The Accad and Koka Report

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Ep. 56 Conflicts of Interest in Health Policy: A Different Ball of Wax? Jan 14, 2019

Show notes

Anish Koka, MD

We have become highly sensitized to the question of conflict of interest in healthcare—and rightly so. But the dominant narrative seems to be one-sided: doctors and scientists getting personally paid by industry sponsors and letting those payments color their judgment, consciously or unconsciously.

Personal financial conflict of interest is certainly an important and pervasive problem, but there are many aspects of COI that get less attention and may be equally harmful to society at large. To discuss this topic, our own Anish Koka engages Michel Accad in a lively discussion that tries to probe the topic in depth, even when such probing reveals uncomfortable truths.

GUEST:

Anish Koka, MD. Twitter

LINKS:

Anish Koka. Commissioning Health Policy: Hospital Readmission and Its Price Tag

Michel Accad. The Institute of Medicine and the Doctrine of Perpetual Conflict

Michel Accad. Austin Frakt’s Conflict of Interest Disclosure

Michel Accad. COI and empirical fundamentalism

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Ep. 55 Waste in Healthcare: Is the Narrative Too Simplistic? Jan 09, 2019

Show notes

Lisa Rosenbaum, MD

It doesn’t take great insight to assert that healthcare waste is rampant. There is an obvious epidemic of testing and treatments that make no difference in patients’ lives or could possible even harm. But what is the cause of the epidemic and what should be done about it? In the last decade, a popular narrative has emerged, claiming that the waste has obvious causes and remedies. That narrative, however, overlooks the complexities of the problem and the trade-offs and potential harms of the remedies proposed.

Our guest to discuss the “Less-Is-More” movement is Lisa Rosenbaum, MD, one of the best medical writers of our generation. Dr. Rosenbaum is a national correspondent for the New England Journal of Medicine, a cardiologist at the Brigham and Women’s Hospital, and an Assistant Professor of Medicine at Harvard Medical School.

GUEST:

Lisa Rosenbaum, MD. Twitter

LINKS:

Lisa Rosenbaum. The Less-Is-More Crusade—Are We Overmedicalizing or Oversimplifying? (2017 New England Journal of Medicine. Free preview available)

Lisa Rosenbaum. Let Fear Guide Early Breast Cancer Detection. (2015, Open access in The New York Times)

Lisa Rosenbaum. The Problem With Knowing How Much Your Health Care Costs. (2013, Open access in the New Yorker)

Michel Accad. The Apostles of Less-Is-More (blog post on Alert and Oriented)

Michel Accad. On Squandering Medicare’s Money (blog post on Alert and Oriented)

Michel Accad. Overdiagnosis: The Disease That Cannot be Diagnosed. (blog post on Alert and Oriented)

RELATED EPISODES

Ep. 12 John Mandrola: The Case for Less-Is-More

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Ep. 54 How to Jump Ship and Practice Medicine on Your Own Terms, with Dr. Kathleen Brown Jan 04, 2019

Show notes

Kathleen Brown, MD

The healthcare system continues to inflict “moral injury” on physicians, causing burnout, depression, or apathy. And, built as it is on a mountain of debt, the edifice may also not provide any long term security for those who choose to remain on board. Yet the prospect of jumping ship may seem daunting to many.

Our guest today shares with us her personal story of how she did abandon the titanic and forged for herself a successful path to professional sanity.

Kathleen M. Brown, MD, obtained her medical degree from the Eastern Virginia School of Medicine and practiced dermatology and internal medicine for several years in Maryland. In 1997, she and her family moved to the coast of Oregon to join a multi-specialty group of which she was a partner in the group until mid-2011. This group was a good fit but the administrative and financial burdens of the system were increasingly taking a toll on her enjoyment of medicine.

After passage of the Affordable Care Act in 2010, she saw that continuing to stay within an insurance-contracted system would make her style of medical practice impossible. In July, 2011, with help from her husband, Jack, she opened a direct pay Dermatology practice with a transparent fee schedule. Within a month of opening she had a full schedule and a restored sense of professional satisfaction.

GUEST:

Kathleen Brown, MD. Email and Practice Website

LINKS:

Facebook page of the Oregon Chapter of the Free Market Association.

RELATED PODCAST EPISODES:

Ep. 10 Free Market Medicine: Ethical, Workable, and Unstoppable

Ep. 49. Why Are We Insuring Primary Care? Lee Gross of the DPC Movement

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Ep. 53 Health vs. Illness: Pat Caslin on Living with Multiple Sclerosis Dec 30, 2018

Show notes

Pat Caslin

We spend billions of dollars a year on healthcare yet no one can give a satisfactory definition of health. Is our inability to articulate what health is precisely the reason for our insanely dysfunctional healthcare systems?

Our guest today will give us his very personal reflections on that question. Pat Caslin is a business strategist from Dublin, Ireland who’s had a successful career nationally and internationally, working for a variety of financial and business development institutions. Eleven years ago he was diagnosed with relapsing-remitting multiple sclerosis. Five years ago the disease became progressive and he lost his ability to walk.

Instead of letting the illness take over his life, Pat went through a profound change of perspective regarding his health and what it means to be healthy. As a result, he has been sharing his insights, both in writing and in speaking engagements, with students, with physicians, with patients, and with the public at large. He was recently selected to give a Ted talk in Dún Laoghaire, Ireland.

GUEST:

Pat Caslin. Twitter

LINKS:

Pat Caslin. Chronically Ill, Very Healthy (Tedx talk)

Michel Accad. Taking Stick of Our Existence: Gawande vs. Frankl on the Meaningful Life (blog post)

Michel Accad. That Most Nagging Question in Healthcare (blog post)

The Widowmaker (documentary, available on YouTube)

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Ep. 52 Should Doctors Get Involved in Healthcare Policy? A Med Student’s Perspective Dec 26, 2018

Show notes

Aamir Hussein, MD Candidate 2019

Doctors are embroiled in a healthcare system they appear to have no control over. It therefore seems plausible that if they got involved in healthcare policy, they might be in a position to “steer the ship” or at least have a say in how the ship is steered.

We discuss the pros and cons of healthcare policy in general—and of a doctor’s involvement in such policy—with Aamir Hussein, a 4th year medical student at the University of Chicago Pritzker School of Medicine.

A native of Farmington, CT, Mr. Hussain also holds a master’s degree in public policy from the University of Chicago Harris School of Public Policy and a BA from Georgetown University in Government. He writes frequently about interfaith dialogue, Islam, and the intersections between healthcare and spirituality and has given lectures around the United States on these topics. He has been interviewed by The New York Times, Al Jazeera, and PBS, and his writings have been featured in medical journals and several online outlets including Religion News Service and The Huffington Post.

GUEST:

Aamir Hussein: Twitter.

LINKS:

Milton Friedman at the Mayo Clinic: YouTube clip

RELATED EPISODES:

Ep. 44 Economic vs. Political Means to Healthcare: A Conversation with Jeff Deist

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Ep. 51 The Expert vs. the Algorithm: Gary Klein on Decision-Making in Healthcare Dec 18, 2018

Show notes

Gary Klein, PhD

Doctors are increasingly asked to follow decision rules, guidelines, and “evidence-based” algorithms. Is that the right approach to take care of patients? Are cognitive errors over-emphasized in healthcare?

Our guest on this episode is Gary Klein, one of the most important figures in cognitive psychology in the world. His pioneering work in the field of naturalistic decision-making has become a major challenge to the established schools of thought on how experts make good decisions.

He is a leader of a growing research community focused on understanding how human beings acquire and apply knowledge to complex situations under uncertainty. He has developed novel explanatory models and training methods for decision-making that are widely recognized as ground-breaking. He is the author of numerous books, including the best-sellers Streetlights and Shadows: Searching for the Keys in Adaptive Decision-Making and Seeing What Others Don’t: The Remarkable Ways We Gain Insight. He is notorious for having gained the respect and admiration of his intellectual opponent, Nobel Prize winner Daniel Kahneman, with whom he co-authored a widely read paper contrasting their somewhat divergent views.

GUEST:

Gary Klein, PhD: Website and Twitter.

ShadowBox training website.

LINKS:

Gary Klein. Streetlights and Shadows: Searching for the Keys in Adaptive Decision-Making. A Bradford Book. 2001 (Amazon link)

Gary Klein. Seeing What Others Don’t: The Remarkable Ways We Gain Insight. Public Affairs. 2015. (Amazon Link)

Daniel Kahneman and Gary Klein. Conditions for Intuitive Expertise: A Failure to Disagree. American Psychologist. Sep 2009 (open access).

Klein ED, Woods DD, Klein G, and Perry SJ. Can We Trust Best Practices: Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision-Making. 2016 (open access)

RELATED EPISODES:

Ep. 30 Beyond EBM: Case-Based Reasoning and the Integration of Clinical Knowledge

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Ep. 50 Thieves of Virtue: How Bioethics Stole Medicine Dec 13, 2018

Show notes

Tom Koch, PhD

Did bioethics emerge to defend the interests of patients or to rationalize the needs and actions of the state and its corporate allies? Are bioethicists too complacent about their grasp of economics? Do they have sufficient understanding of the complexities of medical decisions to weigh in on them? Are Hippocratic ethics so inadequate that they needed to be replaced by ever-morphing “Kantian” ethics? A fascinating discussion with our guest, Tom Koch, a man whose resumé and whose many books read like great adventure stories.

Professor Koch is an author, journalist, historian, philosopher, and educator. He holds an inter-disciplinary PhD in medical cartography, ethics and medicine He has taught medical ethics to medical students at the University of Toronto. He is a consultant in gerontology. And he has written numerous books both for an academic audience as well as for the general public. His books include Cartographies of Disease, Ethics in Everyday Places, The Wreck of the William Brown, and the volume that will be the focus of our discussion today, Thieves of Virtue: When Bioethics Stole Medicine.

GUEST:

Tom Koch, PhD. Website

LINKS:

Tom Koch. Thieves of Virtue: When Bioethics Stole Medicine. MIT Press. 2011 (Amazon link)

Tom Koch. Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury. MIT Press. 2017 (Amazon Link)

RELATED EPISODES:

Ep. 29 Why Hippocrates Still Matters

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Ep. 49 Why Are We Insuring Primary Care? Lee Gross on the DPC Movement Dec 09, 2018

Show notes

Lee Gross, MD

“We’re not going to ask permission to take care of our patients.” It is with this epiphany, that our guest on this episode became one of the pioneers and leaders of the most hopeful trend in health care today: the direct primary care or DPC movement.

Dr. Gross shares with us how the light bulb went off in his mind that there is no good reason to insure primary care and, in fact, that insuring primary care hurts everybody: patients, doctors, and society. He walks us through his success stories and the efforts he is leading at the state and federal level to remove regulatory barriers to direct care.

Dr. Gross is the founder of Epiphany Health in North Port, FL, and is regularly consulted by lawmakers at the local, state, and national level. He has offered testimony on behalf of the direct care movement for the US Health and Human Services Department, the US Congress, and for the White House. He also serves as president of the Docs 4 Patient Care Foundation and he is the recipient of the 2016 HCA Frist’s Humanitarian Award and of the Beacon Award from the Free Market Medical Association for his leadership in healthcare reform.

GUEST:

Lee Gross, MD. Twitter

LINKS:

Lee Gross. Direct Primary Care Can Rein In America’s Out-of-Control Healthcare Costs (in the Washington Examiner)

Epiphany Health: Dr. Gross’ practice website

Doc 4 Patient Care Foundation’s website

US Department of Health and Human Services. Reforming America’s Healthcare System Through Choice and Competition (Report)

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Ep. 48 Many Statisticians, Many Answers: The Methodological Factor in the Replication Crisis Dec 04, 2018

Show notes

Brian Nosek, PhD

In 550 BC, the Greek philosopher Heraclitus famously declared: “No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.” In this episode, we learn from our guest whether scientists can step into the same data pool and obtain the same research results twice.

Brian Nosek is Professor of Psychology at the University of Virginia. He is also the co-founder and Executive Director of the Center for Open Science, an organization dedicated to fostering transparency and collaboration in scientific research.

In 2015, Professor Nosek and his team published in the journal Science a widely acclaimed and widely discussed paper that shed light on the extent to which psychological research findings may not be reproducible when the research is conducted anew.

More recently, his Center conducted a unique project where a single data set was sent to be analyzed by about 30 independent teams of statisticians for the purpose of answering a single question. The variability in the methods chosen and in the answers obtained was also perhaps sobering, if not perplexing.

GUEST:

Brian Nosek, PhD. Profile and Twitter

LINKS:

Silberzahn R, Uhlmann EL, Martin DP et al. Many analysts, one dataset: Making transparent how variations in analytical choices affect results. (2018, Advances in Methods and Science in Psychological Research, open access pre-print here)

Klein RA, Vianello M, Hasselman F, et al. Many Labs 2: Investigating Variation in Replicability Across Sample and Setting. (2018, open access pre-print here)

Open Science Collaboration. Estimating the reproducibility of psychological science. (2015 in Science, open access here)

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Ep. 47 Drug Dosing: One Size Does Not Fit All Nov 30, 2018

Show notes

David C. Norris, MD

Patients come in all sizes and shapes, and with varying tolerance for complications and risk. Is it plausible that a single dosing regimen can optimize treatment for everybody? If not, what is keeping the pharmaceutical industry from endorsing a more dynamic and patient-centered drug dosing regimen?

Our guest is Dr. David Norris, a physician, mathematician, and inventor. David operates a scientific and statistical consultancy focused on methodology development for ‎precision-medicine applications. He developed Dose Titration Algorithm Tuning (DTAT), a methodological framework that conceives dose individualization as a seamless learning process, beginning in early-phase trials and continuing throughout the drug development process. Before earning his M.D. at Brown University, he worked in diverse application areas including mathematical finance, operations research and systems engineering.

GUEST:

David C. Norris, MD. Patreon and Twitter

LINKS:

Norris DC. Dose Titration Algorithm Tuning (DTAT) should supersede ‘the’ Maximum Tolerated Dose (MTD) in oncology dose-finding trials. F1000Research. 2017 (open access)
Norris DC. One-size-fits-all dosing in oncology wastes money, innovation and lives. Drug Discovery Today. 2018 (open access)
Norris DC. Precautionary Coherence Unravels Dose Escalation Designs. bioRxiv. 2017 (open access)

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