• Gluten free

    Via Bill Gardner and in honor of Aaron’s Healthcare Triage video on the subject, which I had requested:

    gluten free2


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  • Healthcare Triage News: Pot, Foul Language, and Pain

    This week’s HCT news:

    What are people talking about this week? Better yet, what should they be talking about? We’re talking about marijuana and obscene language.

    Enjoy! Tell your friends to watch!


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  • Best in the world my a$$!

    Readers of the blog know of my many, many, many problems in trying to get my prescriptions filled. And I’m an expert in the health care system! Today, Charles Ornstein (also an expert) relates his difficulties in trying to fill a prescription for his son. The story is maddening. He has some advice at the end:

    If you find yourself in such a predicament, what should you do? First, be prepared. Sign up for an account online with your health insurance company, review your benefits and review your claims. You’ll be amazed by how much — and sometimes how little — your health insurer pays for various treatments and drugs. Second, if you encounter a problem, ask questions. While you may have to pay the bill at the pharmacy if you want to leave with the prescription, you should follow up with your health plan and ask to speak with a supervisor.

    Finally, if the stakes are high enough, consider a health advocate like Ms. Gardner. Some advocacy firms are run by former health insurance executives, who help navigate the roadblocks that their former companies have erected.

    But, ultimately, you may well end up doing what I did: paying the higher fee with gritted teeth and gaining a new appreciation of how confusing our health care system really is.

    It’s the last sentence that grates on me.

    By the way, I still own the site bestintheworldmyass.com. I just haven’t figured out what to do with it yet!


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  • System pressure

    It was this Freakonomics podcast episode that persuaded me to read Allan McDonald’s book Truth, Lies and O-Rings, which I finished on my flight home from DC yesterday. I’m sure you can already guess what it’s about: the Space Shuttle Challenger disaster.

    McDonald was in a unusual position and did a difficult thing. He knew more about the solid rocket booster’s O-rings than just about any other engineer on the planet. Because low temperatures degraded their ability to keep hot gas from escaping the booster’s joints, he did not approve of launching the Challenger in the extremely cold conditions on January 28, 1986. He was in the room when the decision was made to do so anyway, over his objection. And in the subsequent investigation into the cause of the explosion of the Challenger, he was one of the few who spoke the full truth without attempts to paper over the flawed decision-making process.

    What gave NASA cover to launch—but in the full context of the situation was inexcusable anyway—was a signed blessing of the O-ring’s adequacy from the solid rocket booster’s manufacturer, Morton Thiokol. Despite the low temperatures, McDonald’s superiors at Morton Thiokol decided the O-rings would be fine. This was what drew me to the story.

    Why did Morton Thiokol executives make the go-for-launch call when their engineers and the data strongly argued the risk of failure was high?

    I imagine it was a tough call. I sure hope it was! Try to put yourself in their position. On one side, you’ve got engineers telling you the O-rings can’t handle the conditions, and they have some data to support that position, though it’s not an air tight argument. There’s always room for some doubt, some probability things will be fine.

    On the other side you have what? “System pressure,” as David Newman would call it, also known as “conflicts of interest.” The pressure to please the client, NASA, was high. NASA was, at that time, considering Morton Thiokol’s next contract. A lot depended on keeping the money flowing. Jobs were at stake. It’s no small thing to displease a client, lose a contract, and have to lay off hundreds of workers who are counting on you. NASA had its own form of system pressure, in wanting to maintain a tight schedule of launches to show Congress—which controls the purse strings after all—it could perform as promised.

    System pressure should never have ratcheted up so high that it created strong incentives to launch on January 28, 1986. That was NASA’s fault. Perhaps overly politicized “oversight” by Congress can and did play a role as well. (This is not unique to NASA and the Shuttle.)

    But even in much less vital circumstances—ones even you and I face—there is some system pressure. We become invested in our positions, feeling our reputations ride on them. We have some responsibility to maintain our salaries and even grow them. Some of us are responsible for creating revenue that others and their families rely on. There are professional and cultural norms that we are loath to cross.

    Sometimes, though by no means always, these forces push against doing the right thing. We are conflicted, at least somewhat. And sometimes they do so when there’s some ambiguity as to just what the right thing is. Here’s where it’s easy (or easier) to shade, to lean, to allow those system pressures to tip the scales so we can have it all. We find a way to justify doing the thing that doesn’t disrupt the status quo, even when without those system pressures we would not do that thing.

    It’s very hard to be fully in tune to when this is happening. Most of the time it doesn’t matter much. Few decisions are anywhere near as important as whether or not to launch the Space Shuttle in temperatures below those at which its components have been tested. But sometimes a decision matters just enough that one is risking one’s integrity and credibility (if not worse) by succumbing to system pressure when it opposes what is empirically the (more) right call.

    McDonald did a hard, brave thing by resisting system pressure. He paid a price for it, though his career seemed to have gone quite well anyway. It’s no small feat, what he did, and some of his colleagues couldn’t do it. Is it so clear you or I could in the same circumstance? In what ways do you or I allow system pressure to chip away at our credibility and integrity, if only imperceptibly? I find it disturbingly interesting to ponder these questions.

    The book is long, both because it is so detailed, but also because it tells the history of the aftermath of the disaster linearly. It was investigated several ways: by Presidential Commission, by congressional committees, and in various lawsuits. In each part of the story some of the same arguments and episodes are covered. I found some parts of the book overly technical. But it’s easy enough to skim and skip. If you don’t read it, at least listen to the Freakonomics episode.


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  • A little bit of money means a lot to many, many people

    A couple of years ago, the tires on my wife’s car needed to be replaced immediately. She called me, concerned, because they were going to cost a couple hundred bucks, and we really didn’t have the time to shop around. I told her not to worry, and to buy them.

    I distinctly remember feeling immensely grateful after I got off the phone. This, really, was “wealth”. Not fancy vacations or expensive meals, but the comfort of knowing that it was nearly impossible for “small”, incidental charges like this to really affect our lives.

    I thought of that when I saw this story this morning in Time:

    On a recent San Francisco afternoon, I returned to where I’d parked my car, but it was gone. A “No Parking” sign indicated that parking was prohibited after 3:00 PM on weekends. It was 3:15. I called the telephone number on the sign and a clerk affirmed that my car had been towed to an impound lot.

    I took a cab and entered a single-story brick building where a few dozen people were crowded together in a scene that evoked Kafka; weariness, frustration and anger were palpable. Some stood in line, some paced and some sat hunched on the floor. A family huddled in a corner, an infant asleep on the father’s shoulder. A woman on a pay phone wept as she begged whomever was on the line to find money so she could get her car back–she said she needed $875. “I’m gonna lose my job if I’m not there at 5.”

    Clerks sat on stools behind Plexiglas. At a window, a man pleaded with an agent, “I have to pick up my kids in less than an hour. What am I supposed to do?” At the next window, another man railed loudly and furiously, yelling, “How the hell am I supposed to get my goddam money if I can’t get to goddam work?” The clerk said, “If you can’t get cash, you can pay by credit card or cashier’s check.” The man shouted, “And if I had a goddam limousine, we wouldn’t be having this conversation.”

    To many Americans, a towed car is a nuisance. A real one, yes, but in the scheme of things, no more than that. That’s wealth. That’s privilige. For many others, a couple hundred bucks is all it takes to destroy the fragile framework of what passes for security in their lives.

    Think about that the next time someone tells you that a $100 copay shouldn’t be a “big deal”. Or how a $25 premium is “insignificant”. Or how over-the-counter birth control is “cheap”.

    It may be to you. But not to everyone. Not to far more people in this country than you likely realize.



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  • Why can’t I look up my service history?

    I am in the waiting room at a Toyota dealership, getting service on my Prius. There is a loose panel underneath the car that’s making a noise. And while I am in, I thought I would catch up on the car’s routine maintenance.

    The problem, however, is determining what has and hasn’t been done. I haven’t had this car serviced at this dealership before. I’m in a commuter marriage, I’ve been living in two cities, and I seem to travel all the time. So the car has been worked on at several dealerships in several cities. And of course, I have no clear memory of what I’ve gotten done when.

    No problem. The car has a VIN number. Dealerships are independent enterprises, but Toyota has an international database that has all the service records from all the dealerships. The service manager and I are looking at the records in seconds and we quickly make a decision about the needed service.

    This is interesting only because I can’t do this for my body. I have a congenital arrhythmia and a pacemaker. Like my car, my heart needs a lot of routine maintenance. I have to get care in two cities, but neither site can access the other’s records. There is also the occasional semi-emergency, when the cardiologists always regret that that they can’t read the trace data that are (they hope?) stored at the other clinic. I get pdfs of some of my records, but collecting these things in my Dropbox has been, shall we say, a less than world class solution.

    The engineering and legal work required to make electronic health records interconnect is harder than the engineering required to connect Toyota dealerships. Nevertheless, it is seriously stupid that I can access complete service information on my car but not my heart.


    For previous TIE writing — and complaints — about the disconnected state of electronic health records, see here, here, and here; and listen to podcasts available here.

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  • Dash of Salt Does No Harm. Extremes Are the Enemy.

    The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

    For years, we have known that diets high in salt can be bad for people with high blood pressure. A study published recently in The New England Journal of Medicine confirmed this fact. It monitored more than 100,000 people in 18 countries and found that people who consumed more sodium generally had significantly higher blood pressures than those who did not.

    Another manuscript in the same journal looking at the same study population went even further. It found that people who consumed more than 7 grams of sodium per day had a significantly higher chance of death than people who ate 3-6 grams per day. People consuming high levels of sodium had higher rates of heart attacks, heart failures and strokes as well.

    These results confirm that people who eat too much salt should eat less of it. The problem with the way we respond to such information, though, is that we often run too far and too fast in the other direction.

    Americans consume, on average, 3.4 grams of sodium per day, or about the equivalent of three and a half tablespoons of soy sauce. This is on the low end of the “safe zone” of 3-6 grams in the study. The United States Food and Drug Administration thinks that’s not low enough. It recommends 2.3 grams per day. The World Health Organization says it should be 2.0 grams. The American Heart Association goes even further and recommends we consume no more than 1.5 grams.

    Upshot Salt

    Why? There’s surprisingly little rationale for this belief. Last year, experts convened by the Institute of Medicine assessed the evidence concerning sodium intake around the world. They agreed that efforts to reduce excessive sodium were warranted. But they cautioned that no such evidence existed to recommend a very low salt diet. They hoped that future research would assess the potential benefits of a diet where sodium intake was 1.5 to 2.3 grams per day.

    The second New England Journal of Medicine study did just that. In addition to looking at high sodium diets, it compared the health outcomes of those who had very low sodium diets. What they found was worrisome. When compared with those who consumed 3-6 grams per day, people who consumed less than 3 grams of sodium per day had an even higher risk of death or cardiovascular incidents than those who consumed more than 7 grams per day.

    This result would be shocking if we in the medical community hadn’t seen it before. But we have. In 2011, researchers published a study in the Journal of the American Medical Asssociation after following 3,681 people over almost a decade. They, too, found that excessive salt intake was associated with high blood pressure. They also found that a low-sodium diet was associated with higher mortality from cardiovascular causes.

    Why experts and organizations feel the need to go from one extreme to the other is unclear. But it’s unfortunately something we do far too often in medicine.

    Take cholesterol. Initially, people believed that the evidence was pretty compelling that high cholesterol was bad for you. But instead of focusing on those who are really at high risk, or those at the very highest ranges of cholesterol levels, we saw recommendations emerge that told us that all cholesterol was bad. We began to eliminate it from our diets completely. Eggs were shunned.

    But later research showed us that egg consumption had no relationship to cardiovascular disease for most people. In fact, a majority of people’s serum cholesterol level has little to do with how much cholesterol is in their diet.

    Today we use medications to lower our cholesterol levels. Once again, though, our sights keep shifting lower. Instead of focusing on those who are most at risk, we’ve decided cholesterol is so unhealthy that a 60-year-old African-American man with a total cholesterol of 150 might be placed on therapy. Just two years ago, a total cholesterol level of 200-239 was considered to be a definition of “intermediate” cardiovascular health. Theaverage total cholesterol value in America is 200.

    This problem doesn’t run solely in the direction of eradication, though. It’s well understood that vitamin deficiencies can lead to significant diseases. Our response has often been to take them in ever increasing megadoses. There’s no evidence that this does any good, and some vitamins can actually harm usif we consume too much of them.

    More often than not, though, the body can’t use the extra vitamins, and just gets rid of them. The truth is that vitamin megadoses mostly just createvery expensive urine.

    Too many calories are bad for us. That doesn’t mean we should consume none. Too little exercise can lead to bad outcomes. That doesn’t mean you exercise to the point of hurting yourself. Too much sun can cause cancer. That doesn’t mean we should never go outside.

    It’s a cliché but true: In so many things moderation is our best bet. We have to learn that when one extreme is detrimental, it doesn’t mean the opposite is our safest course. It’s time to acknowledge that we may be going too far with many of our recommendations.


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  • People and Perspectives: worth some of your time

    I have been alerted to the existence of People & Perspectives:

    People & Perspectives (P&P) is a digital story-telling library supported by PRIM&R (Public Responsibility in Medicine & Research).

    P&P features stories of those working in the research field, including institutional review board (IRB) and institutional animal care and use committee (IACUC) professionals, research staff, committee members, institutional officials, researchers, subjects, advocates, regulators, industry representatives, ethicists, and anyone else who considers themselves part of the human subjects and animal care and use enterprise. It is a collection of stories in multiple mediums, i.e., audio- and video-recordings of oral histories and interviews, essays, content from PRIM&R’s ample archives, and profiles of leaders and luminaries.  Some content is contributed by individuals, and some is recorded and gathered by PRIM&R for this purpose.

    We hope that you will help us make history by adding your story to this library, and to honor the history of the field and of those in it by viewing and sharing these stories.

    Some of the videos are by very well-known people in research ethics. They’re the kind of people who do amazing work, but don’t necessarily publish in the journals we cover here. It’s amazing to be able to see some of them in action. For instance, here is Eric Meslin talking about “The Tsunami of Information on the Internet“:

    More Eric here. More videos here.


    *Eric is a close friend and colleague, and therefore I’m obviously potentially conflicted about him. Don’t care. Go watch.

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  • Who ordered that?

    Who Ordered That? The Economics of Treatment Choices in Medical Care,” by Amitabh Chandra, David Cutler, and Zirui Song is a worthwhile read. Below are my highlights. All are direct quotes.

    • [T]here are over 7,000 cardiology guidelines for individual clinical decisions. Only 11 percent are based on randomized controlled trials, and 48 percent are from expert opinions, case studies, or prior standards of care. [...] There are over 4,000 infectious disease guidelines.
    • None of the theories for which there is a lot of evidence can be shown to explain a major part of cross-individual or cross-area variation in treatments.
    • [C]ost sharing affects whether a person gets into the system, but not what happens once a person is in the system. To take an example, cost sharing might influence whether a person with chest pain sees a cardiologist, but not what services the cardiologist performs once care has been initiated.
    • When cost sharing increases, people use fewer services, but the services foregone are neither uniformly valuable nor wasteful.
    • Higher cost sharing deters recommended preventive and chronic care, which may lead to undesirable “offsets” in greater use and spending on other services, such as hospital care. [...] Raising costs for prescription drugs increases hospital costs, and lowering costs for preventive care has only a modest effect on utilization if people need to see their primary care physician before accessing preventive care.
    • [R]egional variation is extensive in the Medicare population. People living in areas with the highest quintile of spending use, on average, 50 percent more care than people living in areas with the lowest quintile of spending.
    • [V]irtually none of these regional differences is accounted for by differences in area income or poverty rates.
    • Health status differences explain about 18 percent of the difference in spending across areas, and the rest is unaccounted for.
    • [T]he combined impact of supplemental insurance on regional differences in spending is small. [Zuckerman et al. (2010)] estimate that income and supplementary insurance together explain 1 percent of the higher spending in high-cost areas compared to low-cost areas. Thus, while price and income matter for spending, they are unlikely to explain a large part of why spending differs so much across people or areas.
    • Our conjecture is that differences in preferences do not explain a large part of treatment variation—not because preferences do not differ, but because they are frequently not accounted for in actual treatment decisions.
    • The literature is clear that providers respond to payments, and that the response can be very large.
    • [T]he physician that a patient sees matters far more for treatment than the patients’ preferences.
    • Among cardiologists given patient vignettes, whether their colleagues would have ordered a cardiac catheterization in the same situation predicts whether respondents ordered a catheterization.
    • [E]vidence from Cesarean sections in Florida shows that while physicians do learn from other physicians, residency programs explain less than 4 percent of the variation in rates of operations (Epstein and Nicholson, 2009). Physicians did not seem to update their prior beliefs, even newly trained physicians, producing a within-area variation that approximately doubled between-area variation.
    • An example of stinting is obstetricians avoiding high-risk women, for fear that the baby will be impaired and they will be blamed. Negative defensive medicine would arise in a malpractice environment where adverse events such as injuries receive compensation even though malpractice had not occurred. The combined effect of defensive medicine and stinting has been estimated in several studies (Brennan et al., 2004; Localio et al., 1991; Mello et al., 2010). These estimates are not without difficulty: measuring malpractice pressure in an area is difficult, and finding an exogenous measure of that is harder still. Even so, studies have surmounted this problem using area variation in malpractice premiums or other measures of malpractice pressure such as the size of indemnity payments. The results show a surprisingly small net contribution of malpractice concerns to what physicians do. Mello et al. (2010) estimate that medical malpractice and efforts to manage its risks cost the national health care system more than $55 billion a year, about 2.4 percent of annual health care spending. The study summed various components of the medical liability system, including payments made to malpractice plaintiffs; defensive medicine costs; administrative costs, such as lawyer fees; and the costs of lost clinician work time. Defensive medicine costs were the largest segment of total malpractice spending and amounted to approximately $45 billion a year annually. In other work, Baicker et al. (2007) note that malpractice pressure increases the use of imaging procedures but exerts a small overall effect on total spending, perhaps because of the presence of negative defensive medicine.
    • In a systematic review of 35 studies, both providers and patients understood natural frequencies better than probabilities in the presentation of risk (Akl et al., 2011). For example, a 50 percent risk reduction was perceived to be substantially larger than an absolute risk reduction from 2 to 1 percent. Statistics presented as number needed to treat were least persuasive, such as 100 people treated to prevent one case of the disease. Perhaps because of this, there is widespread overly aggressive screening and treatment in prostate cancer (Drazer et al., 2011; Schroder et al., 2009).

    The Akl et al. paper comparing persuasiveness of different ways to present risks is in my pile.


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  • What’s the second best US city for culture? You’ll never guess!

    Click bait, yes, but I don’t care:

    Property Shark, a property research website, put together a list of the 20 U.S. cities with the most activities dedicated to culture and recreation, including museums, libraries, theaters parks, and stadiums.

    The team then factored in how many attractions there were per capita to create the final ranked list.

    What’s the second best city? Indi-freaking-anapolis:

    #2 Indianapolis, IN

    One cultural attraction for every 705 people

    Indianapolis may not seem like a cultural capital of America, but it has six different cultural districts and a rich heritage.

    The city has also tried to become a destination for arts and culture with 1,184 properties, including the Children’s Museum of Indianapolis and the Indianapolis Motor Speedway and Hall of Fame Museum.

    Suck it, rest of the United States! Except, I guess, Seattle*, which was #1.


    *For the record, I lived in Seattle for five years before moving to Indianapolis. So I guess that makes me the most cultured man in America.

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