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Are Patients Harmed When Physicians Explain Things Too Simply?

Poultry and Hog Farms Face Possible Dioxin ContaminationA quick quiz before we start today’s lesson.

What do we call a tree that grows from acorns?

What do we call a funny story?

What sound does a frog make?

What is another word for a cape?

What do we call the white part of an egg?

On that last question, were you tempted to answer “yolk?” If so, you are in good company, because most people give that answer even though the correct answer is “albumen.” People answer yolk – after oak, joke, croak, and cloak – because that’s the fast choice. Primed by rhymes, people provide the wrong answer.

Sometimes fast-thinking is not so good. Which raises an interesting question for physicians trying to help patients navigate important medical decisions Will they harm patients by explaining things so simply that patients make fast, erroneous choices? (To read the rest of this article, please visit Forbes.)

Posted in Behavioral Economics and Public Policy, Medical Decision Making | Tagged ,

The Key to Winning a Pulitzer? Don’t Take Time To Think!

Bret Stephens won a Pulitzer Prize for his foreign affairs column  in the Wall Street Journal op-ed page. Only in his early 40s, Stephens can already boast of an enviable number of accomplishments. He has already been Editor-in-Chief of the Jerusalem Post. And he is now Deputy Editor at the Wall Street Journal, one of the nation’s best newspapers. Pretty decent for someone who graduated college 20 years ago.

So what’s his secret? Apparently, it’s his ability to avoid thinking before publishing. I wish I was making this up, but here is how Stephens described his Pulitzer Prize-winning writing technique, in an interview published by the University of Chicago Magazine:

“Columns are a bit like pancakes,” he said. “They need to be cooked and eaten right away.” To his credit, Stephens demonstrates an excellent understanding of pancakes. Nothing is as good as fresh off the griddle. But what do pancakes have to do with newspaper editorials? Stephens elaborates: “I’ve never written a column on a Thursday and just put it aside and then run it on Monday night. I think that’s deadly.”

What?!? Deadly to wait a few days, revisit your ideas after you’ve had time to reflect on them, before publishing them in one of the world’s most influential newspapers?!?

Copyright The University of Chicago Magazine

Copyright The University of Chicago Magazine

I’ve had more than several days to consider Stephens remarks, and I continue to find them deeply disturbing. I am not disturbed simply because one prominent writer brags about his unreflective methods, but because I expect he is describing how many prominent opinionaters work. They crank out columns. They react to the issues of the day with little desire to slow down and ponder what is truly important. (To read the rest of this article, please visit Forbes.)

Posted in Uncategorized

The Lost Art Of Not Ordering A CAT Scan

CatscanShe didn’t talk like a stroke victim. “I…I…I…k…kkk…can…can…can’t…t…t…t…talk.” She struggled with her words, struggling on early syllables, only to then spurt out full and correct words. “N…N…N…No.” Recognizing this unusual speech pattern, the neurologist Allan Ropper, author of Reaching Down the Rabbit Hole, expertly queried the patient and her loved ones, and determined she had just experienced a stressful break up with her boyfriend. “From the very first sounds out of her mouth,” Ropper writes, “I concluded that it is very unlikely that we are dealing with damage to her brain from a stroke, seizure, or any other acute problem.”

The residents [physicians-in-training] pushed for an emergency CT, also known as a CAT Scan. Ropper knew better and explained why they should slow down and rely on their clinical examination findings “but they feel the stroke issue has got time value,” Ropper writes. “They prevail, and she heads off to the floor to get a big dose of radiation.”

What?!?!?! (To read the rest of this article, please visit Forbes.)

Posted in Medical Decision Making | Tagged ,

Podcast on 3.0

NEJMThe Managing Editor of the New England Journal of Medicine interviewed me about the piece I wrote, with David Comerford and Eric Johnson, on redesigning the health insurance exchanges. For those of you with long commutes, here is that podcast: 3.0

Posted in Behavioral Economics and Public Policy, Health Policy | Tagged , ,

More on 3.0


Here is a nice follow-up story on my recent New England Journal article on improving the design of health insurance exchanges.

Comparing health insurance plans – whether signing up through or weighing employer-sponsored plans with a spouse – can feel like wading through a sea of information on deductibles, co-payments and monthly premiums. Now that more than 11 million people have chosen a plan during this year’s enrollment period, which ended on Feb. 15, three experts are pondering how to make this intimidating task even easier for next year’s registrants? They have laid out their prescription for improving the health insurance marketplace, grounded in psychology and behavioral research, in a perspective published Wednesday in the New England Journal of Medicine.

“This is a really complicated decision to make and a pretty high-stakes one, too — it can mean a lot of money,” Peter Ubel, a co-author and health marketing expert at Duke University, says. “I think a better designed system would actually be faster to go through and yet still help you make a better decision.”

In the existing marketplace, the authors don’t like the way plans are sorted into gold, silver and bronze categories.They think these labels make the gold plans inherently more desirable. The team did a preliminary test of this theory by presenting a choice of two plans to public bus riders in North Carolina – one offering lower monthly premiums but higher out-of-pocket costs than the other – and alternately labeled them “gold” and “bronze.” Inevitably, more than half of riders chose the “gold” plan, no matter if it had the higher or lower premiums and deductibles. (To read the rest of this article, please visit International Business Times.)


Posted in Behavioral Economics and Public Policy, Health & Well-being, Health Policy | Tagged ,

Q & A With Richard Thaler On What It Really Means To Be A “Nudge”

Copyright The Telegraph

Copyright The Telegraph

Nudge is one of the most important and influential books on behavioral science and public policy I’ve ever read. Co-authored by economist Richard Thaler and lawyer Cass Sunstein, the book lays out the rationale for adopting policies designed to make it more likely that people will act in their own best interests rather than, say, spend money they shouldn’t spend or eat food they shouldn’t consume. In the book, Thaler and Sunstein discuss how recent advances in behavioral science should inform our attitudes towards rational decision making. Specifically, these behavioral science findings show that people don’t always make rational decisions, raising questions about when or whether outsiders—like governments or employers–should step in to help people avoid making bad choices.

But has enthusiasm for the book led people to see nudges where they don’t exist? That was the question I posed in a recent post, where I argued that it was wrong to call a well-designed traffic light a nudge: “Not all good design, even good design that influences behavior, is a nudge,” I wrote. “A well-designed prison cell is more likely to deter prisoners from trying to escape than a poorly designed one. But that does not make it a nudge.”

The day after I wrote those words, my email inbox included a forthright message from Dick Thaler, telling me I was seriously misguided about nudges. That email began an exchange that turned into a question and answer session reproduced here with Thaler’s permission. (To read the rest of this post and leave comments, please visit Forbes.)

Posted in Behavioral Economics and Public Policy | Tagged , 3.0–Improving the Design of the Obamacare Exchanges

NEJMI joined two other, much smarter, colleagues in calling for the use of behavioral economics and decision psychology to improve the design of the websites people use to purchase health insurance in the U.S. That article came out today in the New England Journal of Medicine. Here is a taste:

In October 2013, the Affordable Care Act introduced a new insurance market — state and federal exchanges where people can purchase health insurance for themselves or their families. Although the rollout of the exchanges was disastrous, around-the-clock efforts fixed many of the biggest technical problems, and nearly 7 million people purchased insurance in the new market. The second round of enrollment exposed some new problems with the exchange websites — for example, Colorado’s website had difficulty determining whether people were eligible for tax credits — but these problems paled in comparison with those encountered when the exchanges were first rolled out. In short, we have a largely glitch-free system of health insurance exchanges that present millions of people with a robust set of health insurance choices.

Which means that it will soon be time to tackle the much more challenging job of designing exchange websites in ways that maximize the chances that consumers will choose plans best suited to their needs and preferences. If the first round of open enrollment was primarily about avoiding catastrophe and the second round was about ironing out wrinkles in the underlying programming code, then version 3.0, in our view, should focus on redesigning the way exchanges present their insurance choices, to avoid features known to bias people’s decisions.

Posted in Behavioral Economics and Public Policy, Health Policy, Medical Decision Making | Tagged , , , ,

When It Comes to Cancer Screening, Are We All Nuts?

Washington-Post-LogoIn a recent Health Affairs article, David Asch and I wrote about how hard it can be to stop screening aggressively for things like breast and prostate cancer even when the evidence suggests we are doing more harm than good. Well, journalist Steven Petrow has a nice piece in the Washington Post looking at the good old testicular exam. Lots of nice insights, so I thought I’d share it:

Late last year, “Today” show anchors Willie Geist and Carson Daly took one for the men’s team when they underwent testicular cancer exams on live TV. Lots of predictable joking ensued, especially from co-anchor Savannah Guthrie, who ad-libbed: “When I heard what you guys were doing, I thought it was nuts!” The “attending” urologist, David Samadi of Lenox Hill Hospital in New York, also took to wordplay, asking: “Who’s going to play ball first?” Geist stepped up.

Within minutes both anchors received clean bills of health along with Samadi’s congratulations for getting the exams. Samadi also encouraged the rest of maledom to perform testicular self-exams monthly in the interest of early detection, which he said can save lives — but do they?

Nearly 9,000 cases of testicular cancer in the United States are diagnosed every year — especially among men ages 15 to 34, where it’s the most common cancer — so the “Today” segment seemed like a useful public service announcement.

But unfortunately there’s no evidence that self-exams detect testicular cancer at an earlier stage, according to Durado Brooks, director of colon and prostate cancer prevention programs for the American Cancer Society. Even if these exams did, says Kenny Lin, an assistant professor of family medicine at Georgetown University Medical Center, early detection has little, if any, bearing on outcomes for those who are diagnosed. Lin calls the “Today” segment “a stunt cloaked as a health message,” and he points out that even the august U.S. Preventive Services Task Force recommends against testicular cancer screening — a change from the past.

Other routine screening tests have also earned a thumbs down from the medical establishment in recent years, as more clinical evidence has been gathered showing them to be less beneficial than once thought. Among the tests no longer universally recommended: PSA screening for prostate cancer, breast cancer self-exams for women and mammograms for women younger than 50, and Pap smears for cervical cancer for women younger than 21. Not only do these exams have nearly no effect on outcomes, the task force said, they can sometimes do more harm than good.

Regarding testicular screening in particular, it “is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer” while “potential harms include false-positive results, anxiety and harms from diagnostic tests or procedures,” according to the task force.

So why do some doctors continue to recommend these screenings — and why do some patients still want them? (To read the rest of this article, please visit The Washington Post.)

Posted in Behavioral Economics and Public Policy, Medical Decision Making | Tagged , ,

New Danger: Third-Hand Smoke?

Smoking kills. But you knew that already. So does second-hand smoke. Inhaling a smoker’s exhalations can cause heart disease and cancer.

But now it turns out that just watching other people smoke is dangerous, especially if those other people are movie stars inhaling on the big screen (in their inimitably attractive ways). Researchers reviewing the scientific literature have shown that the more exposure adolescents have to smoking in movies, the more likely they are to try smoking themselves:

New Danger Third Hand Smoke
If people in Hollywood care about kids (beyond getting their money), they’ll stop promoting cigarettes in their movies.

Posted in Health & Well-being

Proven: People Don’t Take Medicine They Can’t Afford

Take one Per Day as Affordable.Cholesterol pills are one of the great medical advances I’ve witnessed during my professional career. I am talking specifically about a category of medications called statins, drugs like Lipitor and Pravachol. These drugs have prevented probably hundreds of thousands of heart attacks and strokes. Only one problem with these drugs, however: statins won’t help people who don’t take them. And according to a study in the prestigious Annals of Internal Medicine, when physicians prescribe trade versions of statins rather than generics, the extra cost dissuades many people from filling the prescription.

If physicians want to help their patients, they need to prescribe affordable versions of accepted medical interventions.

The study was led by Joshua Gagne, a pharmaco-epidemiologist (a person who lives and breathes hardcore data on medications and population health) at Harvard (an up and coming university located, I think, somewhere near Boston). Gagne and colleagues analyze data from Medicare patients who got their prescription benefits from CVS Care Mark. (To read the rest of this post and leave comments, please visit Forbes.)

Posted in Health Policy | Tagged , , , ,