Peter Ubel

I gave a talk Wednesday as part of an ethics series here at Duke.  Here is one take on my presentation.  See if you can spot the Far Side reference!

In a recent post, I asked for your thoughts on how you would feel if your doctor posted an anti-health reform letter in his waiting room. Link

The letter was a direct quote from one posted in Dr. Hal Scherz’s urology clinic in Atlanta. Scherz is president of Docs4PatientCare. For all I know, Scherz is a talented and knowledgable urologist. But let’s look for a minute at his confusion about what he calls “ObamaCare.”

To quote Scherz again:

“Dear Patient: Section 1311 of the new health care legislation gives the U.S. Secretary of Health and Human Services and her appointees the power to establish care guidelines that your doctor must abide by or face penalties and fines.”

Sounds serious. Guidelines! Penalties and fines!

Should we be worried? That depends. We have to consider the alternative first, which, in this case, would be for Medicare to pay doctors without any regard to whether they are offering appropriate care.

Don’t you think doctors should be accountable for the quality of care they provide?

Or is it impossible to figure out whether doctors are practicing good medicine?

As it turns out, the science of measuring quality of medical care is still in its infancy, or maybe entering its preadolescent period, but there’s enough evidence in enough domains of medicine, that it would be irresponsible to ignore our ability to tell whether doctors are doing what they ought to do.

Yet Scherz would have us believe that no one other than the individual doctor is in a position to judge that doctor’s professional competence:

“In making doctors answerable to the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions.”

This is horribly confused. Let’s look at a couple of errors Sherz made.

Error #1: Saying that doctors would be government employees. Physicians have made gazillions of dollars caring for Medicare patients over the years. Yet now that the Medicare office is planning to develop some guidelines to assess the quality of such care, with modest financial incentives to encourage doctors to follow such guidelines… only now does Scherz think doctors are becoming government employees?

Error #2: Concluding that a financial incentive to follow guidelines suddenly means that you and your doctor are no longer in charge of your health care decisions.

Has Dr. Scherz ever interacted with a health insurance company?

Medical decisions haven’t been exclusively controlled by doctors and patients for quite some time. Some doctors perform excessive numbers of procedures on their patients, either out of ignorance or greed. Insurance companies have been trying to reduce such overutilization for a few decades now.

Now the government wants to promote some well-established clinical guidelines, backed by evidence from medical literature, vetted by leading medical organization, and suddenly “big brother” is controller our doctor’s every thought?

I don’t know if Scherz is legitimately confused about the health care reform legislation, or if he is simply worried that any effort to control Medicare expenditures will reduce his sizable income.

Either way, we shouldn’t let doctors scare us off from developing a Medicare system that holds health care providers accountable for the quality of their care.

View original post and comments at Scientocracy

I need to know what you think of the following situation.

You walk into your doctor’s office, turn your insurance information into the clerk, take a seat in the waiting room and discover the following letter sitting on the couch-side table, authored by your very own doctor:

“Dear Patient: Section 1311 of the new health care legislation gives the U.S. Secretary of Health and Human Services and her appointees the power to establish care guidelines that your doctor must abide by or face penalties and fines. In making doctors answerable in the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions. This new law politicizes medicine and in my opinion destroys the sanctity of the doctor-patient relationship that makes the American health care system the best in the world.”

The letter goes on to add:

“The current party in control of Congress pushed this bill through with legal bribes and Chicago style threats and is determined now to resist any ‘repeal and replace’ efforts. This doctor’s office is non-partisan-always has been, always will be. But the fact is that every Republican voted against this bad bill while the Democratic Party leadership and the White House completely dismissed the will of the people in ruthlessly pushing through this legislation. [...]Please remember when you vote this November that unless the Democratic Party receives a strong negative message about this power grab our health care system will never be fixed and the doctor patient relationship will be ruined forever.”

I will evaluate the content of this letter in an upcoming post. But first some questions for you readers:

1. Was it ethical for this doctor to place copies of this letter in his waiting room?
2. Would you feel the same way if the letter stated strong support for the health care reform bill?
3. If you were seeing this doctor for the first time, would this letter have an impact on your relationship with him?

I’m very interested in your thoughts.
Thanks.

The source of the letter can be found at: http://online.wsj.com/article/SB100014240527487033697045754618405…

View original post and comments at Scientocracy

No sooner had the Obama administration committed a billion dollars to comparative effectiveness research than the critics began laying out their concerns: such research is a prelude to rationing, they said; it threatens to thwart doctors’ and patients’ abilities to make their own decisions. It will transfer too much power to government bureaucrats and treat medical practice like a cookbook.

Now that the Institute of Medicine has issued its priorities for comparative effectiveness research (CER), I will look at a common criticism: that it acts as if medical care is a “one size fits all” enterprise, and thereby forces policy makers to make blunt decisions that will unjustifiably harm people who don’t respond to medical interventions the way an “average” person would respond. This concern is legitimate, but an intelligent use of CER should allow us to avoid this fate.

If your life, like mine, has been touched by breast cancer, then you probably share my hope that researchers will find new treatments to reduce the harms of this awful illness. But if you also share my concern for the fiscal solvency of our nation, you might also be disturbed at the high price of some new cancer treatments.

Consider a drug like Avastin: a treatment that increases life expectancy of patients with some metastatic cancers by interrupting blood flow to the tumors. Avastin can cost more than $100,000 per patient, and in some cancers leads to an increase of only two months in median survival. Two months for $100,000—a steep price to pay.

With medical costs consuming an increasing portion of government budgets, and with U.S. businesses struggling to offer employees healthcare coverage, many experts contend that we cannot afford treatments that bring such modest benefits at such a startling price.

How might comparative effectiveness research inform such issues? CER strives to provide information to guide decision making. A comparative effectiveness study might evaluate the cost effectiveness of competing breast cancer treatments. Or it might not analyze cost at all, and focus instead on estimating the relative impact that alternative treatments have on people’s quality and quantity of life.

In neither of these cases would CER, on its own, show us whether to use these treatments. Like its name suggests, CER promises to provide decision makers with information on the relative effectiveness of common medical interventions, so that government payers, insurance companies, doctors and, yes, patients can spend their health care dollars more wisely.

To understand the “one size doesn’t fit all” criticism, let’s suppose that a new drug increases median survival in patients with metastatic breast cancer by two months. That doesn’t mean that it increases everyone’s survival by two months. It might have no effect on the majority of patients, harm a small minority, and bring huge benefits to another minority.

CER, by lumping all patients into one group, would ignore these important differences. And if policymakers, unimpressed by this two-month figure, decided not to pay for this drug, some patients will lose a chance at these huge benefits.

This criticism of CER, however, overlooks more nuanced ways decision makers can potentially use CER information. With the right data, CER can improve medical decision-making by splitting patients into relevant groups, rather than lumping them into a single group.

For example, if we know in advance that patients who meet certain criteria stand to gain much more than other patients, then CER is a tool to help identify this subgroup. A treatment that costs $600,000/life year across all patients may be much more cost effective in a specific subgroup of patients.

A treatment that brings no benefit to the majority of patients but a substantial benefit to a minority of patients could very well deserve to play an important role in the treatment of that subgroup of patients. CER can potentially identify such subgroups. Indeed, if our country starts emphasizing comparative effectiveness in making treatment coverage decisions, it will give researchers in academia and in industry an incentive to find out which patients stand to benefit the most from various healthcare interventions.

On the other hand, if we do not know in advance who will benefit from a specific treatment and who will be harmed – if we can’t, for instance, figure out who will gain years rather than months of survival from the drug – then the only rational way to decide whether to use such a treatment is to assume that each patient is roughly the same and has the same chance of benefit and harm as all other patients.

If only 5 percent of patients benefit from a certain treatment, and we don’t know who those patients are upfront, then we have to assume that any given patient receiving that treatment stands a 5 percent chance of benefiting. And then we have to decide, as a society, whether that 5 percent chance of benefit is worth the costs – both medical and financial – of that treatment.

It would be unwise to use CER to lump together the unlumpable: the long-term survivors from those destined to die soon regardless of treatment. But rather than dismiss CER for treating everyone as if they are average, we should fund the kind of research that will identify who stands to benefit the most from the health care available to them.

View the original post at The Hastings Center.

Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.

After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.

While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer.

On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.

I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical or a social question. It was his wife who replied — angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business.

She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.

Was it my duty to tell this patient what to do or, instead, to give him the medical information he needed to make up his mind?

Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences.

Should a middle-age woman with mildly elevated cholesterol take a statin, for example? That depends on whether she thinks the pill’s benefits outweigh its burdens, burdens that only she can judge: costs, possible side effects and the inconvenience of taking medications.

Should an elderly man have knee-replacement surgery? That depends on how much he is suffering, how much he cares about the risk of surgical complications and how willing he is to undergo lengthy and painful rehabilitation.

According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options.

So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.

I advised him to smoke.

“You two obviously love each other very much,” I said. Then I turned to his wife.

“I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker,” I continued, as I recall. “But those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax. What matters is that you two stick together, because these next few months are going to be really difficult.”

I reminded them that the cancer wasn’t curable, that we were hoping to improve his quality of life, and that the best way to do that was to spend quality time with the people he loved.

Every situation is different, of course. But my duty as a physician is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do.

Even if it means encouraging them to smoke.

To read the original article at nytimes.com, CLICK HERE.

With jobs disappearing faster than a major league fastball, the public is understandably irate at the damage that greed has wrought upon our economy. Financiers destroy their companies, and our retirement portfolios, and then complain when their bonuses are less than 7 figures.

The greedy behavior in recent headlines has not been limited to Wall Street. Last fall, for example, Congress uncovered the shocking details of Dr. Charles Nemeroff, Chair of psychiatry at Emory University, who had made almost $3 million in consulting fees from the same drug companies whose products he was prescribing. More disturbingly, he was responsible for evaluating these same drugs in federally funded research trials. Then in November, we learned that renowned Harvard psychiatrist, Joseph Biederman, had received hundreds of thousands of dollars from Johnson & Johnson, a company which made medications that, not by coincidence, treated the same childhood psychiatric illnesses that Biederman had become famous for publicizing to doctors.

With all of these disturbing stories, it is natural to attribute our current economic problems to excesses of greed.

Greed is indeed a prominent theme in many recent headlines, but it doesn’t explain what has been happening. Greed is a reliable constant in human affairs. Attributing the current situation to greed is like attributing someone’s headache to the fact that they have a brain. The real explanation lies not with greed, but with our failure to deal with conflicts of interest.

Conflicts of interest have played a central role in many of the disasters that have befallen our economy in recent decades. Enron and other corporate debacles a decade ago were aided and abetted by accounting firms that were providing consulting services to the same companies they were auditing, creating a situation in which the right-hand was expected to raise the alarm about financial practices being suggested or condoned by the left hand. The dot-com crisis was similarly aided by stock analysts who provided buy recommendations for companies whose stock their firms were underwriting. And now in the most recent debacle, it has emerged that credit rating agencies, entrusted to identify risky finances, were aggressively drumming up business from the same lenders whose credit they were rating.

As highlighted by publicity over the payoffs to psychiatrists, conflicts of interest have also contributed significantly to another less acute but equally serious problem plaguing our economy: the ever-intensifying problem of skyrocketing health care expenditures. Despite numerous calls for change, pharmaceutical companies continue to shower physicians with gifts, and an increasing proportion of medical school faculty obtain an increasingly large proportion of their income from industry. (Disclosure: I am an academic physician, but I have made a practice of staying independent from industry funding. That independence has come easily, given that most companies have no interest in a primary care physician who studies decision making and ethics!) As a result, the newest and most expensive interventions are enthusiastically embraced by the medical community, often before their safety and effectiveness have been firmly established.

In the face of economic turmoil, it is tempting to look for greedy villains. By the time there are villains to punish, however, it’s usually too late to fix the problem. Shooting the fox won’t restore chickens to the hen house. Instead, we need regulations to reign in the pernicious effects of conflicts of interest.

How can we do this? Beyond calls to punish perpetrators, the most common response is to call for greater disclosure of conflicts. Medical journals and medical schools, for example, have largely tried to address conflicts of interest by requiring physicians to disclose their outside income. However, disclosures are not a solution. For starters, people often don’t report their conflicts. Nemeroff famously failed to report the majority of his $3 million in consulting fees. More importantly, disclosure can cause outsiders to drop their guard – when a physician readily admits working with a drug company, other people mistakenly assume that he must therefore be being forthright about his research results.

The only way to reduce the effects of conflicts of interest is to reduce the conflicts themselves. Auditors and bond raters shouldn’t be hired by, or provide other services to, the companies they are rating. Stock analysts shouldn’t be allowed to provide buy recommendations on stocks their firm underwrite. Physicians shouldn’t be allowed to accept gifts from pharmaceutical companies.

As Obama continues to implement policies meant to avert future economic disasters, it will be essential for his administration to take a hard look at regulating the conflicts of interest that pervade our economy. Only by doing so can we get our economy back on track, and prevent another precipitous derailment.

Note: I am joined in today’s post by George Loewenstein, Herbert A. Simon Professor of Economics and Psychology at Carnegie Mellon University.

To read more of my blogs, and to learn more about my new book, Free Market Madness, check out my personal website: http://www.peterubel.com

View original post and comments at Scientocracy

Lance Armstrong will soon be competing again in bicycle races around the world, meaning that the casual biking fan will once again show interest in the sport. It also means that doping allegations against Armstrong are likely to resume. If Lance wins some big races — at his age and after so long away from the sport — some people will be convinced he has found a way to cheat. If he loses, then who cares about his age and his time away from the sport — his losses will be evidence that he must have cheated in the past and is failing at the sport now only because it’s harder to cheat.

I confess to having mixed feelings about the cheating rampant in sports like bicycling. No system will ever pick up all the cheaters. Part of me, then, thinks we should let people do whatever they want — mainline steroids, experiment with gazelle DNA, whatever — and let the fastest creature win.

But a larger part of me yearns for clean, unadulterated performances. I’d like to see what humans can do when pushed to their natural limits.

When it comes to EPO, however, I am less conflicted. I don’t see the point in banning this drug, when there are natural ways to reap its benefits.

EPO is a hormone secreted naturally by the kidneys, to stimulate the body to produce red blood cells. Red blood cells carry oxygen around our bodies. And oxygen, I have discovered, is a good thing to have in abundance when riding a bicycle up a relentless incline at high altitude.

Our bodies normally produce enough EPO to keep our hemoglobin level (that’s the blood test we doctors rely upon to assess oxygen carrying capacity) at a standard level, a level that varies a bit person to person within a fairly narrow range. A person who takes EPO, however, will experience a rise in their hemoglobin count. A person who takes too much EPO, in fact, will get so many extra red blood cells that their blood will become thick, and they will risk experiencing a stroke.

Athletes who use EPO try to increase their hemoglobin level enough to increase their performance, without experiencing a stroke. This isn’t too hard to do. There’s a good margin of error.

In fact, athletes have found natural ways to increase their hemoglobin supply. The simplest way is to simply train in high altitude. When our bodies are regularly deprived of oxygen, our kidneys squeeze out EPO so we can absorb available oxygen more efficiently. Some athletes, rather than train at a high altitude, sleep in specialized tents that mimic the conditions of high altitude.

Do you see why I’m ambivalent about EPO? We live in a strange world, where it is wrong to boost your hemoglobin supply by taking synthetic EPO, but okay to do so by sleeping in a special tent. We live in a world where you’re banned from sports if you live in Texas and inject EPO, but rewarded if you live in the Himalayas and benefit from your body’s natural EPO production.

I think we should lift the ban on EPO and make rules that set limits on hemoglobin levels. Athletes will be banned from performing if their hemoglobin exceeds some level, put on probation if it is in some gray zone, and allowed to compete if it’s below the accepted cutoff. Professional athletes would monitor their own hemoglobin, take EPO or sleep in a specialized tent if their hemoglobin falls below their target, and drain some blood out of their system if their hemoglobin rises too high. With this system, everyone’s hemoglobin will sit somewhere in the safe zone, whether it gets there naturally or unnaturally, and we wont have to worry about somebody having an advantage over anyone else. Nor will test monitors have to monitor that people have found ways to mask the use of synthetic forms of drugs like EPO.

I’m sure such a system would be more complicated than I’ve laid out here. Heck, this is a blog post, not an academic paper.

But isn’t this idea worth serious consideration?

View original post and comments at Huffington Post