Latest Blog Posts & Articles

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 , , , ,

You Thought Innovation Was Hard, How about De-Innovation?

HealthAffairsJournalDavid Asch and I recently published an article in Health Affairs on the challenge of getting healthcare practitioners to stop doing things they are accustomed to doing, even when the evidence that those things are harmful becomes overwhelming. Here is a teaser from that article, and a link to the full piece:

As hard as it may be for clinicians to adopt new practices, it is often harder for them to “de-innovate,” or give up old practices, even when new evidence reveals that those practices offer little value. In this article we explore recent controversies over screening for breast and prostate cancer and testing for sleep disorders. We show that these controversies are not caused solely by a lack of clinical data on the harms and benefits of these tests but are also influenced by several psychological biases that make it difficult for clinicians to de-innovate. De-innovation could be fostered by making sure that advisory panels and guideline committees include experts who have competing biases; emphasizing evidence over clinical judgment; resisting “indication creep,” or the premature extension of innovations into unproven areas; and encouraging clinicians to explicitly consider how their experiences bias their interpretations of clinical evidence.

Posted in Health Policy, Medical Decision Making | Tagged , , , ,

Sneaky Way to End Run the FDA?

FDA Not ApprovedIn an earlier post, I wrote about the dietary supplements industry, which is largely unregulated by the FDA, to the detriment of the American consumer. Well here is a recent news story showing how a company is looking to take advantage of this lack of regulation:

An anti-aging pill that is backed by five Nobel laureates and some serious science — albeit on mice — “is wading into the murky world of dietary supplements,” the Boston Globe reports, in order to avoid all of the testing required by the Food and Drug Administration to allow it to be sold as a medicine.

The active ingredients in the pill, which is called Basis and will cost $60 for a 30-day supply, “are nicotinamide riboside, a substance that makes NAD and is found in traces in many foods such as milk, and pterostilbene, an antioxidant found in blueberries,” reports Stefanie Friedhoff, who adds that both are available individually as supplements.

“There have been a lot of new findings in the past five years identifying some extremely promising compounds that promote wellness and health. [We want to] make them available for people to improve their health before they get sick,” Leonard Guarente, Elysium Health founder and its chief scientific officer, tells Friedhoff.

Elysium Health was founded in 2014 to bring scientific validation to the world of consumer health products,” according to its website. “Our team of researchers and collaborators comprises the world’s top 0.01% of scientists and clinicians, including multiple Nobel Prize winners and numerous other thought leaders, pioneers, and innovators who are at the top of their fields.”

The company “hopes to elude the U.S. Food and Drug Administration and death at the same time,” is the way Karen Weintraub puts it in the MIT Technology Review. Indeed, “with Elysium, Guarente and his colleagues are entering an industry with a mixed reputation,” Friedhoff writes.

Read the rest of this article here!

Posted in Health Policy | Tagged