• Help me learn new things in 2018 – the schedule!

    After my post asking for your recommendations for books/topics I should learn about in 2018, I got a lot of great responses. If I didn’t choose yours, it’s likely because I already felt like I knew something about the subject (like programming) or because I liked something else just a little bit more. There’s always 2019.

    Here’s my proposal. I think I’ll go from past to present. January isn’t happening.

    1. February – Rome
    2. March – The Fall of Rome/The Dark Ages
    3. April – The Revolutionary War
    4. May – The Civil War, part I
    5. June/July – Cocktails
    6. August – The Civil War, part II
    7. September – World War I
    8. October – Nazi Germany
    9. November – World War II
    10. December – TBD/Overflow

    Some things to note. I gave The Civil War two months because there were so many books to read. And, I think it deserves it. I also left December open. If I fall behind, this will allow me to push things back. If I stay on schedule, we’ll add something on the fly.

    The summer will be for cocktails. Well, the whole year is for cocktails, but I’ll learn a lot this summer. I also want to try and knit more then. We’ll see how I fare. I also need to get back into meditation.

    One week before each new month, I will post a query for book suggestions. I have a lot, but there could always be more. I’ll list what I have and ask for more. That will give me time to order them and get going on the first of the month.

    I’m excited.


    Comments closed
  • Healthcare Triage News: Get Your Flu Shot! It’s Not About You, OK?

    It’s not too late to get a flu shot! You may have heard that the flu shot this year is “less effective” than in earlier years. That may not mean what you think it means. Less effective is a relative relationship, and in absolute terms, the shot is still pretty useful.

    This episode was based on a column I wrote for the Upshot. Links and resources found there.


    Comments closed
  • Still Not Convinced You Need a Flu Shot? First, It’s Not All About You

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    One of the biggest problems in trying to convince people that they need to immunize against things like the flu is that they don’t really feel the pressure. After all, for most people, the flu shot is an inconvenience, and they’re unlikely to get the flu in a given year. So why bother? Quite a few readers expressed this view after my article “Why It’s Still Worth Getting a Flu Shot” on Thursday, including this one.

    I promise this is an honest question: Are people routinely being destroyed by the flu or something? (I mean, first I’d ask, ‘Is everyone but me simply vaccinated, and thus gifting me with herd immunity?’ And so I did. My first Google search brought me to yearly C.D.C. flu-vaccine coverage statistics, and for the last four years, the percentage of flu-vaccinated adults has been in the low 40s. So… nope.)

    I’m not a particularly healthy person — I get colds, sinus infections, etc. — but I just can’t recall ever having had the flu, or at least *knowing* I had it. This seems to indicate that the flu is either 1) rare enough that it’s possible for me to have been lucky forever (in which case it’s fairly rare, apparently), or 2) not severe enough of an illness for me to have noticed experiencing it.

    Both lead me to conclude that skipping the vaccine is fine.

    I’m just a regular idiot, presumably representing other regular idiots, amenable to changing their habits, but who haven’t done so — not due to obstinance or contrarianism, but due to signals so mixed as to inspire ambivalence — and if this article can be said to have provided the ‘why’ its headline promises, unfortunately it hasn’t provided the ‘why’ idiots like me need to hear:

    Why is the flu a big deal literally at all? — Chrystie, Los Angeles

    Although I devote some of my articles to telling you not to worry so much about some diseases or other risks, influenza is one thing you actually should worry about. It’s terrible; it’s also far too common.

    Influenza, commonly called the flu, spreads easily. You can catch it from someone who coughs, sneezes or even talks to you from up to six feet away. You can infect others a day before you show any symptoms, and up to a week after becoming sick. Children can pass along the virus for even longer than that.

    Influenza is not a reportable disease, so its prevalence must be estimated. The Centers for Disease Control and Prevention believes that, since 2010, between 9.2 million and 35.6 million people have come down with the flu in the United States each year. That means that in a bad year, more than one in every 10 people in the United States might get it.

    Many of those people end up in the hospital. In a good year, we might see as few as 114,000 people hospitalized with flu-associated illnesses. In a bad year, that number rises to more than 700,000.

    In 2014, more than 57,000 people died of influenza/pneumonia. It was the eighth-most common cause of death, behind diabetes (just under 80,000 deaths). It’s also the only cause of death in the top 10 that could be significantly reduced by a vaccine. Lowering risks of heart disease, cancer or Alzheimer’s are much, much harder to do.

    In 1995, the worst year of the AIDS epidemic in the United States, fewer than 51,000 people died of it. In 2014, just over 6,700 deaths were attributable directly to H.I.V. Yet it is H.I.V., not the flu, that people dread far more.

    Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.

    Worldwide, just over 10,000 people died in the 2014-15 West African outbreak of Ebola: a relatively new, frighteningly contagious illness that people feared could become a global pandemic. It’s not surprising that it got a lot of attention. Yet the tens of thousands who died of influenza in the United States the same year barely made the news.

    It’s possible that so many adults ignore the danger because it seldom affects them directly. Most of the hospitalizations and deaths occur among children and older people. The rates of hospitalization of those less than 5 years of age are twice that of adults under 50. The rates among those 65 or older can be 10 times that of other adults. Almost two-thirds of deaths are among older people.

    So much of this is preventable. The C.D.C. estimated that in the 2015-2016 flu season, the flu shot prevented more than five million cases of the flu, about 2.5 million medical visits and more than 70,000 hospitalizations. It was also estimated that it prevented 3,000 deaths.

    If just 5 percent more people had been immunized, we could have probably avoided 500,000 illnesses, 230,000 medical visits and 6,000 hospitalizations.

    We should also note that the 2015-2016 flu season was also mild. More worrisome is something like what happened with the Spanish flu in 1918-1919. One third of the world population was infected, and about 675,000 Americans died.

    They died from the flu.

    If you fall into one of the lower-risk groups (i.e., adults age 18-50), you might still think that the flu isn’t such a big deal, and that you don’t need to worry much. I could argue that there’s evidence that even if the shot doesn’t prevent you from getting the flu, it could make your illness less severe. But even this misses a huge point. You don’t get immunized just to protect yourself. You also get immunized to protect those who can’t protect themselves.

    Chickenpox — and the varicella virus that causes it — had long been considered a “nuisance” by many. When a vaccine was introduced in 1995, some questioned whether it was necessary for children, since most who got the disease were fine. Pediatricians disagreed; they had cared for the many young children who were hospitalized by the illness, and the surprising number who died — mostly infants.

    study published in Pediatrics in 2011 made the case for why thinking about only yourself is the wrong way to look at varicella vaccination. The first thing it showed was that from 2001 through 2007, as rates of vaccination rose, the rates of death from varicella were low, with just a few children dying from chickenpox nationally each year. But more significant, from 2004 through 2007, not one child younger than 1 year old died in the United States from chickenpox.

    What was amazing about this finding was that we don’t vaccinate children that young for chickenpox — therefore, those babies’ deaths were not prevented because they were vaccinated. Their deaths were prevented because we vaccinated their older siblings. That achieved the herd immunity necessary to slow or prevent the rates of infection significantly.

    Adults need to get vaccinated to protect children and babies. They need to get vaccinated to protect older people and the immuno-compromised. This is true for almost all diseases, including the flu. Less than 50 percent of children are immunized against the flu. About two-thirds of people 65 and older are.

    But only a third of adults 18 to 49 are.

    They can do better. If not for themselves, then for those they love.


    Comments closed
  • I’m the new Web and Social Media Editor at JAMA Pediatrics! We’ve got a podcast you might like.

    So first off, the news if you missed the headline: I’m the new Web and Social Media Editor at JAMA Pediatrics. I’ve been on the editorial board there for years, and it’s a privilege to serve in this new role.

    One thing I’m going to try and do is change up their audio stream. We’re going more podcast. As close-to-every-week as I can manage, I’m going to make a less-than-ten-minute episode talking about a paper being released this week. We’ll try and pick a good one. As often as we can, we’ll make that paper free to read.

    You can listen to the first episode here. You can subscribe to the podcast at the bottom of the page here.


    Comments closed
  • What should I learn about in 2018?


    I spend 2016 learning new things, and 2017 learning new skills. I think 2018 should be a combination of both. I would like to spend most of the year reading history. I’m open to biographies as well. I need recommendations, though. I’m opening comments to allow for those. Or, tweet me. Here are my top level thoughts:


    • Roman Empire
    • The Civil War
    • World War I
    • World War II
    • Nazi Germany
    • The Revolutionary War
    • The Dark Ages


    • Origami
    • Making paper airplanes
    • Cocktails – complex stuff

    What am I missing? What should I read? If you don’t help me, I’ll have to pick for myself!


  • Why It’s Still Worth Getting a Flu Shot

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    This year’s flu season is shaping up to be a bad one. Much of the country endured a bitterly cold stretch, causing more people to be crowded together inside. The strain that has been most pervasive, H3N2, is nastier than most. And, we’re being told, the vaccine this year is particularly ineffective.

    That last fact has had many people wondering if they should still get a flu shot. If you read no further in this column, know this: The answer is yes, you should still get a flu shot. The flu season typically peaks December through February but can last until May, and it usually takes about two weeks for the shot’s immunity to kick in.

    It’s worth exploring what we mean by effectiveness when we’re discussing the flu vaccine.

    The flu virus is unstable, and it changes a lot each season. This means that the immunity you gained from a shot a year ago doesn’t work so well this time around. Each summer, scientists gather and try to make a best guess on which variants are going to be more common in the coming year. They look at data from countries like Australia (whose flu season comes before ours), then they make the shot to match.

    This season, the flu vaccine is most protective against an H1NI, an H3N2 and a B/Victoria lineage strain. Some vaccines also protect against a B/Yamagata lineage strain.

    The scientists’ guess wasn’t bad, as it included H3N2, the strain making most of the news right now. Vaccines don’t work as well against it in general because it tends to mutate more than other strains. It’s also harder to produce a targeted vaccine for H3N2 than for other variants, because of the way we produce the vaccine using eggs. That, along with other factors, makes for more infections and more severe illnesses.

    In any year, even when you’re vaccinated, you can get the flu. The shot is about reducing your risk, not eliminating it. Still, even when the flu vaccine is “less effective,” it’s a good bet.

    One reason is that “less” and “more” effective are relative terms. We need to be careful about these words and focus more on absolute risks.

    In 2010, researchers published a meta-analysis of all available flu shot studies. They showed that when a vaccine is considered effective, 1.2 percent of vaccinated people had the flu, while 3.9 percent of unvaccinated people had the flu. That’s an absolute risk reduction of 2.7 percentage points. This means that the number of people who needed to be treated for one person to see the benefit — a concept known as N.N.T. — was 37. Given the millions who are vulnerable to flu and the thousands of deaths each year, this is a big payoff in public health.

    In studies in which the flu shot was considered ineffective, 1.1 percent of vaccinated people had the flu compared with 2.4 percent of unvaccinated people. The absolute risk reduction was 1.3 percentage points, and the N.N.T. was 77.

    Let’s say that this year’s flu vaccine is even worse than we think. Maybe the absolute risk reduction will be as low as 1 percentage point, making the N.N.T. 100. That’s still not that bad. Even at an N.N.T. of 100, for every 100 people who get a flu shot, one fewer will get the flu. That’s a pretty low N.N.T. compared with many other treatments that health experts recommend every day.

    Further, a Cochrane review published in 2016 showed that the N.N.T. in children 6 years old or younger to prevent one flu case was just six — an astonishing payoff in medical terms. It has even been shown to be effective in preventing death in children from flu-related causes.

    The negatives of a flu shot are almost nonexistent, and significant side effects are very rare. Even in an ineffective year, the benefits greatly outweigh the harms. The Centers for Disease Control and Prevention estimates that 9 million to 36 million people become ill with the flu each year in the United States. Somewhere between 140,000 and 710,000 of them require hospitalization, and 12,000 to 56,000 die each year.

    No vaccine is perfectly protective in any year, so it’s important to practice good infection control. That includes regular hand washing — especially before eating — and limiting contact with others when you or they are sick. But to minimize your chances of illness, yes, you should still get the flu shot this year, and any year.


    Comments closed
  • Healthcare Triage: Alcohol and Cancer and How We Think About Risk

    Recently, there have been big, splashy headlines about how drinking ANY alcohol increases your risk of cancer. As usual, there’s more to the story than the scary headline. We look at the studies that made all the news, and talks about risk, and how we can think about managing risk in our day to day lives.

    This episode was based on a column I wrote for the Upshot. Links to further reading and sources can be found there.


    Comments closed
  • The James Altucher Show: Ep. 302 – Aaron Carroll: It’s All Relative: Nutrition Myths Debunked

    I was a recent guest on James Altucher’s Podcast, which was a ton of fun. Go listen!

    Also, buy my book. Links on the right.


    Comments closed
  • Administrative actions to “improve” health insurance markets

    Yesterday, Jennifer Haberkorn of Politico reported on the Trump Administration’s plan to “improve the individual and small group markets most harmed by Obamacare.” The plan is in a memo obtained by Senator Bob Casey and shared with Politico. It’s a 10-point plan encompassing the following areas, though details are lacking to such an extent that I don’t fully understand what some are getting at:

    1. Special enrollment periods (require verification of eligibility)
    2. Grace periods (tighten rules about paying premiums)
    3. Open enrollment periods (shorten them)
    4. Network adequacy (return authority of it to states)
    5. Essential health benefits (allow states more flexibility)
    6. Section 1332 waivers (expedite them)
    7. Third party payment of premiums (steering patients to private coverage instead public coverage is a no-no)
    8. Permit lower cost direct enrollment pathways (more flexibility to states)
    9. Benefit design flexibility (more flexibility to states)
    10. Encourage skinny exchanges (more innovation)

    According to the Politico piece, seven of these have already been implemented: 1, 3, 4, 5, 9 are among those seven, I think (though I’m confused about how 5 and 9 differ). The piece then says 4.5 of these had not been implemented, but had been proposed at the time the memo was written. Numbers 7 and 10 are among those not implemented, I think. Anyway, 7 + 4.5 makes 11.5 proposals out of 10, so I’m confused.



    Comments closed
  • JAMA Forum: The Problem With Work Requirements for Medicaid

    Given today’s news about Medicaid work requirements, it’s hard to imagine my latest post at the JAMA Forum could be more timely. Go read it!


    Comments closed