Tag: medicine

Monday is good for something after all: surgery.

Aug 11
Perhaps you’ve heard the advice to avoid hospitals in July on account of the legions of just-graduated doctors who will kill you with their inexperience. Thus far, the claim, though plausible, remains unsubstantiated. However, a recent study showing a variation in mortality after surgery depending on the day of the week it’s performed seems to have more to it.

According to a report that came out in the British Medical Journal, the risk of death after undergoing non-emergency surgery is lowest on Monday (1%), and goes up every day of the week thereafter. People who have surgery on Friday are 44% more likely to die than those who have it on Monday (the rate increases from 1% to 1.44%). The news is still worse for the small number of people who have surgery on the weekends, when the risk of death from complications rises 82% compared to Monday (the rate increases to 1.82%).

Researchers think one explanation for this is the relatively high-risk 48-hour period following surgery, when people are at the highest risk for complications like post-operative bleeding and infection. People who have surgery later in the week may not have as ready access to care, as fewer doctors and nurses work on the weekends than during the week.

It’s important to note that the risk is still low (it reaches around 1.82% on for people who have weekend surgeries, an increase of 0.82%). That said, obviously there should not be such a notable variation in mortality based on day of the week surgery is scheduled. One solution might be that going forward, high-risk or major surgeries should only be performed in the beginning of the week, saving lower-risk procedures for later in the week. Combined with increased efforts to educate patients on recognizing signs that they need to seek medical attention, perhaps this increased risk can be brought back in line.

Disclosure? Not Good Enough.

Jul 09

In compliance with a federal integrity agreement, pharmaceutical giant Pfizer released details of its financial involvement with the medical community.

 

According to the New York Times, the drug maker disclosed that it paid $20 million in consulting and speaking fees to 4,500 doctors in the second half of 2009. The company also shelled out $15.3 million to U.S. academic medical centers for their clinical trials.

 

A few other drug makers have disclosed their payments to physicians in the past, but this is the first time a company has disclosed its payments for clinical trials. As such, some may see this as a good deed on Pfizer’s part, a noble step towards eliminating or reducing some of the conflicts of interest in medicine.

 

Only, disclosure doesn’t seem to help. Several studies have shown that when professionals disclose their conflicts of interest, this only makes the problem worse. This is because two things happen after disclosure: first, those hearing the disclosure don’t entirely know what to make of it — we’re not good at weighing the various factors that influence complex situations — and second, the discloser feels morally liberated and free to act even more in his self-interest.

 

So, in this case the people who run Pfizer will likely feel even more entitled to disregard the public good, and the public, in turn, will not know what to make of the numbers it released. After all, what do you make of the numbers? It’s hard to figure out from a statement of disclosure just how much influence the conflict of interest had on the discloser, and to what degree we should be wary of them as a result.

 

The real issue here is that people don’t understand how profound the problem of conflicts of interest really is, and how easy it is to buy people. Doctors on Pfizer’s payroll may think they’re not being influenced by the drug maker — “I can still be objective!” they’ll say — but in reality, it’s very hard for us not to be swayed by money. Even minor amounts of it. Or gifts. Studies have found that doctors who receive free lunches or samples from pharmaceutical reps end up prescribing more of the company’s drugs afterwards.

 

It’s just a fact of human life: we are compelled to reciprocate favors, and an ingrained inability to disregard what’s in our financial interest. As author Upton Sinclair said, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”

 

Conflicts of Interest in Dentistry

Jul 05

According to an article in SmartMoney, as many as 48% of U.S. dentists have seen their profits plummet thanks to the recession.

In and of itself, this isn’t a particularly remarkable statistic – after all, most of our wallets have taken a hit this past year – but what follows is an interesting discussion:  how are dentists coping with this drop in income? Angie C. Marek reports a variety of tactics in her article (including lowered rates, freebies, eliminated IOUs, etc.), most of which benefit the patient – but they don’t all. Some dentists are softening the financial blow by upselling and overtreating patients.

One example came from a woman who, upon switching cities and dentists, was surprised to learn that her hitherto problem-free mouth was suddenly rife with problems: several cavities required coatings and two veneers needed replacement. Or so her dentist told her. However, this turned out to be just another case of overtreatment.

The problem here is conflicts of interests (COIs), which are instances when professionals are pulled in two directions, torn between personal gain and the good of the patient. And the sad news is that when faced with COIs dentists (or physicians) sometimes end up going the self-interested route, and this can have undesirable consequences for the patient.

Conflicts of interest are nothing new, they have been a problem for as long as there have been professions, and they are very pervasive. For instance, there’s the doctor who at accepts consulting fees from a drug company and studies their drug, the one who prescribes the treatment a drug rep pushed on him the week before over a free lunch, and even the doctor who urges a treatment on a patient in part so that he can use his costly new medical equipment.

This isn’t to say that these are dishonorable people who only see dollar signs and say to hell with the patient. Rather, COIs can deeply color the person’s perception, and thereby end up leading even the most upstanding citizens astray, and this happens often.

The long and short of it is, next time you are at the dentist’s office – think about your dentist’s conflicts of interests.

A Dinner with Drug Reps

Jun 27

Over the years I’ve written all sorts of blog posts on dishonesty, and because the new book release, I want to repost an updated version of them to accompany. For the next few days I’ll post one every other day. Enjoy!

Janet Schwartz of Tulane University and I once spent an evening with a few former pharmaceutical reps, men who used to be in the business of selling a wide range of drugs to treat all kinds of diseases and conditions, from fibromyalgia to depression to restless leg syndrome. As drug representatives, they would go from doctor to doctor attempting to convince physicians to prescribe their company’s drugs. How? Typically they would start by passing on informative pamphlets and giving out products like pens, clipboards, and notepads advertising their drugs.

But we knew there was more to the story, so we tried the pharmaceutical reps at their own game – we took them to a nice dinner and kept the wine flowing. Once we got them a bit sauced, they were ready to tell all. And what we learned was fairly shocking.

Picture these guys: attractive, charming young men. Not the kind of guys who would have trouble finding a date. One of them told us a story about how he was once trying to persuade a reluctant female physician to attend a seminar about a medication he was promoting. After a bit of persuading, she finally decided to attend – but only after he agreed to escort her to a ballroom dancing class. This, according to our new friends, was a typical kind of quid pro quo where the rep does a personal favor for the doctor and the doctor promotes the rep’s product in return.

Another common practice was to bring meals to the doctor’s office (one of the perks of being a receptionist), and one office even required alternating days of steak or lobster for lunch in exchange for access to the (well-fed) doctors.

Even more shocking was that when the reps were in the physician’s office, they were sometimes called into the examination room (as “experts”) to inform the patients about the drug directly. And the device reps experienced a surprisingly intimate level of involvement in patient care, often selling medical devices in the operating room, while the surgery was going on.

Aside from learning about their profession, we also realized how well these pharmaceutical reps understood classic psychological persuasion strategies, and how they employed them in a sophisticated and intuitive manner. One clever tactic they used was to hire physicians to give a brief lecture to other physicians about a drug. Now, they really didn’t care what the audience took from the lecture, but were actually interested in what the act of giving the lecture did to the speaker himself. They found that after giving a short lecture about the benefits of a drug, the speaker would begin to believe his own words and soon prescribe accordingly. Psychological studies show that people quickly start believing whatever comes out of their own mouths, even when they are paid to say it. This is a clear case of cognitive dissonance at play; doctors reason that if they are touting this drug, they must believe in it themselves — and so their beliefs alter to align with their speech.

The reps employed other tricks like switching on and off various accents, personalities, political affiliations, and basically served as persuasion machines (they may have mentioned the word “chameleon”). They were great at putting doctors at ease, relating to them as similar working people who go deep-sea fishing or play baseball together. They used these shared experiences to develop an understanding that the physicians write prescriptions for their “friends.”  The physicians, of course, did not think that they were compromising their values when they were out shooting the breeze with the drug reps.

I was recently at a conference for the American Medical Association, where I gave a lecture about conflicts of interest.  Interestingly, the lecture just before me was by a representative from a device company that created brain implants.  In his lecture he made the case for selling devices in the operating room because doctors could need help learning how to use the device. And in order to fight conflicts of interest, the company no longer takes physicians to Hawaii for their annual conferences — and instead they have their conference in Wisconsin.

So, what do we do?  First, we must realize that doctors have conflicts of interest.  With this understanding we need to place barriers that prevent this kind of schmoozing, and to keep reps from undue access to physicians or patients. They, of course, have the right to send doctors information, but their interactions should stop there.

I have one more idea: What if we only allow people to be drug reps if they are over 75 and unattractive? Not only would these individuals have more personal experience with the healthcare system, it also could reduce conflicts of interest and open up job opportunities to an undervalued population.

Tiny Irrationalities That Add Up: Texting While Driving

Nov 05

Sad story out in the New York Times describing growing concerns about texting while driving. In Britain, a woman was sentenced to a 21-month sentence after it was found that she had been texting while driving, which resulted in the death of a 24-year old design student. In many ways, texting while driving illustrates a case in which tiny, individual irrational decisions can accumulate and cause widespread suffering, not only for the individuals who are texting, but their unsuspecting victims. Unlike cases of drunk driving, in which the driver’s decision making abilities are impaired, drivers who text are at their full wits to wait until they’ve pulled over to check their texts, and yet in the process they routinely underestimate the risk they impose to themselves and others.

Aside from being another example of a common irrational behavior (and who among us did not text or checked their email while driving), this leads me to wonder, what is the best way to solve this problem? While presently the issue is being hotly debated here in the US on a state-by-state basis, England has taken a tough national stance on texting while driving, which includes hefty minimum point penalties on the offending party’s license, and fines upward of 60P. If you watch the video in the linked article, you’ll also find a very graphic video depicting the carnage of a texting accident–shocking and informative public service announcements are yet another option. Alternatively, we can hope that cell phone companies are continuing to explore voice activation technologies that can read text messages aloud and also transcribe them from voice — thereby by-passing the problem altogether.

We have lots of irrational problems to deal with, and the realization that tiny, seemingly innocent little ones, like 10-second text messages, can cause so much damage should make us look around for more such problems.  perhaps ones that are not as obvious (think health care), but are potentially just as damaging.

Irrationally yours

Dan

PREDICTABLY IRRATIONAL SHORT STORY SERIES NO. 5

Sep 30

How are people’s judgments affected when they learn of shocking news? How do they see the world differently? Gordon Closter, a student of mine, explores this topic in the latest Predictably Irrational Short Story. It can be found here.

surprises from our recent economic history

Sep 20

Reflecting back on our recent economic history bring to my mind a two sad surprises.

Even as a behavioral economist who generally believes in the prevalence of irrationality in our every day life, I place some stock in the main mechanism that should have maintained the efficiency of the financial markets: competition. In principle, the drive for competition among individuals, banks, and financial institutions should get the actors in the market to do the right thing for their clients as they fight to outdo their competition. After the Wall Street fiasco, I expected and hoped that in the spirit of competition some financial institutions would change their way given the new information about the risks they were talking and self-impose restrictions on themselves. I did not expect that they would do so because they were benevolent, but because they wanted to get the business of those who have lost trust in the financial institutions.

Surprise one: Sadly, the forces of competition do not seem to have any effect on the functioning of our financial institutions and Wall Street seems to be back to is pre-fiasco structure.

We are now discussing the possibility of health care reform, which arguably is even more messed up than our financial institutions (about 18 percent of GDP, bad incentives, bad intuitions, and the leading cause for bankruptcy before the current housing problem). When I look at the health care debate, it seems to be fueled by ideological beliefs about the importance of competition and freedom of choice on one hand, and the evilness of regulations and limits on the other. As someone who loves data beyond theories, it is surprising to me how little we know about the effectiveness of different versions of health care, and how sure people are in their own beliefs — which makes it an ideological and not a very useful debate (this is just a small surprise).

But what is the most surprising to me is that the tremendously expensive lessons we have experienced about the efficiency of markets and self interest do not seem to carry to the health care debate. As a society, we still seem to be enamored with the ideology of free markets, and have not seemed to update our beliefs in their efficiency despite the evidence. On the bright side, it looks like behavioral economists will have a lot of work for the foreseeable future.

Pigs replace economics

Apr 29

It’s hard to displace a global economic crisis from headlining the news, but the pigs did it. A n variant of the H1N1 flu virus, associated in our lore with the 1918 flu pandemic, has jumped species and infected humans. There are reported deaths (though numbers and details vary wildly) and cases appear to have spread globally.

The media jumped on this new new new crisis, the politicians around the world thanked Providence for something to distract voters from their ethical lapses and the opportunity to pad their budgets, pharmaceutical stocks rallied, airline stocks tanked, and the conspiracy theories are running wild. The Russians stopped importing pork, even though you don’t get the flu from eating pork.

On the positive side, a few more people started washing their hands. This is a rational response; hygiene is an innovation that works. (Purell and other hand disinfectants work in a pinch, but washing your hands for at least one minute, with a long rinse in running warm water is better.)

Three of our predictable irrationalities give the swine flu story much more impact than it should have — and in this case, it would be better if we were more rational.

One: Unlike the agents in economic models, we have limited memory and limited thinking capacity; to manage it we shift our attention depending on outside information. Or, in non-academese, we pay attention to what’s happening now: things that are recent and things that are repeated often get more attention, even if they are not that important. Because the news focus on the negative (it’s their business model) we keep hearing about the cases discovered, and not about the millions of people who were exposed and didn’t get sick. Which gets us to point two:

Two: We overweigh new risks relative to comparable risks we are accustomed to. Around 100 people per day died in US roads in 2008, an enormous improvement over previous years but still. People obsessing about spending 5 minutes in elevators with others (an infinitesimal chance of contagion) will blithely cross the street against the light to have a artery-clogging triple cheeseburger with fries and then smoke a pack of cigarettes. These things have much higher risks, but because we have grown accustomed to them, we don’t think of the risks. They are not, in the technical term, salient; but they are much more dangerous. Still, their dangers are dry statistics and people are not good with statistics, which gets us to point three:

Three: Brains are wired to work well with stories. And there are many stories one can make from the news reports: pandemics amplified by airport air recycling and global travel; mass extinction followed by anarchy and mayhem; terrorism taking advantage of the burden on the health system; the flu as prelude to alien invasion from Alpha Centauri. Ok, the last one only works around the MIT Media Lab. But we love stories, and forget that the plural of anecdote is not data. Statistics, dry as they may be, give a lot more information than stories.

It is not that this problem is not real and important, I just don’t think that relative to our other problems, it is as big as we are making it to be.

What can we do: as the British said during the Blitz, keep calm and carry on. Take appropriate precautions, wash your hands, and if you’re sick get help and keep out of crowds.

CDC page on this flu

The Psychology of Pain: "I didn’t mean it!"

Feb 10

There’s a phrase we hear all the time, and one that suggests something about our psychological makeup: we’re not just concerned with actions, but with their attendant mens rea – or lack thereof – as well. If it wasn’t intentional, then it’s not as painful.

And, as it turns out, that is quite literally true: Harvard researchers Kurt Gray and Daniel Wegner recently found that we experience greater pain when we perceive it to be deliberately inflicted, rather than by accident.

In their clever experiment, they had volunteers perform a variety of tasks, including an assessment of discomfort. This involved receiving electric shocks and then rating them on a 1 to 7 scale. When participants thought their “study partner” (who was actually a research accomplice) had selected the task for them to complete, they rated their perceived pain as higher (Mean ratings = 3.62) than when they were told the selection was computer-generated the pain was lower (Mean ratings = 3.00).

What’s more, deliberate pain was not just more acute, it also lasted longer: whereas participants rated the unintentional shocks less and less unpleasant as the experiment progressed, the intentional shocks remained just as painful.

So next time you are at the doctor try to think that he or she really cares about you.

Conflicts of Interest – More Pervasive and Problematic Than We Think

Jan 30

Here’s a very interesting piece from the New York Times’ Review of Books: “Drug Companies & Doctors: A Story of Corruption.”

The basic story is that whereas only a few decades ago physicians generally lacked any lucrative ties to pharmaceutical companies, these days such conflicts of interest permeate the field, and debase it.

Take the example of Dr. Charles B. Nemeroff, the psychiatry department chair at Emory University. He received a NIMH grant to study drugs made by GlaxoSmithKline AND at the same time he also got $500,000 in fees from GlaxoSmithKline. Talk about a conflict of interest!

That’s not the only egregious case – there are many.  As it turns out a recent survey found that about two thirds of academic medical centers hold equity interest in companies that sponsor research within the same institution… And here is another one:  Of the 170 contributors to the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), ninety-five had financial ties to drug companies.  The top dogs aside, many physicians accept hefty salaries to consult for drug companies, and most accept pharmaceutical gifts like pens and free lunches.

So the medical profession is teeming with conflicts of interest – but it doesn’t stop there. Look at politics, wall street, consulting — it is everywhere and I worry that unless we  understand just how big this problem is,  we are not going to deal with it.

   

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