Shannon Brownlee: All Related Content

Imagine you are sitting in first class on a plane, waiting for the plane to push off from the gate, when you see two people in uniform, the pilot and co-pilot, dash from the Jetway into the cockpit. A few seconds later, a voice comes over the intercom, saying, “This is Captain Jones, please be sure your seat belts are fastened. We’re ready for takeoff.” What crucial event could not have occurred in this scenario? The pilot and co-pilot did not go through their checklist of safety measures. Fuel tanks full? Check! Flaps up? Check!

Dr. Jack Wennberg's work on variation in medical treatment serves as the foundation for a lot of what we do in the Health Policy Program at New America. His pioneering research showed huge differences in the way that similar patients are treated in different places, and the vast unnecessary spending that results. While the restructuring health care delivery is far from complete, it has come a long way, sometimes rapidly, often as the result of Dr. Wennberg's work, which in our view deserves a Nobel Prize in economics for exposing the pervasiveness of supplier-induced demand in health care.

Last week, Dr. Wennberg was awarded a different prize, the first MacLean Center Prize in Clinical Ethics and Health Outcomes by the MacLean Center for Clinical Medical Ethics at the University of Chicago. While he is not a clinician, his contributions to shared decision-making and understanding patient preferences have had a profound effect on moving toward a very different ethos in medicine, toward what he calls informed patient choice. Shared decision-making, which grew out of work Wennberg and  colleagues began in the 1980s, has become a watchword in both clinical medicine and health policy circles, and will one day reshape the doctor-patient relationship for the better. 

Everybody knows obesity is a massive problem in the U.S. It rivals smoking in terms of its health hazards, according to a report in the February 2010 American Journal of Preventative Medicine. As a society, we’ve made great strides, giant leaps even, in reducing rates of smoking. Smoking bans on airplanes, in public buildings, in restaurants, have helped. So have negative ad campaigns aimed at teenagers, higher insurance premiums for smokers and higher taxes on cigarettes.

About a year ago, I accompanied my 80-year-old mother on a visit to the cardiologist’s office. She had been having unexplained dizzy spells and a rapid, irregular heart beat and was in for tests to see what the problem was. After the first test, we sat with the electrophysiologist, who explained Mom’s results.

As chief medical and scientific officer of the American Cancer Society, Otis Webb Brawley — who is also a professor of oncology and epidemiology at Emory University — is the public face of the cancer establishment. He operates in a world of similarly high-achieving, multiple-credentialed, respectable professionals, where insults tend to be delivered, stiletto-style, in scientific language that lay people aren’t meant to understand.

In light of the media discussion surrounding PSA testing at the moment, Health Dialog (a producer of patient decision aids for medical decisions) is making their PSA test decision aid available free of charge on their website. The decision aid includes video, booklet, and web-based formats, and presents the evidence about the risks and benefits of PSA testing impartially. If you are a man considering having a PSA test, the decision aid may help you come to an informed decision.

The medical blogs are on fire this week with comments about the US Preventive Services Task Force (USPSTF)'s newest recommendation on the prostate specific antigen (PSA) test. On the basis of the latest scientific data, the task force is now recommending against PSA screening. An earlier recommendation said that routine screening was unnecessary in men over 75, or those with life expectancy shorter than 10 years; the update will recommend against routine PSA testing for any man of any age.*

Not surprisingly, this has set off an angry howl from many pro-PSA patient advocacy groups, some physicians, and battalions of outraged men, many of whom gave personal testimonials to the effect that the PSA test saved their lives. In the words of one Bruce Rogers, from Champain, Ill., "Were it not for the PSA tests, today I would be dead and buried."

Of course, all the men who have died from the treatment for prostate cancer or are too sick or debilitated to get to their keyboards aren't able to tell their side of the story, and whether or not the test actually saves lives is at best debatable. (You can read about the evidence for and against the test in a story that will appear in this Sunday's New York Times Magazine.)

The other common reaction to the new task force recommendation was expressed by a fellow calling himself "whoami2day," who wrote in response to a CNN story:

"Here we go again. OUR government in the pockets of the insurance companies and oil companies. How much longer are we going to put up with this crap.  . . . "

In other words, the task force's recommendation is all about saving the government money by denying men a test that could save their lives. Whoami2day is right that the debate over PSA testing is partly about money, but he may be targeting the wrong villain.

In one of the great comedy skits of the 20^th century, Geraldine Jones, played by comedian Flip Wilson in drag, delivers chicken to football player Jim Brown. Geraldine holds up the bucket of fried chicken, wiggles her hips and says, “No fancy ribbons on our meat. What you see is what you get!”

In medicine, it’s not so much what you see as who you see that determines what you get. In a new report (by the Health Policy Program’s Shannon Brownlee and Vanessa Hurley, based on analysis by Stanford’s Laurence Baker), the California HealthCare Foundation argues that who you see for your care (and where you live) have a huge effect on the likelihood of receiving a broad variety of elective medical procedures. The variation can’t be explained away by levels of illness in different communities—the study controlled for a number of factors related to illness, including income, level of education, and rates of heart attack and diabetes in the area, as well as typical controls like age, sex, and race. Even after adjusting for all of those factors, the variation didn’t disappear. Areas with the highest usage of angioplasty*, for instance, had rates ten times as high as areas with the lowest use.

Some readers of this blog have heard this before, but it bears repeating: Poor patient understanding of treatment options is a primary cause of such unwarranted variation. When patients don’t have enough information, or information they can understand in order to participate fully in their treatment decisions, the choice of how to manage a condition falls to their doctor.

The 1940 biopic Dr. Ehrlich’s Magic Bullet made famous both the physician who found a treatment for syphilis and the idea there was a single cure for every disease. Most of the old infectious killers have been eradicated, or nearly so, by drugs and vaccines, but the era of the magic bullet is coming to a close. Today’s medical challenges are chronic diseases like diabetes, heart disease, cancer, and Alzheimer’s – diseases that can’t be cured, but only prevented or managed – and we’re trying to address them with a health care delivery system made inefficient in part by the fact that it is caring for chronically ill patients as if they had acute ailments.    

Yet the notion that there’s a single solution to the conundrum of today’s health care delivery system lives on. Proponents of ideas like consumer-driven health care, electronic medical records, the patient centered medical home, comparative effectiveness research, ACOs, and training primary care doctors like to imagine that their preferred solution is the magic bullet, the one technocratic fix that’s going to bring down costs and improve quality.

Maybe it’s time to take a hint from another complex problem: climate change. In a paper published in Science in 2004, climate scientists Robert Socolow and Stephen Pacala argued that rather than waiting around for some new innovation that will magically make all that excess carbon go away, we should be tackling carbon emissions with existing technologies.

Socolow and Pacala called their seven intervention ideas “wedges” because of their shape on the graph (left). Each intervention has a small effect on the level of carbon dioxide emissions, and each effect shows up on the graph as a slice of the stabilization triangle, shaped like a wedge. Put into effect simultaneously, there are enough emissions-reducing technologies–such as carbon capture and storage at power plants and broader use of solar, wind, and nuclear power—to stabilize carbon dioxide levels in the atmosphere for the next 50 years.

In a speech last week at a Health Affairs briefing on “The New Urgency of Cost Control,” Don Berwick, the Administrator of the Center for Medicare and Medicaid Services, applied Socolow and Pacala’s idea to health care costs, arguing that we need to look at a broad range of existing delivery and payment system reforms—each of which is too small to stabilize medical costs individually, but that meet that goal when taken together.

Last week, U.S. Food and Drug Administration Commissioner Margaret Hamburg told the advocacy group Public Citizen that the FDA may loosen conflict-of-interest rules for experts who serve on the agency’s advisory panels. These panels wield considerable power when it comes to FDA decisions about approving drugs and medical devices, and for pulling them off the market when evidence surfaces that they may cause patients harm.

Why loosen the rules? Commissioner Hamburg said the agency is having trouble finding experts to fill its advisory panel slots. In other words, anybody expert enough to be on an FDA panel undoubtedly has a conflict.

Or maybe the FDA just isn’t looking very hard. In 2008, Jeanne Lenzer -- an independent journalist -- and I created a list of more than 100 experts in fields ranging from epidemiology to neurology to emergency medicine, every one of them independent from industry conflicts of interest. We made the list available to our fellow journalists at the website, Healthnewsreview.org, a site that grades health stories. Dozens of journalists from top news outlets, including the New York Times, Bloomberg, and the Wall Street Journal, have requested the list, and used it to find sources for their stories -- or at least we hope they have. 

Larry Husten, a medical reporter who specializes in cardiology, wrote a post over the weekend responding to my piece on the blog last week about a donation from the Parsemus Foundation to the "Less is More" series in the Archives of Internal Medicine. The Parsemus Foundation, in Husten's view, is biased against angioplasty and stents, and the grant to the Archives represents a conflict of interest. Husten goes on to suggest that the Archives didn't want to disclose the fifty grand it got from Parsemus Foundation, which he calls, "medical Luddites who stand against one of the most important advances in modern medicine."

Wow. "Medical Luddites." We're talking about a family foundation with nothing to gain financially from a decline in the use of angioplasty and stents. When we talk about conflict of interest in medicine, the topic is usually the billions of dollars spent by the drug and device industries to influence physicians, systematically bias medical science, and pack medical journals with studies that amount to what psychiatrist and medical critic Barney Carroll calls "experimercials." Richard Horton, editor of the British medical journal, The Lancet, went further in an essay in The New York Review of Books:

"Indeed, medical journals have become an important but underrecognized obstacle to scientific truth-telling. Journals have devolved into information-laundering operations for the pharmaceutical industry."

The Parsemus Foundation hardly seems to be in the same league in terms of its power to sway medical opinion, but maybe there's a deeper issue here with regard to the Less is More series. In an editorial launching the series in 2010, Archives editors wrote that it was intended to "highlight situations in which the overuse of medical care may result in harm, and in which less care is likely to result in better health." The fact is, Less is More represents a tiny dissenting voice in a medical literature that for the last 50 years has been saying, in effect, More is More.