By Patricia Salber

Kudos to the American College of Physicians (ACP), the medical society that represents Internists, for taking a leadership role in the battle against waste in healthcare.  The College’s recently published Ethics Manual (Sixth Edition) clearly points out that physicians not only have an obligation to individual patients, but also to society.  In particular, the College takes on the issue cost-effectiveness of care pointing out that:

”Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

As health care costs continue to gobble up more and more of America’s money, leaving less and less for other items of importance, such as food, housing, education and infrastructure, it is critical that physicians are as thoughtful about evaluating the value of their decisions as they are about all other aspects of care they provide to their patients.  This includes decisions about which diagnostic and screening tests they order.  We can no longer afford a “check all the boxes” approach to test ordering.

An editorial in the January 17, 2012 issue of the Annals of Internal Medicine suggests that “High Value Testing Begins with a Few Simple Questions.”  They propose a short list of questions physicians should  ask themselves before ordering tests.   I think these questions should be asked and answered not only by physicians, but also by their patients…reigning in the healthcare cost demon requires participation by the entire team.

Before a test is ordered (or agreed to), these questions (modified from the ACP list) should be asked and answered by both the physician and the patient:

  • Has this test been done before?  If yes, when was it done and what was the result?  If you don’t have the results right now, can you get them so that you don’t have to repeat the test?  Do you really have to repeat the test just because “it wasn’t done here?”  The ACP editorial suggests repeat testing because of distrust of another institution’s results is usually not justified.   And, now the big question:  If the test is repeated, is it likely to be significantly different from the last result? For example, if the LDL was high 6 months ago and nothing has changed with regard to diet, weight, or medications, how likely is it that the LDL level will meaningfully different now?
  • Will the test result change anything?  Will it lead to a new treatment or recommendation for behavior change?  Will it motivate the patient to eat better, exercise more or drink less?  Or is it just “nice to know?”  A friend recently told me he really wanted to get an MRI of his knees.  I asked him if he had problems with his knees, he said no, he just want to know they were ok.  Patients and their family members should be asked why they want the test…what is it they hope the test will do for them?  Can the “itch” be scratched in a different way – with a physical exam where the key findings are pointed out and explained?
  • What are the probability and potential adverse consequences of a false-positive result?  Too often both docs and patients think there are no downsides to getting a test…more is better, right?  But tests do have consequences ranging from radiation in the case of imaging to bruising and tenderness after a blood draw.  False positives can make patients anxious until they are proven to truly be a false positive.  They can also lead to further, sometimes more invasive, testing with related expenses and related risks.  Remember when consumers were flocking to the total body imaging centers about a decade ago?  My sister-in-law was gifted such an image only to learn that she had a potentially abnormal finding – something clinicians call a ditzel or incidentaloma.  As is often the case, this finding was evaluated further (“worked-up” in the language of medicine) and turned out to be nothing of importance.  But doing the work-up required more testing, more time, more money, and more anxiety.  By understanding and discussing the probability that a test will yield an actionable result and the consequences of a false-positive, the doctor and patient can decide whether the test should be done.
  • Is there a potential danger in the short term if this test is not obtained?  How often have you ordered a test “just to be safe?”  Or had a patient (or family member) badger you into ordering an x-ray or CT to be sure that a highly unlikely condition was not present.  Ok, I know some of you are thinking, well sure I did, because if I didn’t I would get sued or the patient would be unhappy with me and go elsewhere or give me a bad review on DoctorBase or Zocdoc.  This certainly needs to be taken into account, but it should not be the sole or even major driver of test ordering behavior.
  • Both physicians and patients should ask the “why” questions:
    • Why am I ordering the test? Hopefully, the answer will be something like this:  Mrs B started on a diuretic a month ago, I need to make sure her potassium is in the normal range.  Not like this:  I check potassium on all my patients because you never know what you will find.
    • Patients need to ask (or be asked) why do you want that test?  What are your worried about?  What do you hope to learn from it?  Is there another way I can get the answer I need?

Now, I know that it is easier to write about stuff like this than to actually do it.  But I think the ACP is onto something here.  Controlling the ever increasing costs of health care is going to require that we are vigilant about everything we do (or in the case of patients, ask for).  Some might argue that CBCs or Chest X-rays or even CTs and Echocardiograms are cheap compared to other big ticket items in health care like hospital stays or cancer drugs.  So why focus testing as a cost containment mechanism?  But if we have learned anything over the last several decades of trying to address the cost problem, there are no silver bullets.  If there were, they would have been found and used a long time ago.  Rather, there are thousands of golden BBs-each one of which needs to be aimed at a different part of the cost problem, large and small, so that the result, at the end of the day, is high value health care.  Easier said than done?  Yes, but contributions, such as the one that the ACP has made with respect tohigh value testing are a good addition to the cost control armamentarium

 

 

 

 

 

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By Dov Michaeli

Neo Nazi demonstration, January 27, 2012,

 

The  evidence that a conservative world -view is highly correlated with rigidity, hierarchy and yes, prejudice and racism is overwhelming. But here is a paper, reviewed in LiveScience, that attempts to get at the root cause. Following is the post, by Stephanie Pappas. 

There’s no gentle way to put it: People who give in to racism and prejudice may simply be dumb, according to a new study that is bound to stir public controversy.

The research finds that children with low intelligence are more likely to hold prejudiced attitudes as adults. These findings point to a vicious cycle, according to lead researcher Gordon Hodson, a psychologist at Brock University in Ontario. Low-intelligence adults tend to gravitate toward socially conservative ideologies, the study found. Those ideologies, in turn, stress hierarchy and resistance to change, attitudes that can contribute to prejudice, Hodson wrote in an email to LiveScience.

“Prejudice is extremely complex and multifaceted, making it critical that any factors contributing to bias are uncovered and understood,” he said.

Controversy ahead

The findings combine three hot-button topics.

“They’ve pulled off the trifecta of controversial topics,” said Brian Nosek, a social and cognitive psychologist at the University of Virginia who was not involved in the study. “When one selects intelligence, political ideology and racism and looks at any of the relationships between those three variables, it’s bound to upset somebody.”

Polling data and social and political science research do show that prejudice is more common in those who hold right-wing ideals that those of other political persuasions, Nosek told LiveScience.

“The unique contribution here is trying to make some progress on the most challenging aspect of this,” Nosek said, referring to the new study. “It’s not that a relationship like that exists, but why it exists.”

Brains and bias

Earlier studies have found links between low levels of education and higher levels of prejudice, Hodson said, so studying intelligence seemed a logical next step. The researchers turned to two studies of citizens in the United Kingdom, one that has followed babies since their births in March 1958, and another that did the same for babies born in April 1970. The children in the studies had their intelligence assessed at age 10 or 11; as adults ages 30 or 33, their levels of social conservatism and racism were measured.

In the first study, verbal and nonverbal intelligence was measured using tests that asked people to find similarities and differences between words, shapes and symbols. The second study measured cognitive abilities in four ways, including number recall, shape-drawing tasks, defining words and identifying patterns and similarities among words. Average IQ is set at 100.

Social conservatives were defined as people who agreed with a laundry list of statements such as “Family life suffers if mum is working full-time,” and “Schools should teach children to obey authority.” Attitudes toward other races were captured by measuring agreement with statements such as “I wouldn’t mind working with people from other races.” (These questions measured overt prejudiced attitudes, but most people, no matter how egalitarian, do hold unconscious racial biases; Hodson’s work can’t speak to this “underground” racism.)

As suspected, low intelligence in childhood corresponded with racism in adulthood. But the factor that explained the relationship between these two variables was political: When researchers included social conservatism in the analysis, those ideologies accounted for much of the link between brains and bias.

People with lower cognitive abilities also had less contact with people of other races.

“This finding is consistent with recent research demonstrating that intergroup contact is mentally challenging and cognitively draining, and consistent with findings that contact reduces prejudice,” said Hodson, who along with his colleagues published these results online Jan. 5 in the journal Psychological Science.

A study of averages

Hodson was quick to note that the despite the link found between low intelligence and social conservatism, the researchers aren’t implying that all liberals are brilliant and all conservatives stupid. The research is a study of averages over large groups, he said.

“There are multiple examples of very bright conservatives and not-so-bright liberals, and many examples of very principled conservatives and very intolerant liberals,” Hodson said.

Nosek gave another example to illustrate the dangers of taking the findings too literally.

“We can say definitively men are taller than women on average,” he said. “But you can’t say if you take a random man and you take a random woman that the man is going to be taller. There’s plenty of overlap.”

Nonetheless, there is reason to believe that strict right-wing ideology might appeal to those who have trouble grasping the complexity of the world.

“Socially conservative ideologies tend to offer structure and order,” Hodson said, explaining why these beliefs might draw those with low intelligence. “Unfortunately, many of these features can also contribute to prejudice.”

In another study, this one in the United States, Hodson and Busseri compared 254 people with the same amount of education but different levels of ability in abstract reasoning. They found that what applies to racism may also apply to homophobia. People who were poorer at abstract reasoning were more likely to exhibit prejudice against gays. As in the U.K. citizens, a lack of contact with gays and more acceptance of right-wing authoritarianism explained the link.

Simple viewpoints

Hodson and Busseri’s explanation of their findings is reasonable, Nosek said, but it is correlational. That means the researchers didn’t conclusively prove that the low intelligence caused the later prejudice. To do that, you’d have to somehow randomly assign otherwise identical people to be smart or dumb, liberal or conservative. Those sorts of studies obviously aren’t possible.

The researchers controlled for factors such as education and socioeconomic status, making their case stronger, Nosek said. But there are other possible explanations that fit the data. For example, Nosek said, a study of left-wing liberals with stereotypically naïve views like “every kid is a genius in his or her own way,” might find that people who hold these attitudes are also less bright. In other words, it might not be a particular ideology that is linked to stupidity, but extremist views in general.

“My speculation is that it’s not as simple as their model presents it,” Nosek said. “I think that lower cognitive capacity can lead to multiple simple ways to represent the world, and one of those can be embodied in a right-wing ideology where ‘People I don’t know are threats’ and ‘The world is a dangerous place’. … Another simple way would be to just assume everybody is wonderful.”

Prejudice is of particular interest because understanding the roots of racism and bias could help eliminate them, Hodson said. For example, he said, many anti-prejudice programs encourage participants to see things from another group’s point of view. That mental exercise may be too taxing for people of low IQ.

“There may be cognitive limits in the ability to take the perspective of others, particularly foreigners,” Hodson said. “Much of the present research literature suggests that our prejudices are primarily emotional in origin rather than cognitive. These two pieces of information suggest that it might be particularly fruitful for researchers to consider strategies to change feelings toward outgroups,” rather than thoughts.”

I have been watching with fascination the Republican presidential debates. More than the substance of the debate, however meager, it was the crowd’s reaction to red meat one-liners fed to them by the candidates that made me ask “who are these people”? Now I know.

 

 

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The High Price of New Cancer Drugs

January 26, 2012

by Merrill Goozner First posted 1/24/12 on Gooz News Julie Gralow, an oncologist at the Fred Hutchinson Cancer Center in Seattle, recently prescribed an exciting new therapy for a 60-year-old woman with metastatic breast cancer. Three-and-a-half years into her battle against the disease, the patient had already exhausted three different anti-estrogen therapies, each of which only put a [...]

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Why Only Non-Health Care Business Can Save America From The Health Care Industry

January 26, 2012

Brian Klepper Posted 1/26/12 on Care & Cost The attached PP deck is a presentation I’ve given several times that has received an overwhelmingly positive, if frightened, reception. It is, perhaps, the most disturbing public argument of my career (which is going some), because it tries to document the health care industry’s “capture” of health care regulatory processes, particularly [...]

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Lecithin: The Dark Side of a Dietary Supplement

January 25, 2012

by Dov Michaelli Lecithin as a dietary supplement has been heavily promoted as a panacea for: Cardiovascular health Liver and cell function Fat transport and fat metabolism Reproduction and child development Physical performance and muscle function Cell communication Improvement in memory, learning and reaction time relief of arthritis Healthy hair and skin Treatment for gallstones [...]

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Turning 60? Depressed? Maybe you need a good long swim

January 24, 2012

by Patricia Salber Milestone birthdays are always hard.  20 year-olds bemoan the big 3-0.  Some amongst us view hitting 40 as the beginning of the long slide down to “the end.”  50?  Well you tell yourself, at least I am not 60!  But then it arrives.  60.   Now it is clear, no matter how [...]

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10 Sex Tips for Better Looking Health Insurance

January 24, 2012

by Michael Millenson First posted on Forbes on 1/22/2012 OK, maybe I misread the cover of the dog-eared copy of Glamour perched in a magazine rack at the gym. Perhaps I was confused by the multi-colored headlines promising an improved physical appearance (“101 One Minute Makeover Tricks”), a more organized daily routine (“12 Ways to [...]

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The Wonderful World of Parasites

January 24, 2012

Today we are going to go on a circuitous and fascinating journey that will start with, brace yourself…cockroaches, but will end up in the brain of…maybe your own. I recently came across a mind-blowing article in the Scientist online edition on how parasites manipulate the brain, and behavior, of their victims. Describing the rich tapestry of host-parasite interactions is close to impossible, so I’d [...]

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Hugo Campos fights to get his defibrillator data

January 22, 2012

by Patricia Salber Hugo Campos has Hypertrophic Cardiomyopathy and is prone to arrhythmias.  He has an implantable cardioverter-defibrillator (ICD) to zap the arrhythmias as soon as they are detected-a intervention that prevents sudden death in patients with this condition. Campos is also a self-quantifier.  He obtains data on himself via wireless scales, a Fitbit accelerometer, [...]

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Physician Leadership Development

January 22, 2012

by Margaret (Maggi) Cary I’m designing a client-specific physician leadership development workshop for creating high performance care teams and so I’m revisiting leadership literature. I came across the Center for Creative Leadership’s “Future Trends in Leadership Development.” Nick Petrie took a one-year sabbatical at Harvard University, interviewing experts in leadership development for their opinions and [...]

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