like reading Mark Stephens (to separate from others who also use the Cringely persona). Every once in a while he strays into the intersection of his world and health care. In a recent post the argument seems to be that big data has allowed the underwriters to hyperspecifically target to deny or price out individuals at risk.

[I]n the 1990s something happened: the cost of computing came down to the point where it was cost-effective to calculate likely health outcomes on an individual basis. This moved the health insurance business from being based on setting rates to denying coverage. In the U.S. the health insurance business model switched from covering as many people as possible to covering as few people as possible — selling insurance only to healthy people who didn’t much need the healthcare system.

It’s a nice theory but I don’t think this has played a large role in the rise of the uninsured in America. I think its small potatoes in the factors that are driving such.

Many states have specific restrictions on the use of individual data in underwriting. New York and Vermont have essentially pure community rating (at least for some insurers). Many other states have other, less restrictive but still important limitations on the use of individual data in underwriting or on how it can be used to determine premiums. These include Maine, Rhode Island, Massachusetts, Connecticut, New Jersey, Washington, Oregon, Colorado, Minnesota, North Dakota, South Dakota, Iowa, New Hampshire, Montana, Nevada, Utah, Kentucky, Idaho, Louisiana. All of these restrictions put some brakes on the influence of big data in moving underwriting much. Not that such methods aren’t nowadays used by health insurance actuaries but the influence may be overstated.

The fact is that the majority of Americans continue to receive their health insurance through group plans, primarily through their employers. And most of those people get their insurance through large group plans where such individual underwriting has less to no influence on premiums.

The rise in the percentage of uninsured correlates nicely with the decline in employer provided insurance and that reflects the growing costs of premiums. Indeed the individuals buying insurance on the open market, those you would imagine most hurt by complex underwriting techniques based on big data, has remained relatively stable.


Source: U.S. Census Data

There are plenty of factors behind the rise in group premiums which have driven employers to drop health insurance as a benefit but I don’t think the use of big data by actuaries is a major one of them.

Wednesday, October 30th 2013

Where We’re Spending Healthcare Dollars

Tuesday, October 29th 2013

Obamacare Is Leading To Canceled Insurance Plans

Across Fox News and the internet are stories of individuals having their insurance plans canceled or not offered for renewal as a consequence of Obamacare. In the place of their previous plans they are being offered more expensive health insurance options.

This despite President Obama’s promise.

Let’s just get to it, that promise by the President was stupid because the Affordable Care Act was designed to basically costs people with bare plans, with marginal benefits specifically to lose their insurance.

Forbes is running a composite piece of stories out of the AP and Kaiser Health News and others, comparing how many plans have been canceled versus how many people have been able to sign up for new plans in the exchanges.

Needless to say the headline reads: “More Americans In 3 States Have Had Their Insurance Canceled Under ObamaCare Than Have Filed An Exchange Account In All 50″

Technically true.

But Sarah Kiff over at Wonkblog explains why this is happening and why this was actually a planned consequence of the Affordable Care Act.

Some — or maybe even most — of the plans offered on the individual insurance market right now don’t meet certain requirements in the health-care law. They may not offer preventive care without co-payment, for example, or leave out coverage of maternity care, one of the health-care law’s 10 essential benefits.

And insurances simply aren’t grandfathering in these plans as their underwriting changes. So they’re having to cancel them because they don’t meat the requirements under the law. And people are losing their plans.

The stupid thing isn’t necessarily that this is happening. If you’re a proponent of the Affordable Care Act you’ll see the more expensive plans people may have to buy as a necessary thing for the success. If you’re an opponent this doesn’t change your opposition.

What’s stupid, and should be universally agreed as such, is the fact that the administration pretended like this wasn’t going to happen. Including, most unforgivably, the president himself.

Friday, October 25th 2013

Transparency And Volume Can Help Healthcare

Competition can be good for driving down the costs of healthcare. A lack of transparency is one obstacle to legitimate competition. Prices are negotiated between payers and providers without a sense from the actual consumer or a sense of what payers have negotiated with other providers. Providers keep their numbers lower to upwardly influence their negotiations with payers.

I’ve written before about Devi Shetty and his ambitions in India and the Cayman Islands. What I largely took away from him is efficiency and volume and how regulations increase costs. But a big part of his effort is also transparency in costs.

And while I don’t know if it will stick, such transparency is coming in small pieces to the U.S.

Here’s a profile of the Surgery Center of Oklahoma which is publishing its prices, taking cash or direct payments only and negotiating directly with businesses as a matter of course.

Of course, one thing the Affordable Care Act does very limit for is transparency. The hopes for this as a true trend and as a disruptive force in American health care seem muted at best.

But here’s to hoping.

Thursday, October 24th 2013

The Hands of Healthcare

I’ve previously written about how technology threatens physicians futures. There are some big proponents of computers doing what docs currently do and potentially doing it better. Whether its Watson dong oncology or a machine doing conscious sedation. This latter is the new thing,

Patients are hooked up to Sedasys and sedated intravenously. While connected, a patient’s condition is monitored by the machine. It measures oxygen levels, for instance. If there is a problem, the machine alerts the physician, and is supposed to take action, such as increasing the oxygen supply and stopping the anesthesia, and resumes only if the patient’s condition normalizes.

Patients also wear an earpiece, in case they drift into too deep a level of sedation and need to be awakened. As a doctor or nurse would do, the machine would, through the earpiece, tell the patient to wake up.

Its coming, even for surgeons eventually.

Saving grace might be the lack of a human touch.

Wednesday, October 23rd 2013

Healthcare Of The Rich & Famous

People sometimes try to generalize the care that famous people receive. There’s been some controversy after Angelina Jolie revealed she was BRCA positive and opted for a double mastectomy. Another example might be when other patients try to rush back to imitate the rehab of a professional athlete.

Or when we look to the care received by Presidents.

If even our most prominent and well-connected citizens can’t get the best evidence-guided care, where does that leave the rest of us? Though doctors are some of the most hypereducated professionals around, they frequently don’t deliver care that has stood up to the most rigorous research.

I would argue though that often times patients don’t want evidence-guided care however. They want the hi-tech and most informative care; the care they saw on television.

Evidence-based care is for the population as a whole. If you do it for everyone the population sized outcomes will be better. But patients are individuals and they have trouble understanding in terms of such epidemiological measures.

No that cardiac CT scan likely won’t change our individual outcome and there are low risks. But we want to know what it shows and what it adds to the prognosis and in the off chance we’re one of the unique where it finds something.

No this microdiskectomy with two weeks of pain won’t lead to a better outcome at a few months compared to being conservative but we want the chance of relief now.

I’m not sure that sometimes it’s a matter of better informed consent or communication with patients. Not just sometimes but perhaps often patients perceive more as better and no office visit or computerized informed consent it going to disuade that.

Wednesday, October 23rd 2013

Empathy In Medical Training

I think I lost some empathy during medical school when I started my clinical rotations. There’s some evidence I’m not alone in the literature. Danielle Ofri has written a book on physician empathy and what it means for patients. And she’s commented on the loss of empathy during the third year of medical school over at Slate,

Students are not just learning medicine during the third year of medical school; they are learning how to be doctors. Despite the carefully crafted official medical curriculum, it is the “hidden curriculum” that drives the take-home messages. The students astutely note how their superiors comport themselves, how they interact with patients, how they treat other staff members. The students are keen observers of how their supervisors dress—and how they may dress down those around them. They figure out which groups of patients can be the object of sarcasm or humor, and which cannot.

On a daily basis, the students witness fear, anger, grief, humiliation—in patients and doctors alike—all of which are largely unacknowledged. They see egos rubbing up against each other, hierarchies at play, bureaucracies in action. They observe that many of the niceties of patient care fall prey to the demands of efficiency and high patient turnover. Much of what they learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.

It’s no wonder that the third year of medical school figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees.

Very true. A first year medical student is something more optimistic and bright eyed than most attending physicians and these initial years of clinical training seem to play a lot into that change.

While it seems to level off in the evidence as physicians go through training, I personally have found empathy a difficult thing to preserve. I imagine much of that has to do with the patient populations I’ve worked with, especially early in my training.

Like many interns and residents my early training has dealt with individuals often times with significant social stresses, poor socioeconomic factors, poor medical compliance and poor health literacy. There are many self inflicted health problems. These can be frustrating interactions for any physician, especially new ones.

But what perhaps is more unique to my training and has perhaps dealt my empathy a larger blow is the trauma population I’ve cared for. I spent the vast majority of my early years of training a the large trauma center for a sizable encatchment. It is one thing to see patients do harm to themselves by refusing to comply with medical advice or by daredevil stunts that end in injury. That is trying enough. It is, at least for me, considerably more stress on my optimism and faith in humanity to see people injure others either intentionally or even by negligent stupidity.

And while it must not be the case, it always seems those at fault get the easy end of it and the innocents take the brunt of the injury. That drunk driver has some contusion he’s going to be fine from it always seems; it’s that nine year old in the car he hit who is struggling.

Empathy is tough to preserve during the early years of training; especially really early in that third year of medical school. But it’s important and schools are starting to pay more attention to such and trying strategies to try to preserve it in their students and trainees. I know those programs are going to grow and I think they’re worthwhile.

Tuesday, October 22nd 2013

Bias & Poor Communication Skills

Patient advocate Steve Wilkins has an interesting personal story up at his blog Mind The Gap. It is really worth a read.

In short he reports poor communication and planning with several physicians who appeared to hold a relatively poor opinion for his wife’s future with recurrent NSCLC.

It sounds like really terrible communication between multiple physicians and his family.

He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.” The doctor never called us back.

He reports his wife is improving back on a tyrosine kinase inhibitor, despite some of the physicians they saw seemingly having reluctance about further treatment.

But I’m not sure their anecdote speaks to a failure based on bias. I would argue what comes across as a bias in this story is really physicians doing their job. Here is what he says about the ordeal,

Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door. These attitudes and beliefs color the decisions clinicians make.

[...]

Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about…the person’s odds of survival – slim to none.

You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.

But physicians are supposed to prognosticate and that’s supposed to help drive the discussion. Advanced, recurrent adeno does have a poor prognosis. It seems to me a thoracic surgeon should seriously question the utility of a risky, painful, invasive procedure and have a discussion on the merits of such. Similarly for an oncologist discussing chemotherapy; even chemotherapy as comparatively well tolerated as erlotinib. These discussions don’t appear to have happened appropriately and that seems to be the failure of the story. Prognostication is imperfect but I don’t think though that represents a bias or something inappropriate in these settings.

Beyond “people’s lives…cut short” by “wrong conclusions” plenty of cancer patients in this country get aggressive treatments that offer extremely poor chances of contributing to their survival or quality of life. These treatments often have side effects and consequences including hastening death if by no other means than by lowering functional status (which is something strongly associated with survival). I would argue in my neurooncology experience probably far more people get unnecessary, overtreatment than don’t get the care they should based on biases.