"Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

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Sometimes I think I sound like a real medical nihilist, since many of my blogs have been about purported treatments that are ineffective, dangerous, done too often, and cost a lot of money (Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?, December 24, 2010; Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011; Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011).  It is a somewhat distressing feeling. I am a doctor; I want to help people, to relieve their suffering, to help facilitate the cure of their diseases. More than that, I am a family doctor, and have a strong preference for prevention, for early detection of disease when it is still treatable rather than waiting for it to be too far gone for treatment to be effective. In addition, I have regularly criticized our health non-system for leaving out too many people, creating financial disincentives for them to seek care early. This leads to their waiting until their diseases become so uncontrolled that they present to the emergency room, then require admission and costly care, making it worse for them (most important) and more expensive for everyone. So I think prevention and early intervention is a really good thing, and it would be great to have tests that could identify disease early in its course so that we can change its trajectory.

But because I want these things to be true doesn’t make them true, as I discuss in the recent post Avastin®, Plan B®, and Magical Thinking, December 31, 2011. Because we can screen you for something doesn’t mean that we should; because a test can be done doesn’t mean that it is a good test. "A good test", in my opinion, is one that has sufficient sensitivity (rate of being positive when a condition is present) or specificity (rate of being negative when a condition is absent) to tell us whether a you have a disease, or if it matters. Because it can be done also doesn’t mean that it is cost-effective. Because a treatment exists doesn’t mean it is a good treatment, a safe treatment, an effective treatment. And, as with most things being sold, the greater the publicity and advertising around it, the more it means someone will be making money on it, which does not exclude its being of benefit, but is certainly not the same thing.

Sometimes, when evidence is discovered that a test or treatment is not of benefit, eventually we stop doing it. "Eventually", however, may be a lot longer than you might think. In a recent “Viewpoint” in JAMA, Prasad, Cifu, and Ionannidis address “Reversals of established medical practice: evidence to abandon ship”[1]. They note that while “Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new interventions outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not.” They go on to discuss a number of treatments that have been “standard of care” but were shown by good, randomized controlled trials, to be ineffective or even dangerous (not to say expensive). These include stenting of coronary arteries for stable coronary artery disease (CAD), postmenopausal hormone therapy to prevent CAD, vertebroplasty for osteoporotic fractures, bevucizamab for breast cancer.

Scarily, but unsurprisingly, “true believers” continued to defend these interventions even after the evidence was clear (their livelihoods depend upon it), and in many cases these treatments continue to be offered and performed. “There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products,” and it is only “Rarely [that]…some investigators find the courage to test established ‘truths’ with large, rigorous randomized trials”. Prasad and colleagues have done many of these latter trials; indeed John Ioannidis is the “guru” of debunking treatments with poor evidence (see David H. Freedman’s article in the November 2011 Atlantic “Lies, damned lies, and medical science.”) The authors have some suggestions, including limiting the role of manufacturers (of drugs, devices, tests) from conducting the trials on them, although they should pay for them: “Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.”

Prevention and screening are also subject to the lure of magical-thinking-compounded-by-the-greed-of-the sellers. Screening for prostate cancer with the use of prostate-specific antigen (PSA) testing is a good recent example about which I have written (while the lack of effectiveness of treatments for prostate cancer is would be included in the group of ineffective therapies that Prasad and colleagues have written about). Pap smears are pretty good screening tests for cervical cancer, but most other cancer screening tests (even mammograms and colon cancer screening, probably the next best) are not nearly as good. Every time there is a recommendation to decrease the frequency of screening (Pap smears, mammography) or not do them at all (PSAs or pelvic exams) there is an outcry from people who think that something has been taken from them. In a scientific sense, what has been taken is unnecessary testing that doesn’t lower their risk of bad outcomes, costs money, and can have significant morbidity when positive screens need additional, more invasive tests, to follow up. But, in a more metaphysical sense, what has been taken is hope, the idea that there is something that they can do that will prevent something bad from happening to them. Something that, while perhaps a little risky (if you understand or believe it), is relatively easy. And also, frankly, something someone else, rather than you, can do. Not like, say, dieting or giving up smoking or exercising. And this false concept is encouraged by half-truths promulgated by passionate advocates of interventions with limited proven benefit, whether traditional allopathic or “alternative”.

Even public health advocates sometimes get so passionate about the health benefits of what they are advocating that they may miss other issues. For example, consider a recent discussion on a progressive public health listserve about “portion control” (limiting the amount eaten at one sitting). This is an important and effective method of addressing obesity, which is in fact a major health problem in this country, but the discussion raised many other issues. These included concerns about “blaming the victim” -- expecting self-control (difficult enough) from people who had historically not had that control in the face of major initiatives by fast-food purveyors to push large portions. Another was the economics involved in asking poor people to pay “more for less” while corporations continue to make huge profits from them. It can, and often is, as difficult for public health advocates to recognize problems arising from their positions and passions as it is for providers or manufacturers to back off from theirs.

The difference, of course, is that the former are really invested in the health of the public, while the latter are invested mostly in, well, their investments.

[1] Prasad V, Cifu A, Ioannidis JPA, Reversals of established medical practices: evidence to abandon ship”, JAMA 4Jan2012;307(1):37-8.

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One thing to NOT worry about: paying for health care -- in France

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I recently saw the film Le Havre, a film set in that French city and made, in French, by Finnish director Aki Kaurismäki. It was a very good film, generally well-reviewed (here is the New York Times review), and part of its appeal for me is its unabashed portrayal of working-class people as the central characters. One of the plots involves the illness of the female lead, Arletty, who suffers severe abdominal pain, is brought to the hospital, and is told that it will be terminal (although, the doctor observes, “miracles do happen”.) I don’t need to share any more of the plot, because what I found striking was really incidental to it.

Kaurismäki goes to some length to depict both the poverty and dignity of his characters. It is an imaginable working class poverty -- this is not the Mumbai of Slumdog Millionaire – but it is certainly poverty. Arletty’s husband is a shoeshine man; they live on an alley off a small street in a house that evokes the apartment of Ralph and Alice Kramden on The Honeymooners. When he sees his wife in such pain, her husband’s main concern is how he will get her to the hospital. He goes to the street to ask a shopkeeper if he can use her phone (they don’t have one), and she offers to drive them.

What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was “nothing” (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.

Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.

There was another aspect of the healthcare portrayed in the film that struck me. The hospital was simple and unostentatious. It looked a little dated, old-fashioned, like the houses and the shops and the working-class lives of the characters, even though the film and its theme are contemporary. Maybe this is also something about France. The hospital is clean, freshly-painted, with clean linen, and private rooms, and IV poles and doctors and nurses. But it is simple. The ceilings are not high, there is not expensive art on the walls, or carpets, or hallways twice as wide as they need to be. It is functional. It is not third-world, but it is basic. It is pretty unlike my hospital, or most of the hospitals that we see in the US (except some of the oldest public institutions). If someone with private health insurance saw this hospital in, say, Kansas City, they would be unimpressed. They might rather, next time, seek one that was “nicer”. Fancier. With really good hotel accommodations. This is what we look for in the US, what we expect. Surely this is what they lose in such national-health-insurance countries as France.

I checked this with a friend, who is from Canada. He said that this is the way hospitals in Canada are; clean, and functional, but not fancy. He told me he was shocked when his wife had a baby in Kansas City and there were hardwood floors. What for, he wondered? Of course, we know what they are for. They are to help to provide a competitive advantage, to make people choose one hospital over another. For the same reason that hospitals buy new MRI scanners when the hospital down the street has one that is underutilized. Why they have fundraisers to be able to support their cancer center, to attract people with cancer (and, of course, insurance!) to them, rather than to the perfectly good cancer center across town. Why, as depicted in a recent New York Times “Opinionator” by Ezekiel Emanuel and Stephen D. Pearson (“It costs more, but is it worth more?”), hospitals such as Mayo Clinic are building their own billion-dollar proton-beam accelerators to treat cancer when there are more than enough in the country to treat the relatively small number of people who require this kind of cancer therapy.

Because, in the US, healthcare provision functions much more as a business than as a social good. The “product” is healthcare for people, but the product is only of value when it can be sold to those who can pay. We have hospitals that compete for some of our people, while there are others who can barely get care. This competition model can work, just as it works for other products – vendors compete for those who can afford it and ignore those who cannot. If we want healthcare to be an industry, a business, rather than health care.

Le Havre is a very good film, and it does not shy away from social issues. In fact, it addresses many of them. But access to health care is not one, it is not Sicko! The themes I discuss here are just in the background of the film,and I imagine they are not even noticed by French audiences. Or Finnish ones. Being able to afford medical care is not an issue in those places.

Which is as it should be.

It’s definitely not about the bike – but is it even about ACOs?

One of the major features of the Affordable Care Act (ACA) is the idea of Accountable Care Organizations (ACOs). The final regulations from Medicare were issued in October, 2011, so the creation of ACOs seems to be moving forward. ACOs will be groups of primary care doctors, specialists, hospitals, and possible other providers who act together to provide comprehensive care, and receive either more money from Medicare (and probably, eventually, other payers) or, at least, smaller reductions in payments. The only thing that is definitely required to form an ACO is a group of primary care doctors, but since groups of primary care doctors rarely have sufficient capital to fund the necessary infrastructure, so it is likely that almost all will include at least one hospital.

The stated purpose behind encouraging ACOs is to increase quality. It is easy enough to see how quality could be improved in our non-system of health. Because the bar is so low, there are tremendous opportunities that come from lack of organization and coordination of care. Hospitals get paid for caring for people who are admitted. Thus, up to a point (the point at which payments do not exceed costs), they want admissions. Patients prefer to stay healthy, or at least healthy enough to not have to be admitted to the hospital, and hopefully their primary care doctors support this goal. Hospitals have already started being financially penalized by not receiving reimbursement from Medicare for readmissions for the same problem they were discharged for, or complications of that problem. Managing this issue will require the ACO to have not only financial relationships with primary care doctors, but often with long-term care facilities as this is where patients are discharged to – and return to the hospital from.

Fisher, McClellan, and Safran, in their New England Journal of Medicine article “Building the Path to Accountable Care”  (December 29, 2011; may require subscription)[1], identify five “challenges” to implementing ACOs with suggestions for how to overcome them. The challenges are providing timely and useful data, overcoming transition costs, gaining consumer support, learning what works and using that knowledge to inform policy and practice, and clarifying the path forward. Their suggested approaches to solving them are largely based upon what is being done in existing integrated health systems (such as Kaiser and Geisinger). This makes sense, as these systems were the model for ACOs and are often relatively cost effective, but it will require major restructuring for other such systems to develop in ways that can work as well. The authors do not address a major challenge for ACOs, which is that every patient will be identified with a particular ACO (based on the physician from whom they receive the majority of their primary care) and that ACO will be held financially responsible for that patient’s costs, but that the patient will be free to receive service from outside that ACO. This is a political decision, intended to avoid the criticism that the ACO program is just “managed care” in new clothes by ensuring that the program will not “restrict” people. Of course, it is a huge flaw. If a patient is not happy with the care they receive from members of their “identified” ACO, whether that is for “good” reasons (denying unnecessary, excess, risky procedures, hospitalizations, etc.) or “bad” reasons (less than the best quality), the patient can go elsewhere and receive that service from someone else. And if Medicare deems it unnecessary or excessive, it is the “identified” ACO that will receive the financial penalty, not those providing the service.

The authors’ final challenge, the vaguely worded “clarifying the path forward”, is about future changes, including (from their table) “Create meaningful alternatives to fee for service for all providers.” This is a good idea, and not a new one. It means that rather than have the provider (hospital or doctor) paid for each particular service, the payment is tied to something else. Most simply, it could be a global fee for providing care to a patient, as the capitated payments in traditional HMOs. This allows practices to budget their resources, and also allows patients to get care in the way they need it. If a doctor is being paid a set amount in advance, there is no financial incentive for them to require a person to have to take off from work, travel, park, and wait to be seen when that person has a question that can be answered by phone or email. You would only have to be seen in person if either you or the doctor thought that there was a reason to do so. The disincentive under the current fee-for-service system is that the doctor doesn’t get paid unless you are seen in person. In addition, the ACA law envisions paying more for higher quality (or less for lower quality). So why were these “meaningful alternatives” not included in ACA? Again, political, and the question is “what will change the politics in the future?”

In another NEJM “Perspective”, “Achieving accountable care – “it’s not about the bike” (published online on December 28, 2011), Walker and McKethan argue that it is the skills and competencies of providers, rather than the structure of the systems, that will determine the success of ACOs. Their metaphor is from Lance Armstrong’s memoir, in which Armstrong acknowledges the importance of having a great bike but says that “Although advanced equipment is very important, winning depends more on athletes' riding skills, physical conditioning, and race-day effort.” Cute, but obvious; any athlete with enough money (and all top cyclists have backers with enough money) can buy the best bike, but it is his or her skill and dedication that leads to victory – or not. Is it, however, a good metaphor for medical care? “If an ACO were a bicycle,” Walker and McKethan write, “its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers' eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated.” They then go on to discuss at some length what ACOs will need to do to “…compel and equip the athletes riding them…” (meaning providers) to do what is necessary, for “…accountable care will depend on a care team's identification of and action on the specific needs and preferences of the individual patient, deploying the most relevant, tailored interventions and supportive services to address patients' specific needs, circumstances, and preferences.”

Sound good? It is an appropriate metaphor in that structure alone will not guarantee success, but it loses strength after that. ACOs are not bicycles, and providers are not athletes. Most important, “success” in the arena of healthcare should not be about “winning”, about “beating” the other “competitors”, but about development structures, methods, practices, and reimbursement procedures in which everyone receives the best, most appropriate care. In which we all win.

And that is going to be one of the big challenges, because neither of these commentaries addresses the fact that not everyone in our country is going to be part of an ACO, and not everyone in our country has health coverage. Those people who do have coverage have found their premiums, co-pays, and deductibles increasing and their benefits diminishing.  ACOs are (at least initially) a program for Medicare recipients, but all we hear from Congress and pundits is that “Medicare costs too much” and that these costs need to be scaled back, so unquestionably the emphasis of programs like ACOs will be on reducing cost.

I have often noted that much of the excess cost in this country is from providing unnecessary, or even harmful, care, and so there is not necessarily a conflict between saving money and increasing quality. But people are different, with different diseases and needs and wants, so there will need to be flexibility. And those who are most disenfranchised will remain outside the pale.

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[1]Fisher ES, McClellan MB, Safran DG, “Building a path to accountable care”, N Engl J Med 29Dec2011;365:2445-2447

Cui bono? Is healthcare financing about funding providers or caring for patients?

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In a recent blog, GME funding must be targeted to Primary Care, December 10, 2011, I wrote about the fact that the financial interests of hospitals lead them to choose to support residency training positions which are not necessarily (or often, or usually) in those specialties that the nation most needs. I urged that funding from the government for graduate medical education (primarily through supplements to Medicare and Medicaid) include mandates as to the proportions of trainees in different specialties, with a strong emphasis on training more primary care physicians. This is only one area, however, in which the financial incentives to hospitals, and indeed all health providers including physicians, do not always jibe with the healthcare needs of our population.

A recent spate of news articles has discussed changes in the organization and financing of healthcare services. The New York Times recently covered the conflict between the governor of the state of New York, Andrew Cuomo, and the mayor of New York City, regarding the potential conversion of Emblem Health to a for-profit company (Bloomberg Predicts Fair Deal if Health Insurer Gets For-Profit Status, by Thomas Kaplan, December 23, 2011). Cuomo wants it because it could bring as much as $1B in tax revenue to state coffers; Bloomberg is concerned because Emblem is the insurer of the majority of municipal employees and he expects such a move will drive premiums up. But, as the title of the article suggests, he thinks they can work it out. Between them. For the benefit of both the city and state governments. Not, however, for the people insured by Emblem. Emblem was created by a merger of Group Health Insurance (GHI) and Health Insurance Plan (HIP) of Greater New York, two early not-for-profit HMOs, or managed care organizations. Except they were created before either term, HMO or managed care, existed. Back in the 1950s, these were consumer cooperatives, where it was recognized that by cutting out the (for-profit) insurance company middleman, people could have more care for the same money, or the same care for less money. No wonder the majority of city employees enrolled.

Over time, rebranded by the Reagan administration with the new name of “HMO” or managed care, became the de facto standard for US health care coverage. Why Republicans could buy into this vaguely populist or socialist concept was that the new HMOs would increasingly be owned by for-profit insurance companies, which they could literally buy into as shareholders. The savings that came from managing care would now accrue to the insurer, not the patient-owner-members. Many of the long-standing HMOs of the early period (e.g., Los Angeles’ Ross-Loos) were purchased by insurance companies, but there were a few holdouts that remained consumer cooperatives (e.g., Group Health of Seattle and the groups that became Emblem). And then, as we remember, came the consumer backlash against HMOs in the late 1990s, with people furious at the restrictions these organizations put on their access to health care. The mistake, however, was thinking that the problem was the organization of care with requirements for only approved therapies, relatively “closed panels” of doctors and hospitals, and capitated payments. The problem was that they were, and are, mostly owned by for-profit corporations, which increase their profits every time care is denied. This is a very different incentive than when the owners are the patients themselves through a cooperative.

As time went on, even the non-profit HMOs and other non-profit groups like the Blue Cross / Blue Shields that are not part of the for-profit Anthem/Wellpoint, have had to act like for-profits to compete. The advantages have all been for the insurers, which remain very profitable, not for the patients, who find both many of the same restrictions they bridled at in the past, and, in addition, increasing premiums, co-payments, and deductibles. If Emblem becomes for-profit, Michael Bloomberg may be able to work a deal where the city government is spared a major premium increase, but the city workers who are insured by Emblem will not be so lucky. In a typically excellent “Quote of the Day”, Don McCanne, MD, discusses the fact that the National Business Group for Health (NBGH) is predicting major increases in deductibles for all employees. As reported in an article in the Nashville Tennesseean, “High deductible plans on the rise”, by Tom Wilemon, December 27, 2011, “Helen Darling, its [NBGH] president, predicts that by 2016 the majority of all health plans will have high deductibles.” McCanne notes correctly that the members of NBGH are the nation’s largest corporations, mostly Fortune 500 companies, which have historically had the best health insurance coverage for their employees. If these deductibles – the amount a family has to pay out-of-pocket before any insurance coverage kicks in – rise to $1500 a year, it will be much worse for those working for smaller, less prosperous companies.

McCanne also comments on reports from the AMA that Highmark, the large Western Pennsylvania Blue Cross / Blue Shield affiliate, will be purchasing its own health system, where it will be able to profit on both ends, or, at least not pay as much for care. He observes that this will enhance its financial status, but not benefit patients, who will be preferentially locked into care at West Penn. The greatest complaints are from the competing University of Pittsburgh Health System, which believes it will Iose patient revenue from such an arrangement. So the conflict here is between the benefit for one health system versus another. It is not benefit for state versus city government as in the Emblem case, but it is still not about the health of the people. It continues to be about how the money from healthcare is distributed among the various players, including as insurance companies, hospitals and doctors.

My hospital, the University of Kansas Hospital (UKH), has done very well financially. In the most recent “Book of Lists” sent to subscribers to the Kansas City Business Journal (not on line; a copy will cost you $65, or $169.95 for immediate download!), it had the greatest revenue in the Kansas City area, at over $2.5B, more than $1B ahead of #2. The physicians who staff the hospital, faculty of the University of Kansas Medical Center, are seeking a restructuring of the current affiliation agreement to share more of that revenue with the doctors. As one of them, I do not disagree with the concept that the physicians, whose work generates much of the revenue, should share more equally, but, as with West Penn and University of Pittsburgh, this is about who gets what, not about how to provide better healthcare for less money to more people.

Health industry consulting groups, such as the Advisory Board, warn hospitals that there will be major cuts to their income resulting from federal budget cuts and programs such as pay-for-performance (P4P) and “value based purchasing” (this is “value” in the economic sense, that is cheaper, rather than having anything to do with “values”, such as caring for the sick!) Hospitals like UKH worry about whether their up-to-this-point successful strategy of investing in the highest-profit “product lines” such as heart disease and cancer will continue to work in the changing reimbursement system. They sense a pressure, as do physicians, to enter into “health systems”, collaborations, to maximize efficiency and profit (or at least not make much less than they are). There is a certain irony in pressures to re-create the managed care era.

But, because that “re-creation” is still about how hospitals, doctors, and insurers can make money, not about how we can provide the best health care for the most people, it is re-arranging deck chairs on the Titanic. If, when, we hit that proverbial iceberg and the ship goes down, many people will be hurt. Sure, just as on the Titanic, it will be the poor people on the lowest decks who get hit the worst. Then, the middle class. And even some of the rich, and some of the officers will go down. But, if you are a betting person, you bet on the most privileged being the most likely to survive; you would have been right in on the 1912 sinking of the boat, and you’d be right 100 years later in health care.

One day maybe we will develop a health policy that engenders behaviors that are about providing the best health to all of our people.
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"How Doctors Die"; post on Zocalo Public Square by Ken Murray

I would like to call your attention to a superb post on "Zocalo Public Square" by Dr. Ken Murray, "How Doctors Die." It addresses what doctors want for themselves when they are dying, which is generally much LESS intervention.

I would suggest that if patients knew that doctors felt this way, rather than that we were trying to "deny" something to them or their relatives, it might be much more effective.

Avastin®, Plan B®, and Magical Thinking

“Magical thinking” is believing something is true because you want it to be true even when there is strong evidence that it is not. It is normal in young children. They believe in Santa Claus and the Easter Bunny and conjurer’s tricks. This is in part because adults encourage them to, and because they do not know the evidence and they haven’t enough brain maturity to make the connections. Beyond a certain age, however, it is not normal. Yet we do it all the time.

It is common enough in politics, for sure. A wise expert (OK, me) once said “Data is only useful if it confirms your preconceived notions”. Otherwise, hearing the data that should demonstrate that you are wrong only confirms your pre-existing beliefs because it reminds you of why you believe it. The evidence is the evidence, and sometimes it is inconclusive and subject to different interpretations depending upon one’s perspective. That’s what makes horse races. Sometimes it is conclusive, but leads to a different conclusion than the one that you want to hear.

Religion is different; it is, by definition, based on faith. It becomes confusing, for me, when this is complicated by searching for evidence (e.g., the Catholic Church searching for evidence of a miracle in order to sanctify someone), but at bottom it is about faith. Some people have lost their faith in the religion in which they were brought up because of seeing contradictory evidence in the world, others have reconciled that evidence with their beliefs, others manage to separate the evidence from their faith, and still others reject all the evidence of their senses if it contradicts their faith. We have classic examples of this last, with lecturers in the early European medical schools reading from Aristotle on anatomy, ignoring the visual evidence provided by the cadavers being dissected in front of them that demonstrated that what Aristotle described was wrong. Luckily for anatomy and medicine, the schools were able to move on from this, in part because Aristotle, while revered, was not a Christian expert. It was rougher for Galileo when he demonstrated that the earth rotates around the sun.

I understand people’s interest in believing to be true things that the evidence demonstrates is not. It is comforting, it offers hope, and it can offer consistency. I wish, sometimes, I had more of it. My son died 9 years ago from completing suicide. If I believed that there was an afterlife, and that he was somewhere happily being cared for by my mother, who died over 30 years ago, it would make me feel better. After all, she was a wonderful, nurturing person, a kindergarten teacher who loved children, and she died just after he turned 2, so never got to see him grow up. It would be great to believe that they were getting to know and enjoy each other now. But I don’t.

Nonetheless, I am sure there are things that I believe that are contrary to the evidence. Certainly, things I believe that have conflicting evidence. Like that people are good, that the world can be a better place, that the ‘better angels’ of our nature may overcome selfishness and greed and hypocrisy and meanness. Sometimes that belief is sorely tried. It has been a particularly hard couple of years as the perpetrators of the greatest worldwide financial crisis have gotten off and maintained and increased their wealth while hundreds of millions of their victims have had their lives ruined, with no end in sight. And with whole cohorts of politicians and pundits advocating that these perpetrators be spared any penalty while slashing any programs that benefit their victims.

For most of us, and in most societies, there are limits to what we tolerate because of people’s beliefs. We do not, as a rule, accept that a false belief, a delusion, about another is an excuse for murder. Of course, if that false belief is on the part of the government that sends young people to war and to kill, it is accepted. And for many zealots, of many beliefs and causes, whether Islamic terrorists or anti-abortion murderers, there is a portion of the population who will accept it.

One group that has good reason to want to believe in things for which there is no evidence is those who are threatened with death from a disease for which there is no effective, “approved”, treatment. Cancer, for instance, or AIDS. In the 1980s and 1990s, AIDS advocacy groups pushed for quick FDA approval for drugs to fight a disease that was killing lots of people. To some degree it happened, and luckily those drugs were effective, and better drugs were developed, and today AIDS is most often a chronic disease. When a study showed that bevacizumab (Avastatin®), an anti-cancer drug created through recombinant DNA that had positive effect for some other cancers such as colorectal cancer, was also effective in prolonging the lives of women with metastatic breast cancer for a few months (not curing them), the large breast-cancer advocacy community pushed the FDA for early approval. It was approved. But then more studies appeared that showed it was not effective. Several of them. And the FDA, appropriately based upon the evidence, withdrew their approval. Blue Cross/Blue Shield of California then decided it wouldn’t pay for it. Yes, much of the motivation was financial – it costs $90,000 per year to treat a patient (except less, really, because few last a year), but it was based on the evidence. Would you pay $90,000 for a drug that didn’t work? How about spending that on treating someone else with a drug that doesn’t work? But having someone else pay for it for you (your insurance company and those other people who are paying premiums)is less painful. There was a big uproar. BC/BS (and Medicare) are now again paying $90,000 a year for treatment of breast cancer with a drug that doesn’t work.

On the other hand, kowtowing to true believers can have the opposite effect. It can lead to restricting access to a drug that does work. This has occurred recently with Plan B One-Step®, “the morning-after pill” which effectively provides emergency contraception if taken within 72 hours (maybe more) of unprotected intercourse. Approved for women 17 and over without a prescription, this form of the hormone levonorgestrel is kept “behind the counter” so those under 17 cannot get it. It doesn’t make sense, since girls under 17 can and do have unprotected sex and get pregnant. It is also safe. So, recently the FDA, examining all the evidence, recommended that it be made available without a prescription and sold “over the counter”. Then Secretary of HHS Kathleen Sebelius overruled, in an almost unprecedented action, the FDA’s recommendation. There was no science or evidence behind the Secretary’s action. Her stated reason, that younger women cannot understand the instructions, would, if one wanted to believe it, be an unreasonable standard. Can they understand the instructions to prevent adverse effects from ibuprofen or acetaminophen? Is the risk of pregnancy in these girls less than the risk from taking Plan B incorrectly? Nonsense. It is a political judgment, pandering to the belief of those who magically believe that because they don’t want young girls to have sex they won’t as long as contraception is not available to them to “encourage” it.

People read and support things that agree with what they think. I do not delude myself into thinking that what I write in this blog “converts” people; I recognize that people who read and like it probably already agree with me. But I do try to present evidence. And sometimes readers challenge me on my interpretation of the evidence (see, for example, the comments on Fluoridation: Dental health for all, October 26, 2011). One of the hardest things for physicians to do is to “un-learn”, to change the beliefs that they have had for years or decades when new information shows that what they believed is wrong. It is hard for them, and harder for the lay public, to understand that doing something was the right thing in the past because of the best evidence at the time, but is the wrong thing now. And what we think is the right thing now, based on the best evidence available, not be true in the future. That is how science evolves.

But magical thinking should have nothing to do with it.

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Oh, yes. And in support of a tradition which Dilbert correctly points out is only a random point in time (and despite his use of "oxytocin" when he may have meant "oxycodone"):

HAPPY NEW YEAR!

Index to Medicine and Social Justice year 3, 12/2010-11/2011

General Medical

Friday, December 24, 2010, Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?

Saturday, January 15, 2011, Risk, Primitive Reactions, and Human Health Behaviors

Tuesday, March 15, 2011, Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?

Sunday, June 19, 2011, The real face of lack of access to health care

Wednesday, July 13, 2011, Direct-to-Consumer Advertising and the Role of Advocacy Organizations: Two Threats to Evidence Based Testing

Friday, August 12, 2011, Greed, corruption and medical procedures: ignoring or suppressing the evidence?

Saturday, October 8, 2011, Healthful Behaviors: Why do people adopt them? Or not?

Friday, September 16, 2011, Unintended pregnancy and health disparities

Wednesday, October 26, 2011, Fluoridation: Dental health for all

Friday, October 14, 2011, PSA redux: The USPSTF finally recommends NOT getting it!

Tuesday, November 8, 2011, MRIs, clinical judgement and access to health care: Where is the money best spent?

Health Policy

Saturday, December 18, 2010, ACA, ACOs, and Meaningful Competition

Wednesday, January 5, 2011, Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage

Friday, February 25, 2011, We are moving in the wrong direction: the health care crisis and American hubris

Sunday, February 13, 2011, Freedom abroad, health at home: experiments in preventive health care

Tuesday, May 17, 2011, Insurance company profits up and patient care down

Saturday, June 25, 2011, The cost of health care: Prevention and Indication “creep”, drugs, and the Sanders plan

Tuesday, July 19, 2011, "Reforming" Medicaid, or Cutting Medicaid: No shortage of folks to cast the first stone

Friday, July 1, 2011, Medicare: We need to expand it, not cut it!

Wednesday, August 31, 2011, Steps toward a solution: Time to put Single Payer back "on the table"

Thursday, August 18, 2011, "Health in All" policies to eliminate health disparities are a real answer

Saturday, August 6, 2011, Cook County Hospital: Health care for the poor or poor health care?

Thursday, September 22, 2011, Legislating Public Health and Medical Care

Thursday, October 20, 2011, No way to run a hospital, no way to run a healthcare system

Tuesday, November 15, 2011, Troubled hospitals, troubled health care system: Not just in Brooklyn

Tuesday, November 1, 2011, Michael Marmot, the British Medical Association, and the Social Determinants of Health

Primary Care

Wednesday, February 2, 2011, Outing the RUC: Medicare reimbursement and Primary Care

Saturday, February 5, 2011, AMA response to "Outing the RUC"

Saturday, February 19, 2011, The challenge of expanded Medicaid and the dearth of primary care physicians
Monday, May 30, 2011, Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center
Saturday, June 11, 2011, EMRs and Primary Care: The good, the bad, and the challenges

Sunday, October 2, 2011, Are primary care physicians fees a major contributor to the high costs of US healthcare? No.

Medical Education

Tuesday, March 22, 2011, US Medicine and Medical Education: The Good Part

Wednesday, March 9, 2011, The Education of Health Professionals and Prospects for Transformation (Guest post by Seiji Yamada, MD)

Sunday, April 17, 2011, Do resident work hours limits create better physicians?

Monday, June 6, 2011, Comments on Free Medical Schools

Sunday, June 5, 2011, Would free medical schools increase primary care?

Sunday, July 31, 2011 Training Rural Doctors: The KU Salina Program

Monday, July 25, 2011, Evaluating the Communications Skills of Potential Medical Students: Looking at the "Whole Person"

Family Medicine in the Era of Health Reform (3 part series)

Monday, May 23, 2011, Family Medicine in the Era of Health Reform - 3

Wednesday, May 11, 2011, Family Medicine in the era of health reform - 2

Thursday, May 5, 2011, Family Medicine in the era of health reform

Medical Ethics

Saturday, April 9, 2011, Conflict of interest 2: Clinical practice guidelines and Deans

Friday, April 1, 2011, Conflict of interest reporting

Thursday, July 7, 2011, Physician Oaths and Social Responsibility

Thursday, August 25, 2011, What is the ethical role for physicians in the "business" of health care?

Thursday, September 8, 2011, "The Doctor's Dilemma": Balancing needs of individual patients and responsible stewardship of health resources

Social Justice

Thursday, December 30, 2010,Immigration and the US: Happy New Year

Sunday, December 12, 2010, Tax Breaks for the "Masters of the Universe" or for the rest of us?
Friday, December 3, 2010, Matthew Freeman Memorial Lecture, Dec 6, 2010

Thursday, March 3, 2011, Fighting for freedom abroad -- and at home

Thursday, April 28, 2011, Perception and reality of economic inequality

Saturday, April 23, 2011, "Cabaret" and "Inherit the Wind": Will we again reap what is being sowed?

Monday, September 26, 2011, Shall we be callous or shall we be people? There is hope.

Friday, November 25, 2011, Veterans Day, the “Bonus Army”, and honoring veterans by actions, not words

The Tucson shootings

Thursday, January 27, 2011,The Devil Inside: Access to Mental Health Care in the United States  (Guest post by Robyn R. Liu, MD)

Friday, January 21, 2011, Tucson is worth struggling for...(Guest post by William Bemis)
Sunday, January 9, 2011, The Arizona shootings: When will we ever learn?

Links to other blogs Monday, February 28, 2011, Common Sense Family Doctor blog: Maybe PSA's time has finally come -- to an end!

Wednesday, February 9, 2011, Education in Medicine: The characteristics of future physicians

Tuesday, February 8, 2011, Non-preventive Health Screenings: Common Sense Family Doctor

Saturday, March 26, 2011, Common Sense Family Doctor: Coronary CT: nonindicated and costly screening test

Friday, April 15, 2011, Disincentives to rural practice: from "Training Family Doctors" blog

Other

 Tuesday, June 14, 2011, Barbara Starfield

Wednesday, July 6, 2011, New blog and post

To improve health the US must spend more on social services

That the US spends far more, in total and per capita, on health care than any other country is a well-established fact which no one bothers to deny. That this expenditure has not brought us greater health is also established fact, although many still find this hard to believe, or don’t want to believe it. That we do not have the “best health care system in the world”, or even close, or even, actually, a health care system at all, is also demonstrably true. This does not stop a larger percent of the population, and particularly the very privileged sector represented by politicians, from maintaining that untruth.

However, in a provocative op-ed in the New York Times (“To fix health care, help the poor”), Elizabeth H. Bradley and Lauren Taylor argue that it is only when health care is viewed in its most narrow sense that the US spends more than other countries. Their study of 30 countries expenditures, “Health and social services expenditures: associations with health outcomes”[1], “…broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.”

Essentially, their data shows that having services available to people that improve the quality of their lives, or, more important, decrease the negative health impact of the adverse circumstances into which they are born, develop, and live, lessens disease burden and improves health. This then decreases the costs of providing medical care to them. For example, they note, “The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.”

Bradley and Taylor indicate that among industrialized countries, the US ranks #10 in total health + social service spending , and is one of only 3 that spend more on health care than on all other social services. This means that, in addition to not getting the preventive or early-intervention health care that they need, Americans are at higher risk of illness and more ill when they come to medical attention. They may not be homeless, although obviously this dramatically increases their risk. People may not have adequate food, not have adequate warmth (see the discussion of “excess winter deaths” in Michael Marmot, the British Medical Association, and the Social Determinants of Health, November 1, 2011), not had a safe environment. They likely had far too little income. Many of them are children, and many of those, and often their parents before them, have had an inadequate education. A large number of the determinants of health are antenatal, and many more are in the early years of life. The other group at high risk of both adverse health outcomes and the poverty-related social deficits that influence them, are the elderly. So what do we see in the US? Threats to cut Medicare, cut Social Security, cut education.

This wouldn’t affect everyone equally, of course. Only the most vulnerable. Or, at least, the more vulnerable. The wealthy, of course, are unlikely to be inadequately housed, inadequately nourished, inadequately educated, and, in a tautology, inadequately employed. Another recent study, from the Organization for Economic Cooperation and Development (OECD), called “Divided we stand: why economic inequality keeps rising”, demonstrates rising inequality in income as indicated by the difference between the income of the top 10% and bottom 10%. “The income gap has risen even in traditionally egalitarian countries, such as Germany, Denmark and Sweden, from 5 to 1 in the 1980s to 6 to 1 today. The gap is 10 to 1 in Italy, Japan, Korea and the United Kingdom, and higher still, at 14 to 1 in Israel, Turkey and the United States. In Chile and Mexico, the incomes of the richest are still more than 25 times those of the poorest, the highest in the OECD, but have finally started dropping. Income inequality is much higher in some major emerging economies outside the OECD area. At 50 to 1, Brazil's income gap remains much higher than in many other countries, although it has been falling significantly over the past decade.”

 

In the report’s “country note” on the US, it observes that “The United States has the fourth-highest inequality level in the OECD, after Chile, Mexico and Turkey. Inequality among working-age people has risen steadily since 1980, in total by 25%. In 2008, the average income of the top 10% of Americans was 114 000 USD, nearly 15 times higher than that of the bottom 10%, who had an average income of 7 800 USD. This is up from 12 to 1 in the mid 1990s, and 10 to 1 in the mid 1980s….Income taxes and cash benefits play a small role in redistributing income in the United States, reducing inequality by less than a fifth – in a typical OECD country, it is a quarter. Only in Korea, Chile and Switzerland is the effect still smaller.” Of course, comparing deciles is deceiving; as the Occupy Wall Street movement emphasizes, the concentration of wealth is in the top 1%, and economist and NY Times columnist Paul Krugman (“We are the 99.9%”, November 24, 2011) and others point out that most of that wealth in the US is in the top 0.1%! The wealthiest 400 families in the US own as much as the bottom 50% of the population.

 

One obvious result of the rising inequality in the US is the increase in the overt control that this wealthy class exerts over the political process, through direct lobbying, political contributions, employment after and between stints of government service, and control of media. The “corporate personhood” decision by the US Supreme Court in Citizens United simply codified and protected this inequality. But income inequality in itself is not sufficient to lead to the destruction of the social safety net that exposes increasing numbers and percents of people to ravages that adversely affect their health. It also requires extreme selfishness and disrespect, so that billionaire people and corporations pay little in tax, and governments are purposely squeezed so that they have neither the will nor the resources to provide services.

 

The findings of Bradley and Taylor are not news to the public health community, of course, which is very familiar with the social determinants of health and the positive impact that investment in basic social supports has on the health outcomes of both populations and individual people. Investment is required to see future benefit, and the investment that we need, and are not making, is in education, is in nutrition, is in housing. It is far more than a shame. It is shameful.  

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[1 Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29