Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!

Cavalcade of Risk: Step 1[49]

Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.

From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.

From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.

From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.

From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.

From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
a) Hypertension
b) Alzheimer’s disease
c) Diabetes
d) Lung cancer
e) Breast cancer

From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.

From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.

From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.

Answer Key
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.

Examiner’s Notes

As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.

The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.

*crickets chirping*

In my defence, I am a second-year medical student, though you might not know it from my taste in health reform jokes.

It isn’t that the content of medical school is intrinsically difficult. In a refreshing change from my previous education in economics and social sciences, there are usually right answers. Unambiguously right answers that rest on a foundation of the (usually) internally consistent logic of human pathophysiology. There are fewer clinically-relevant “models” per se, and their assumptions rarely engender as much bitter controversy as those in… say… macroeconomics. To be fair, my contention that the kidney only makes sense if you posit the existence of a sodium/unicorn dust exchanger in the loop of Henle took a while to gain acceptance.

*more crickets chirping*

What makes medical school hard isn’t the material. It’s the volume that gives us a run for our money. Not only do we have to learn “everything” in two years or less, we have to remember it. For Step 1.

(If you’re a second-year medical student, consider stopping here. For your sanity, of course)

Physicians in the United States are licensed, as are physicians in countries like Canada, the UK, Australia… probably most others. As one might expect, physicians in the US are expected to pass a nationally standardized exam to qualify for licensure. As in Canada, there is one part that is taken before entering post-graduate training, and another part that is taken after at least one year of residency.

However, as politicians are quick to remind us, the US is exceptional. Because in my poking around medical licensure systems of similar countries, the United States Medical Licensing Exam is the only test with anything like Step 1.

(I said it again. Second years, I warned you.)

The simplest way to describe Step 1 of the United States Medical Licensing Exam is as follows: a seven hour long, 322 multiple-choice question, 78 seconds-per-question final exam for the first two years of medical school.

An exam with sacred texts known to medical students across the country: First Aid; Goljan; Robbins Review; the Q-Books; BRS; High Yield…

An exam for which completing a few thousand practice questions is considered “barely enough.”

An exam that plays a significant role in whether you’ll get accepted into the residency program, or even the specialty, of your choice.

An exam for which most students are given 5-8 weeks of time off in which to study full-time right before taking it.

An exam for which many students start studying six months in advance. Which for me is… now.

I tell you all of this because between now and mid-May (when 5 week journey of discovery and practice questions begins in earnest) my posting will be even more infrequent than before, and those posts that are written may well feature less of the policy commentary you’ve grown accustomed to and more… “medical student stuff.” That said, I assure you it will continue to be worth your time.

As for your intrepid blogger/test-taker… despite my flair for the dramatic, I’ll be fine. Just under six months from today, I take the next step on the road to licensure. I will take that seven-hour, 322-question exam. And I will crush it. You heard it here first.

Earlier this year, a Florida-based lawyer wrote a piece at SBM arguing that many quacktitioners are likely committing misrepresentation, in the legal sense, and possibly fraud in some cases. This was followed up with a series examining the background and historical legal status of naturopathy, acupuncture, and chiropractic, and now a proposal to enshrine science-based medicine in law.

Read the whole blog post to get a better sense for what’s proposed. The short version is that the proposed law would limit the scope of practice of licensed healthcare professionals by imposing a two-part test to be interpreted “according to its generally accepted meaning in the scientific community”:

1. Is it (a diagnosis, treatment, procedure, medication, etc.) plausible, based on “well-established laws, principles, or empirical findings in chemistry, biology, anatomy or physiology?”
2. If not, is it “supported, to a reasonable degree of scientific certainty” by either “good quality randomized, placebo-controlled trials” or “by a Cochrane Collaboration Systematic Review or a systematic review or meta-analysis of like quality.” If not… it’s verboten.[a trial that would pass the legal test would have a placebo control group, random assignment, no more than 25% attrition, at least 50 participants in each study arm, and publication in a "high-impact, peer-reviewed journal."]

   If so, has its ineffectiveness been “demonstrate[d], within a reasonable degree of scientific certainty” by the aforementioned controlled trials or Cochrane Reviews? If so, plausibility won’t save it from being forbidden.

With a scheme like this, the devil is usually in the details. In this case, I don’t think one needs to dive in too deep to realize why this is a bad idea.

Politics is a sausage factory, and the science-based medical community should be hesitant to get it unnecessarily involved. Just because something is wrong/a bad idea (like quackery) does not necessarily mean that it should be forbidden in an ideal world. Just because something wouldn’t exist in an ideal world (like quackery), it doesn’t mean that it’s a good idea to use the force of law to ban it.

As narrowly-tailored as it aims to be, this proposed law will have the effect of legislating scientific truth. What constitutes scientific consensus? Plausibility? A high-impact journal? Do we really want these and other scientific questions that are now debated in the literature and the public sphere to be decided definitively by judge and jury? Do we want to give the power to certify science to our legislatures? The same legislatures that have already licensed all sorts of quacks at the behest of their lobbyists?

Science is politicized too easily. Where a scientific conclusion is translated by law into an inevitable legal and policy consequence, the science will make a better political target than the legislation. See this piece on the Endangered Species Act for an example of what I mean.

The best of policies can be undone by politics. I’ve given a fair bit of thought to how one might design an anti-quack law that doesn’t have the potential to go drastically awry. I can’t, though this is likely a result of insufficient creativity on my part.

In general, there are two types of people in government. “Our people” and “their people.” Who they are may vary based on the party or based on the issue, but both types will always be there. And both types win and lose elections.

Here’s the question: do you trust “their people” to exercise good stewardship of scientific truth? If not, let’s not be too hasty in handing over the reins to the politicians.

I think the law bloggers handle this better than we on the medical side do. There are plenty of social media evangelists in both fields who can be found online treating new technology as an end and not a means, promoting the ideal of “saying anything” over “saying something,” and generally clogging the ‘tubes with tweets, blog posts, and comments that barely even try to masquerade as anything beyond marketing. At least there are some lawyers out there willing to call “shenanigans” when they see them.

I have yet to see a physician call out his/her colleagues for scammy/scummy behaviour online. Not like some of the blawgs do. Take Ken and Patrick at Popehat, for instance. They’re brutal, and rightfully so. As another blawger, Eric Turkewitz, puts it: “when you outsource your marketing, you outsource your ethics“.

I am no luminary in the medical profession. Given that I blog pseudonymously, you can’t even be sure that I am a medical student. I claim no special authority to make pronouncements on medical ethics. I don’t need to. The following statement should speak for itself:

If you are a medical professional, comment-spamming blogs is not an acceptable marketing tactic. If you find yourself keeping company with SEO hucksters and vendors of penis-enlargement pills, you’ve made a wrong turn somewhere.Your online obligations don’t end at HIPAA.

Dr. Michelle Scott Tucker of Castle Hill Pediatrics, Carrollton, TX: you wanted search engine visibility. You got it.

These marketing shenanigans are undignified, unethical, and reflect incredibly poorly on the medical profession. I will not be associated with them. If you have a medical blog yourself, I hope you’ll join me. Make it clear to other physicians that indiscriminate spamming is no way to promote a practice. Call them out. Someone has to show them the error of their ways.

***

I will take another page from Popehat’s book and make the following offer to anyone called out for comment spam at this site:

“I will scrub this post of data identifying [you] and [your practice] on two conditions. First condition, [you] must make a sincere apology for [writing spam comments yourself, or] outsourcing [your] reputation and ethics [...]. Second condition, [you] must provide emails or other documentation identifying the marketeer [you] hired who produced the comment spam and proving their responsibility for this, so that we can alter the post to call them out by name.”

My email is in the upper right-hand corner. You know how to reach me.

Though I disagree with their proposed policies, I do respect PNHP as an organization. It is one of the biggest mobilizers of physicians and medical students who are in favour of radically changing how American health care operates. Their passion is palpable at even the most informal event. They do have a contribution to make to the health policy conversation. Unfortunately, while there is an intellectually-coherent case to be made for single-payer (a mistaken case, in my view, but respectable and honest), I have yet to hear it from anybody at PNHP (n=small).

I harbour no illusions about my ability to persuade hard-core single-payer believers in a short blog post. I do, however, have some friendly and hopefully helpful advice on how to talk to the uninitiated and the un-converted more productively:

1) Don’t try to twist the data to support your case. It shows. At best, data on Medicare-vs.-private administrative costs are equivocal, cross-country infant mortality comparisons are spurious, life expectancy at birth captures a lot of mortality that is out of the hands of the healthcare system, and so on. The empirical case for single-payer superiority is thin gruel.

2) When someone asks whether you’d trust a Republican President and Congress to implement single-payer well, don’t duck the question. It’s a more important one than you seem to acknowledge. If you want to centralize control in government, be prepared to talk about how you will deal with your ideological opponents who tend to win elections every now and then.

3) Your moral argument is a lot stronger than your empirical argument. Why not make it explicit? Americans don’t tend towards collectivism, but neither are most people data-oriented policy wonks. Instead of making a weak case based on weak data, you should be prepared to talk about the moral strengths of single-payer relative to the alternatives. Where are the mentions of equity, obligation, and collectivism? (I ask this seriously, not passive-aggressively)

4) Be fluent in the language business, politics, and economics. When your executives are being matched point-for-point by medical students who majored in biochemistry and similar fields, you know you have a problem. If you’re going to call for the dismantling of private insurance, have some idea of how the sector actually operates. If you want to give control of the health system to government, be able to discuss the nuances of Washington power structures. Be able to respond to phrases like “deadweight loss,” “price-vs.-income problems,” and “underwriting” with more than a blank stare.

5) Anecdotes are rarely dispositive of policy questions. When someone points this out about anecdotes involving people you know, don’t get offended; this rarely advances discussion. When you introduce your friend’s problems to the debate, it’s not your opponent who’s trying to use them to score “cheap points.”

6) Milton Friedman is said to have told an up-and-coming Walter Williams, after the latter appeared on TV to discuss school choice, that “[Williams] was right about everything but [had] made one mistake [...], when you talk about liberty, you have to smile.” You may not be talking about liberty as Friedman understood the term, but his advice is every bit as applicable.

In recognition of all of the countries with July independence days, we’re going to be running a carnival sideshow at this blog carnival today. Interspersed with the submissions will be a small number of flags with trivia-esque hints for countries with July national days; the names of the countries will be at the end of the post. Hopefully this will be an entertaining mid-July “trivial pursuit” to accompany the serious business of risk discussed in the submissions!

This country's neighbours include Suriname and Brazil. (is this a trick question?!)

Two related posts from Jacob Irwin and a guest blogger at My Personal Finance Journey discuss the perils of e-commerce and sharing financial information online. Jacob dissects an example of a common ‘phishing’ scam, and the red flags that should cause one to be suspicious of an email that seems designed to separate you from your personal information (and eventually, your money!). His guest blogger, Les Roberts, talks about how to stay safe while shopping online, and discusses some of the basic technical aspects of secure online transactions.

Tom Drake at the Canadian Finance Blog has a comprehensive post addressing what he claims is the conventional wisdom regarding life insurance: buy term and invest the difference. He argues that while the strategy has its obvious appeal, it’s highly sensitive to the assumptions used in the term vs. permanent comparison. Well worth a read!

No, it's not an American flag, though their capital is named for one of America's Founding Fathers.

Hank Stern, writing at InsureBlog, notes in the context of recent floods in North Dakota that sometimes taking a risk with your insurance coverage can be justified, but as with the analysis in the previous post, that it all comes down to how robust your assumptions are. Come to think of it, isn’t that the case with just about anything?

This country currently leads the world for longest stretch without an official government. You might say they've been waffling for the past year or so.

Wondering about health insurance exchanges? Dr. Jaan Sidorov (aka the Disease Management Care Blog) took one for the team and dove into the depths of the details of Utah’s already-existing exchange. He notes that setting up an exchange is far more complicated than one might think at first glance, and that it’s unlikely that they will be functional in every state of the union come the 2014 deadline. He also ponders the potential for exchange listing/delisting to be used as a quasi-extra-legal cudgel (my words, not his!) by state insurance regulators seeking additional ways to force insurers into line.

“Oh no they didn’t!” is a common refrain from business owners wondering how that absurd claim could have been paid out by their workers’ compensation carrier. Nancy Germond has a clear and concise explanation of why, “oh yes they did!“, along with an interesting history of how workers’ comp came to be in the first place. Read on at Allbusiness.com.

Do you remember the Dodd-Frank bill? Thought it only applied to big banks and high-falutin’ investment securitization shenanigans? Van Mayhall III has a post at his Insurance Regulatory Law blog reminding us that the new provisions of the law could also affect larger insurance companies and their affiliates in ways that management will want to be aware of well in advance of anything going wrong.

St. Thomas isn't just one of the US Virgin Islands. This equatorial namesake, however, has a "princely" companion.

At Colorado Health Insurance Insider, Louise Norris asks whether eligibility criteria for the newly-established federal high-risk health insurance pools is hampering enrollment. Colorado is an interesting vantage point from which to observe this: the twenty-year-old program “CoverColorado” is very similar to the new federal one. The differences between the two programs’ eligibility rules generate good insight into where the federal program is going wrong in attracting enrollees.

If you asked this country for a date in 1995, you might find the time being pushed up unexpectedly.

Workers Comp Insider Julie Ferguson and I seem to have been on the same wavelength for this blog carnival! I recently wrote a post arguing that the problem of poor price transparency in health care may be an objection to the use of consumer-directed health plans now, but that early adopters will pave the way forward for the rest of us. The chicken-and-egg issue is not all that intractable! Julie Ferguson, on the other hand, has a far superior post addressing the same topic. She points out the immense price differences for the same medical services that exist across state lines and across street intersections alike, and provides links to seven (count’em!) different resources for employers and individuals to use to get the best bang for their medical buck.

***

This brings CoR-135 to a close. Thank you to all of the submitters for their quality posts on risk, and thank you to Hank Stern for his tireless work managing the behind-the-scenes logistics of every edition of this blog carnival. It really is an honour for this callow medical student to be invited to sit at the grown-ups’ table and host the Cavalcade!

The next edition of Cavalcade of Risk will be hosted by Jacob Irwin at My Personal Finance Journey on July 27th.

***

For those of you who tried your hand at the national flags-and-trivia sideshow, the answers are here.

The first one was something of a trick question. It’s France! French Guiana sits atop the northern coast of South America, and is every bit a part of France as Paris or Nice, and as such France has land borders with Brazil and Suriname. Bastille Day: July 14.

It’s not an American flag, but there is a reason it sorta-kinda looks like one. Liberia was established as a place to which to “repatriate” black Americans in the early 19th century, the idea being that they could live a life of greater freedom there than in the antebellum United States. James Monroe was one supporter of this effort: the Liberian capital is Monrovia, after him. Proclamation of independence from the United States: July 26.

Next up: Belgium! It’s been quite a while since they’ve had an official government, and the country is wracked by political tensions between the Flemish and Walloon communities. Oath of the first King of the Belgians: July 21.

St. Thomas in Portuguese is Sao Tome (can’t figure out accents, sorry!), and the flag is that of Sao Tome and Principe, a small island nation located along the Equator in the waters west of Gabon and Equatorial Guinea. Independence from Portugal: July 12.

Prior to 1995, the Pacific island country of Kiribati was split by the international date line. Makes inter-state time zone differences in the US seem incredibly convenient by comparison, doesn’t it? After kinking the IDL a bit to the east to accommodate the entire country on one side, Kiribati was positioned to be the first country in the world to see each new day. Independence from the UK: also July 12.

A brief discussion in the comments brought out what is one of the more common objections I hear to any attempt to move health insurance in the direction of high-deductible catastrophic care policies: “how are patients supposed to find information on quality and price from physicians and hospitals? It’s not there? This can’t possibly work!”

It’s not a trivial objection, but when all is considered I can’t say that I’m convinced by it.

It’s not as though the health care industry hasn’t caught onto the need to devise, assign, and disseminate cost values for different tests and procedures (even if only for internal purposes), even where cost was never previously a consideration. See the recent highly-publicized study in Archives of Surgery finding that merely giving medical staff information on blood test costs reduced spending by lowering utilization.

As more and more patients start asking for real price and quality data, providers will have an incentive to find it and give it to them. With traditional third-party payment, what does it matter to the physician? They get paid what someone else says they get paid. If my classmates are representative of future physicians more generally, most would far rather not even have to think about pricing and bundling their own services if they don’t have to. That won’t change unless there’s a demand for it, and right now the main source of that is patients with consumer-directed plans.

We already have a great deal of beneficial, effective competition on both price and quality in areas of the health care market that are actually markets, and in which people tend to pay out of pocket. Think of the trends of both price and quality of laser eye correction over the last few decades, or cosmetic surgeries that aren’t covered by insurance. These are elective procedures with real risk of misadventure, as with many services provided by physicians and hospitals. The reason that price and quality data are easier to come by for LASIK than for cardiac catheterization is precisely because patients have an interest in knowing. This isn’t to say that the process of developing the data is necessarily quick and easy, but surely this should disprove claims that transparent pricing “could never happen” in health care more generally.

Right now, I’d imagine that the people most likely to sign up for consumer-directed health plans (though obviously there are many exceptions) are those who want to, or at least are comfortable with managing more of their health care spending in exchange for lower premiums and capped out-of-pocket spending. As with any other new product, it is the early adopters who will pave the way forward for other consumers. My prediction is that as a small but growing group of patients and physicians begin to leave the third-party payment model, whether via HSAs or by exiting insurance entirely for some services, the medical industry will get better at providing transparent price and quality information to everyone who asks. CDHPs (and the providers who accept them) today may be like the first cell phones in the 1980s: as the early adopters push for improvements, we’ll see the product evolve into something that can be used more widely in the future.

Yes, there is something of a chicken-and-egg problem right now. But it’s anything but intractable, and certainly won’t be a problem forever.

***

There is a strong argument to be made that transparency and competition on quality goes hand in hand with price competition. John Goodman from the NCPA makes the case here and here, among other places.

I want to make clear at the outset that this post is intended to be descriptive. My thoughts on Canadian medicare and its implications for proponents of single-payer in the US can wait for another time.

Before delving into the Medscape commentary itself, we should begin with some general background on health care in Canada.^[1]

***

[1] – Much of this background was assembled while preparing a presentation that for the first  health economics course I took in university. I have done my best to bring things up to date. Depending on the minutiae of when laws are introduced vs. passed (and which of the two you refer to), some of the earlier dates in the History section may be 1-2 years off from what you read in some other sources.

History

Canadians feel strongly about their medicare. Most of them love it, or at least love the idea of it. If you’re a politician wanting to discuss the system in terms of anything other than providing more funding for the system, you’re likely to be toast in short order. And don’t even think about promoting “two-tier” health care! Governments at the federal and provincial level have risen and fallen based on the health care issue; it’s a major component of provincial government spending, and many Canadians view medicare as a component of national identity.

Government involvement in Canadian health care began in earnest in 1944, when the government in the province of Saskatchewan introduced a system to provide free health care to the elderly and retirees. This was followed shortly in 1947 by a public hospital insurance plan featuring a $5/person/year premium. In 1959 the socialist government of Tommy Douglas (considered one of the “fathers of medicare“) announced the first universal public health insurance program in Canada. Needless to say, Saskatchewanian (Saskatchewanite? Saskatchewanish?) physicians were wildly opposed, even going on strike for a few weeks in 1962.

A decade later, the ideals that drove the new program in Saskatchewan came to fruition on the national stage, as medicare was introduced in the remaining Canadian provinces beginning in 1967. This was not done in one fell swoop. The constitution in Canada has established health care as the domain of the provinces. The federal government rolled out medicare across the country not by fiat, but by offering matching funds (now block grants) to provincial health plans that met certain legislative criteria; this has given the federal government an important role in both financing and “regulating” provincial health care plans, though in recent years the federal share of health financing has fallen as low as 15-20%, with the rest paid by the provinces. In this sense, the structure of Canadian health care financing more closely resembles that of US Medicaid than of US Medicare. It should also be noted that both the earlier and current iterations of provincial health plans covered mostly to exclusively hospital and physician services: no home care, drugs, devices, etc.

Federal Legal Framework

By the mid-1970s, the last Canadian province had signed on to medicare and the program was not due for another major shake-up until 1984, the year the Canada Health Act was passed. The CHA is still the current governing framework for public health care in Canada. It re-affirmed the five basic criteria and two conditions for federal funding, but unlike the previous federal legislation, the CHA more clearly authorized the federal government to withhold transfer payments as a penalty for provincial transgressions.

The CHA imposes 5 basic eligibility criteria for provincial plans to receive federal support.

1. Public administration: each province’s health plan must be administered by a publicly-accountable, non-profit entity. In practice, this is usually a government agency or arm’s-length government-owned insurer.
2. Comprehensiveness: all “medically necessary” services must be covered, though provinces get surprisingly wide latitude in defining what is medically necessary.
3. Universality: all residents of a province must have access to public insurance on the same terms and conditions. In other words, all insured must be equal, and all are equally insured. The Act defines “insured persons” in such a way that treatment sought under worker’s compensation or auto insurance regimes escapes some of the dictates of the Act. In addition, provinces are allowed to impose minimum residency length requirements (e.g. 6 months in Ontario) before residents are eligible for coverage; in some provinces, this even applies to Canadians moving from other provinces.
4. Portability: provincial plans must reimburse insured persons for medical services used during temporary absences from the province, at least at the rate specified in the provincial plan’s fee schedule.
5. Accessibility: access to coverage must be uniform and barrier-free. There can be no discrimination or disparate treatment based on age, income, health, etc. On the provider side, provinces are required to have a clear and transparent fee schedule, with providers being “reasonably” compensated.

In addition, the CHA imposes two more specific conditions on funding that cut more closely towards health care delivery, as opposed to the five conditions that govern financing.

1. Balance-billing (or “extra-billing” as it’s sometimes called in Canada) is banned. Physicians and hospitals are not allowed to charge provincially-insured persons for provincially-covered services in addition to the province’s payment for the service. This is similar to US Medicare’s ban on balance-billing.
2. Provinces are not allowed to impose “user charges” for insured services. This became an issue recently as the government of Quebec toyed with the idea of introducing modest co-pays for some services for some insured. Not allowed.

The result is a “system” that’s not just one system. Each province (and possibly each territory?) has its own provincial health insurance plan that is run subject to the constraints of the Canada Health Act. The federal government administers health plans for members of the armed forces, the RCMP, and First Nations living on reservations. Worker’s compensation and auto liability insurance also play small roles.

The provincial plans are the major players, and are what most people in Canada and the US think of when they discuss the “Canadian health care system.” Though the criteria laid down by the CHA result in the appearance of national uniformity (and to be fair, a good deal of actual uniformity) in how health care is financed, administered, and delivered in Canada, there is a good deal of meaningful variation between provinces.

The Private Sector

One important dimension of variation is the role of the private sector in delivering and insuring services that are covered by provincial plans.  As of 2005 (I haven’t looked more recently, but am unaware of major changes since them):

• Four provinces (QC, AB, BC, PEI) allowed physicians and other covered providers to set their own fees for providing covered services without billing the province. However, these provinces did not allow any reimbursement of patients or providers for covered services not billed to the province. In addition, these provinces banned private insurance coverage of any service covered under the provincial plan, even if delivered in the private setting.

  In 2005, a physician and his patient sued the Quebec government, arguing that the ban on private insurance coverage of privately-delivered publicly-covered medical services violated the Canadian Charter of Rights and Freedoms and the Quebec Charter of Rights and Freedoms, especially given long waiting times for treatment in the public system. The case made its way to the Supreme Court of Canada, which ruled that the prohibition violated the Quebec Charter of Rights and Freedoms. Given that the decision was grounded in QC provincial law, it had only limited direct impact in the other three provinces.

• Three provinces (ON, NS, MB) forced providers going outside the public payment system to charge at the public fee schedule. They also banned private insurance coverage of privately-delivered care that was also covered by the provincial plan, though two of these provinces (ON, MB) reimburse patients for out-of-pocket expenses paid to private providers.
• Three provinces (SK, NB, Nfld) allowed unfettered private delivery and private insurance for services covered by the provincial health plans. Newfoundland would reimburse patients for out-of-pocket expenditures to private providers up to the provincial fee schedule, whereas SK and NB provided no reimbursement for private expenditures.

   

• Private diagnostic clinics were beginning to emerge in three provinces (QC, ON, AB) in response to a pervasive lack of timely access to diagnostic imaging services. Though these clinics operated outside the public system, Ontario and Alberta actually contracted with some of them to provide services to public patients. For those with the means, however, payment could secure an earlier appointment for imaging, shortening the amount of time waiting for a diagnosis, and where applicable allowing earlier entry into a queue for treatment.

A National Single-Payer?

One of the features of health care in Canada that is often overlooked by proponents of single-payer in the United States is that Canada as a whole does not have a “single payer,” which means it’s hard to make sweeping generalizations about details. Covered services, the quality and quantity of care provided, and physician/provider payment vary across provinces. Not earth-shatteringly so, but enough to introduce a small modicum of inter-provincial competition for physicians, and “competition” in services and benefits mediated through political pressure (e.g. “Patients in BC can get this drug, why won’t you pay for it here in Nova Scotia!”). Given the perennial importance of medicare as a political issue, the importance of popular pressure to increase funding and expand services should not be trivialized.

It’s also worth pointing out that about 30% of Canadian health care spending is individuals’ out-of-pocket payments for things like drugs, home health, hospital amenities, and other non-covered services. This is 2-3 times the fraction of health care spending in the US that comes directly out of individuals’ pockets in exchange for services received.

Unions, Public Employees, and Hospitals

Contrary to what I’m told is common belief in the US, most Canadian physicians are not government employees. Though some provinces hire doctors for what I surmise are analogues to Community Health Centers, the vast majority of physicians are independent contractors paid on a fee-for-service basis according to the provincial fee schedule. In Ontario, some family physicians practicing in so-called “Family Health Teams” are capitated, and some emergency physicians are paid by the hour. An interesting wrinkle is that some provinces have hard caps on how much a physician can earn in any year; obviously this creates disincentives to working so hard / so much that the cap would be reached in a year. (It’s not just hypothetical: I have a few physician friends in Canada who have made great strides in their golf game as a result of this cap).

Hospitals, on the other hand, are closer to highly-regulated public utilities. In Ontario, most hospitals are non-government or arms-length, non-profit entities. Most of their money comes from a “global budget” (i.e. “this is your budget for the year”), though there have been experiments with US Medicare-like prospective payment systems for certain conditions. Patients also pay per-diem fees for non-covered amenities (e.g. private inpatient rooms, phone and TV service as inpatients). Provinces (or regional health authorities, or whichever provincially-created entity is in charge in a given province) have at least some control over hospitals’ capital spending. In Ontario, regional health authorities determine what sorts of specialty services and facilities are available at which hospitals within their purview. Hospitals are allowed to engage in public fundraising for capital campaigns; I’m not sure how this interacts with provincial controls on capital spending.

Physician licensing and governance is a point of special interest to me. There is the usual plethora of physician groups, specialty societies, etc., similar to what is found in the US. However, given the effective monopsony power of provincial governments in the market for physicians’ services, provincial medical associations have emerged whose main function is to represent physicians in fee schedule negotiations with government. Canadian physicians seem to have more input into provincial fee schedules than American physicians do into Medicare fee schedules. Whereas American physicians set the relative weights of various services in the Medicare fee schedule (and only indirectly lobbying for changes in the monetary conversion factor), Canadian physician organizations typically negotiate for dollars directly with government.

The Ontario Medical Association is one of these organizations. Unlike groups such as the American Medical Association, their orientation (and their website!) is very physician-centric. In addition to negotiating the terms of the provincial fee schedule, the OMA also sets maximum rates that physicians can charge for certain non-covered services (phone consultations, insurance forms, etc.).

Physician licensure and discipline is also done at arm’s-length from government. Unlike in the US, where medical licenses and disciplinary action are typically the domain of state government medical board, most (if not all) Canadian provinces have allowed the medical profession to remain somewhat self-regulating. For instance, the College of Physicians and Surgeons of Ontario is the licensing and disciplinary body for physicians in Ontario. Its governing body is composed of 16 physicians elected by their peers, 3 physicians selected from Ontario’s 6 medical school faculties, and 13-15 members appointed by government. Also of note is the fact that many provinces, including Ontario, condition licensure on the Canadian equivalent of specialty board certification. The opposite conditionality holds in the US.

By the Numbers

It would be foolish to try to replicate this series of three posts at the Healthcare Economist, where Jason Shafrin does a wonderful job of collecting the major summary statistics for infant mortality, life expectancy, access to care measures, and physicians per capita.

Next Time

In an upcoming post, I’ll discuss common American medical student perceptions of Canadian health care (as exemplified by the post at The Differential mentioned at the outset, and with some telling anecdotes from March’s AMSA conference), along with the always-hot topic of waitlists for treatment.

Given that the AAMC is one of the organizations raising the alarm about a looming physician shortage, it’s interesting to see that one of their responses is to ever-so-slightly raise the barrier to entry to medical school. That’s one heckuva cartel I’ve got on my side!

Of course, given the enormous mismatch between the number of medical school applicants and medical school spots, this change will not actually reduce the number of medical students (and as readers of this blog know, the real bottleneck is the number of residency slots). It will, however, increase the amount of time, effort, and money needed in order to meet the basic requirements for medical school admission. I suspect the test prep companies will fare especially well.

That said, I’m skeptical that the proposed MCAT changes are that worthwhile. I would be surprised if they do much, if anything, to address the concerns that seem to be motivating them. Here’s why.

1) Unless implemented very thoughtfully, inclusion of social science content will trivialize it by making it simply “another box to check” while studying. The USMLE has had limited success with this; can AAMC really do better?

The two recommendations from the the “MR5″ report that seem to be driving much of the hubbub are these two:

3. Test examinees’ knowledge and use of the concepts in behavioral and social sciences, research methods, and statistics that provide a solid foundation for medical students’ learning about the behavioral and socio-cultural determinants of health.
4. Test examinees’ ability to analyze and reason through passages in ethics and philosophy, cross-cultural studies, population health, and a wide range of social sciences and humanities disciplines to ensure that students possess the necessary critical thinking skills to be successful in medical school.

I’m on record as a fervent supporter of making statistical fluency a pre-requisite for entry to medical school (or a college degree, for that matter). If this change leads to an increase in the statistical literacy of future medical students, that’s a plus. Similarly, as a former economics major, I am fully aware of the applicability of various social science concepts and techniques to the medical field. If a standardized test can assess the ability to analyze ethical and philosophical problems, so much the better (though I would imagine that it would be more likely to measure familiarity with the key buzzwords from each discipline).

The risk of including these topics on the MCAT is that by making these disciplines part of “just another hoop to jump through,” the test won’t be able to adequately evaluate the analytical ability and engagement with the material that the AAMC seems to value. Lest you dismiss this as an idle concern, here’s an actual question from a gold-standard review book for the US Medical Licensing Exam. Step 1 of the USMLE includes questions on sociocultural topics, ethical topics, the doctor-patient relationship, and the same “cross-cultural studies” that will soon be added to the MCAT.

A 40-year-old woman who recently had back surgery does not complain of pain, although magnetic resonance imagery (MRI) reveal re-herniation of the disc with significant nerve involvement. Of the following, this woman is most likely to be of

(A) Welsh descent
(B) Puerto Rican descent
(C) Greek descent
(D) Italian descent
(E) Mexican descent

[(A) is the correct answer, because "Anglo Americans tend to be more stoic and less vocal about pain than to Americans of Mediterranean or Latino descent"]

(from Fadem, B. Behavioral Science in Medicine. LWW, 2004. p. 326)

The chapter for which this question was written is entitled “Culture and Illness;” it reads like a checklist of stereotypes about various ethnic and cultural groups. I have yet to figure out what real value this adds to my skills and maturation as a physician. If this sort of content is to be included on the MCAT, the AAMC will have to do a much better job for it to be worthwhile and meaningful.

2) The MCAT is not the tool by which to evaluate candidates’ personalities. That’s what interviews, essays, and recommendations are for.

The MR5 recommendations continue.

To help medical schools consider data on integrity, service orientation, and other personal
characteristics early in student selection, the AAMC should:
13. Vigorously pursue options for gathering data about personal characteristics through a new section of the AMCAS application, which asks applicants to reflect on experiences that demonstrate their personal
characteristics, and through standardized letters that ask recommenders to rate and write about behaviors that demonstrate applicants’ personal and academic characteristics.
14. Mount a rigorous program of research on the extent to which applicants’ personal characteristics might be measured along with other new tools on test day, or as part of a separate regional or national event, or locally by admissions committees using nationally developed tools.

Lots of people think medical schools should look “beyond test scores” and focus more on “personality” when judging applicants. Dr. Pauline Chen, writing at the New York Times, thinks so. The UChicago medical student with whom I discussed this on Twitter thinks so. Many of my classmates think so. I probably think so as well, but then I can’t pretend to know how these decisions are actually made in real life as it is.

The idea that mastery of social science content (or lists of stereotypes, as seen above) correlates meaningfully to personality is dubious, to put it charitably. Also, with pre-meds being who they (we?) are, I’m skeptical that any dedicated “personality test” section on the MCAT would last more than a couple of years without being dissected, gamed, studied-for, and meaningless as a gauge of an applicant’s character.

If it’s personality that you want in your medical students, the MCAT is not how you’re going to sort them. If the AAMC wants to create standardized tools to help medical schools evaluate applicants without actually needing to interview them (as recommendation #14 seems to imply), then they should go for it. I would think, though, that different medical schools might want different types of students. A one-size-fits all assessment might not serve every school’s needs equally well.

If the MCAT is over-weighted in the admissions process, then the real issue is how it’s used, not what it tests. It’s also worth pointing out that as long as medical school deans care about their US News & World Report rankings, they will place non-trivial emphasis on their entering students’ MCAT scores. That’s a pretty big counterweight to any movement to increase the weighting of “personality” in medical school admissions.

(Briefly discussed later in this post: what personality traits do we want in all of our medical students, why do we want those traits, and are medical schools really being flooded with so many applicants who lack them?)

3) Medicine is about service, but it’s still an applied science.

A common theme in the reactions of some of my classmates (and Dr. Chen’s NY Times piece) is that the MCAT and/or the medical school admissions process is too heavily focused on mastery of science. (Did I mention that I was an Economics major?). While the science content of the MCAT could certainly stand to be tweaked, I would hesitate to write it off completely. It is still the best predictor of success in medical school (where “success” is “not failing out during the preclinical years”), and the only standardized means of comparing science ability across applicants. What has helped me get through the first year of medical school has not been my social science background (though it has helped). It’s been the solid science foundation that I got in undergrad alongside my economics coursework.

If students want to help others and save the world without needing to take those pesky, difficult science courses, there are plenty of other career options open to them. Medicine still requires comfort with science, and that is the reality that we’re stuck with for the foreseeable future.

(For more on why science should not be viewed as an “obstacle” to medical school admission, I urge you to consult the ever-worth-reading David Gorski at Science-Based Medicine).

3a) Barriers to entry to medicine should not be arbitrarily and artificially increased, but it’s worth pointing out that medicine is a field that requires dedication… or at least that’s what they told me.

This is a minor point, but an important one. In my cynical estimation, there are three sorts of people who would want to become practicing physicians in this day and age: the naive; the passionate; and the crazy. Medical training is a long and arduous process, and the practice of medicine in the US isn’t about to get easier in our lifetimes. If someone is discouraged from going into medicine because of the MCAT… what would they do when confronted with Step 1 of the USMLE? The MCAT isn’t a personality test and shouldn’t be used as one, but at the same time, my inner curmudgeon has to question the bona fides of those who claim they would go into medicine “but for the MCAT.” When my classmates tell me that these proposed changes will make the MCAT more accessible to students who otherwise wouldn’t have taken it, there is a part of me that wonders whether that is really an unalloyed good.

4) Is there another agenda at play here? (WARNING: SPECULATIVE)

Even as the debate goes on between social science upstarts and science purists, between those who think that “personality” is over- or under-represented as an admissions criterion, one could be forgiven for wondering what the fuss is all about.

Medical schools aren’t lacking for applicants. There isn’t, to my knowledge, an epidemic of death, destruction, bad outcomes, or other horrors brought about by physicians insufficiently knowledgeable about the social sciences. I doubt that most medical school graduates are uncaring, unsympathetic, offensive brutes.

The main “problem” with medical students today, as far as I can tell, is that too few of them are willing to go into primary care careers. At least… some people see it as a problem with the students. I don’t.

There’s been a lot of attention focused on the primary care shortage over the past few years, some of it focused on delivery reform (think ACOs and PCMHs), and some of it focused on supply (e.g. the medical students). One noteworthy report authored by the American Medical Association in 2007 intimated that the primary care shortage could be solved by finding medical students who are more “service-oriented” and “altruistic,” better able to “be advocates for [...] social justice,” and less “autonomous.” The report proposes including “social accountability issues” among admissions criteria.

Implicit in all of this is the assumption that the problem with the health care system, and the cause of the primary care shortage, is that we’re the wrong kinds of medical students. I’ve blogged about this report before, and why its premises and conclusions on this issue are utterly wrong; I don’t need to re-hash this here.

I can’t help but wonder how much of this line of thinking went into the recommended MCAT changes. No one — not the AAMC, not the many commentators whose responses I’ve read — has explicitly made this connection. But the rhetoric is the same. The implicit assumptions seem to be the same. The same misguided goals via the same misguided methods.

I hope I’m reading too much into things, but if not I can only despair at the solutions that organized medicine has found for our problems.

Heckuva cartel, eh?

The Wall Street Journal’s Health Blog had this to say on physician organizations’ proposals to Congress for longer-term solutions to the SGR mess:

 American Medical Association: Repeal the SGR, then “implement a five-year period of stable Medicare physician payments that keep pace with the growth in medical practice costs.” During that period, pilot “a new generation of payment models” (medical homes, for example), then transition to those that improve quality, care coordination and costs. The AMA also wants Medicare to permit balance billing — physicians charging Medicare beneficiaries for an amount above and beyond what the government program covers.

American Academy of Family Physicians: After SGR repeal, there would be a five-year transition to the patient-centered medical home. Primary-care physicians would receive a higher reimbursement rate than other specialties, and primary-care incentives included in the health-care overhaul law would be increased and extended.

American College of Surgeons: After SGR repeal, set a “realistic budget baseline” for future payment increases, ” which should “fairly reflect the costs of providing quality health care and are sufficient to preserve the patient-physician relationship and ensure patients have continued access to the physician of their choice.” During a five-year transition to different payment models,  reimbursement growth would vary by service.

To my surprise, it’s the AMA that’s on to a nugget of something good: allow balance billing. Not a perfect solution, but it could be a major step towards something sustainable in the long run.

Somewhat less surprising is the willingness of the AAFP to double-down on the model that’s already failed them for so many years. It’s unfortunate. If primary care is going to be attractive to people like my classmates and me, the pay will have to be better, and the job will have to be better. Living an even more bureaucratic work experience and making a living that continues to be at Congress’s mercy aren’t on any medical student’s wish list.

What you’ll find below the cut includes:

• A pamphlet, a bag, and some pens from Medical Protective, a professional liability insurance company owned by Berkshire Hathaway.
• A Merck Manual (yes, that Merck… the one that makes all these ”pharms” of which AMSA claims to be ”free”).
• Materials from various academies of quackery (as seen earlier).
• A pen, a magnet, and some other swag from the FDA.
• Application forms for various forms of insurance/consumer credit provided by or through AMSA.
• Some stuff from banks.
• Swag NOS.

Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).

The debate was something of an unfortunate affair. The topic was supposed to be about the PPACA, presumably with Cannon opposing it and Zarr favouring it. Of course, PNHP are no fans of the health reform bill either.

Mr. Cannon opened with a number of points clearly aimed at his audience: skeptical medical students (except for the one Cato fanboy sitting upfront). He presented reasons why we as (future) physicians should oppose the health reform bill:

1. Insurance expansion doesn’t always lead to health improvement; isn’t our goal health improvement? He cited data from the first 10 years of the Medicare program showing that it didn’t save a single life.
2. The PPACA won’t reduce costs, and won’t reduce the deficit, which will lead to more pain, more taxes, more brutal spending cuts in the future.
3. By increasing the amount of bureaucracy, especially government bureaucracy, the health reform bill will require future physicians to spend less time caring for patients and more time lobbying and advocating. (okay, this one may not have been well-tailored to the median audience member…)
4. If the mandate is found to be constitutional, so will any other government intrusion into areas that fall under the scope of the ever-expanding Commerce Clause.
5. When insurers tried to point out that the act would increase premiums, Secretary Sebelius, tasked with overseeing the thicket of insurance regulations to be written, told them not so subtlely to shut up. What would happen in a government-prone system if physicians tried to speak up?
6. Finally, he argued that the proposed Independent Payment and Advisory Board would substantially reduce the influence of physicians over health policy, and their own practices.

Dr. Zarr’s presentation seemed like a canned pro-single payer PowerPoint that he brought out in response to a speaking invitation. This led to him talking past many of the points that Mr. Cannon made. Now, I’ll be upfront and say that I don’t think that single-payer is a good idea for the US, least of all single-payer implemented on a national scale and overseen by the federal government. Though I may disagree with it, there is an intellectually honest and good-faith case to be made for it. Dr. Zarr did not make that case. His presentation was instead notable for a variety of misrepresentations and misinterpretations of data, peppered with the occasional false or naive statement. Even my pro-single payer classmates didn’t think much of his talk.

Here’s a sampling of some of the goofs he made:

• Implying that a long hospital length-of-stay is a goal unto itself (in comparing the US to countries with longer length-of-stay).
• Pretending that health care systems can be evaluated by looking at life expectancy at birth (a much better case could be made for life expectancy at 60 or 65).
• Getting the statistics on comparative out-of-pocket health care spending simply wrong. 
• Using a deceptive metric to compare Medicare to private insurance overhead. 
• Finally, as with AMSA’s health policy “leaders,” Dr. Zarr continually made the erroneous conflation of “single-payer” with “universal coverage.” At least now we know where AMSA’s PNHP acolytes get it from.

The subsequent presentation from PNHP was substantively better than Dr. Zarr’s bit, but not by much. At least this one was supposed to be about single-payer financing and delivery.

• Dr. Tsou lamented the fact that there is no “mission statement” or central control of health care spending. Someone might think he was begging the question, but then he was preaching to the choir.
• He framed the argument for single-payer as pro-business, pro-jobs, centrist, and patriotic. 
• When discussing the requirements for insurance plans sold on Obamacare exchanges, he completely confused actual vs. actuarial spending values. A minor quibble, perhaps, but something I would have hoped a professional financing reform activist would have grasped.
• According to Dr. Tsou, health IT (and electronic medical records in particular) will not work except within a single-payer framework.
• He made the assertion that in OECD countries with some private financing of health spending, “insurers act as the single payer.” The mental contortions necessary to utter that phrase did not manifest themselves physically.
• Stepping far outside his area of expertise, Dr. Tsou launched into a bizarre diatribe in which he lamented the loss of manufacturing jobs in the US, claiming that “a country that doesn’t produce things is a second-class country,” and that “jobs follow manufacturing.” My notes also indicate that something was said about textiles. Perhaps he thinks that more of us should have gone to work in the t-shirt factories instead of entering our chosen (service sector) profession?

Also of note, Ezra Klein gave the keynote speech between these two sessions. There’s no use in my noting what was said, given that he posted it the night before the talk. The Q&A, however, revealed a curious fascination with the Canadian health care system, and a whole lot of ignorance about how it works.

That said, rumours of my permanent e-demise (if they exist) have been greatly exaggerated. Nothing like upcoming finals to drive a medical student to blogging; what a better way to avoid studying?

And yes, to answer the question that inevitably arises with that last sentence, I will be a doctor one day.

More to come shortly.

The convention as a whole was intense and a lot of fun. It was definitely great to see a lot of people brought to this site by the AMSA coverage. I would encourage those first-time visitors to stick around for more. I can’t promise you’ll agree with everything you see here (I could probably promise the opposite for most of you), but I think you’ll find it thought-provoking and worthwhile.

Now… how long until AMSA 2012?

A: The quacks representatives of the Association of Accredited Naturopathic Medical Colleges.

That’s right… AMSA sold them a booth at the 2011 convention, to say nothing of the smattering of naturopathic students in attendance as participants.

AMSA won’t quite take pharm money (more on that tomorrow), but they have no problem selling out to pseudoscience (that term is far too generous).

I went up to the booth and feigned ignorance as to what naturopathy is. I was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” I pushed harder and harder, and for the longest time they continued to maintain that they’re “just like MD physicians.” Finally, one of their reps cracked, and poured forth the litany of quackery to which they subscribe: homeopathy, herbalism, acupuncture, therapeutic touch, and all sorts of other nonsense.

Fortunately, their written materials were more straightforward about their quackishness, though there were also some materials to recruit MD students for “integrative medicine” training at “Bastyr University“ in the Pacific Northwest (of course). Too bad they’re competing with AMSA’s own summer pseudoscience academy, whose flyers I also picked up.

For an organization that professes to support evidence-based medicine in other realms, and that ostensibly represents those students who are training to become applied scientists, this is really sad. The political gripes I might have with AMSA are one thing, but legitimizing quackery of this sort is truly beyond the pale. A poll of an unrepresentative convenience sample indicated that this is a non-partisan issue. “Open-mindedness” and “tolerance” are great, but when it comes to practices that don’t work, that mislead patients and that cast a pall on scientific medicine, organized medicine (AMSA included!) shouldn’t hesitate to take a stand.

If AMSA could be a forceful voice against pseudoscience much as they are a forceful voice for a variety of health policies with much less evidentiary support, they would be doing medicine, science, and patients a great service indeed.

***

I almost forgot, at the other end of the exhibition hall was the ayurvedic quack booth. I hope these pictures speak for themselves.

• They were surprisingly genial about specialists, and avoided playing the blame and recrimination game. This was welcoming and refreshing. Medicine is divided enough as it is.
• They count Nurse Practitioners and Physician Assistants as primary care providers. I would think that this undermines their cause slightly (“hey, if non-physicians can do the job…”), but I’m sure they have their reasons.
• I overheard one of the speakers talking to a student in the hallway after the main presentation. I caught a bit of their discussion about Qliance. They were both of the opinion that that sort of market-based, patient-centred model will be important to revitalizing primary care. The AAFP speaker was trying to cram the Qliance model into the “ACO” box, but hey… no one’s perfect. It’s great to see some of the professional societies recognize the need to get off the government-dependence gravy train before it derails completely.

Also of note was the following… special moment: one of the students in the audience objected strenuously to the speakers’ use of “industrial,” “corporate” terms like — wait for it! — “supply,” “demand,” “surplus.” He wanted to know how the sky would keep from falling so long as we keep referencing “that paradigm.”

Oy.

Turns out that it wasn’t quite what I was expecting. Silly me, expecting any sort of heterodoxy at an AMSA convention (besides the token non-liberal on one side of tomorrow’s policy debate).

I really wished that Dr. Wilder would have talked more about her business, Core Health and Wellness Centers. Aside from a throwaway mention of its $1 million+ profitability this year (treating mostly poor patients, at that!), and her lack of contempt for the wealthy, the talk was centered mostly on traditionally liberal conceptions of social justice (e.g. how the minimum wage ought to be higher, about how some have the temerity to claim that Medicaid might be associated with worse outcomes than uninsurance, how one might not want an all-mighty public sector union in Wisconsin, etc.).

Which is fine. Those are not unreasonable positions to hold, wrong though I may find them. What’s clear, however, is that Dr. Wilder does believe in an entrepreneurial manner of achieving the social justice goals that she advocates for. There was no mention of needing more grants, no mention of needing to beg government for more. At the end of the talk, she chided us not to be “robots” in “corporate (e.g. academic, government, managed care)” settings and instead to practice the sort of compassionate, patient-centred care we learn in medical school. That is an entrepreneurial vision. Unfortunately, when basic market principles and the idea of entrepreneurial are either foreign or anathema to many medical students here (see my Twitter feed for one egregious example), I would have been excited for her to take a stronger stand in favour of the market and entrepreneurial forces that she merely alluded to.

Unlike the conception of social justice that she shares with the majority here, those values (markets, entrepreneurialism) are in sore need of a strong defense at this conference. I can only do so much from the Internet!

Highlights from his talk:

• “Leadership is the practice of accepting responsibility for enabling others to achieve a common purpose under uncertainty.” [Perhaps the best definition I've ever encountered.]
• Raising “awareness” and starting “dialogue” are rarely useful in situations where different parties have different goals. [something that my generation seems to forget, with the ease of meaningless "awareness" campaigns limited by Facebook/Twitter accessibility]
• The cause of Wisconsin public-sector unions and Egypt’s popular uprising are meaningfully similar/equivalent. [ooookaaaaaay]
• Some of the reasons for the success of the American conservative movement in recent decades are their ability to organize at the grass-roots (e.g. the National Rifle Association), to clearly articulate their values and principles, and their persistence. The left is unable to consistently do this.

Right now: the common purpose of the conference attendees is lunch and swag, with great certainty. Lots, lots, lots of swag to be had. There will be photos.

The first talk of the morning was by a second-year medical student (Shahram Ahari, UC Davis)who spent some time as a sales rep for Eli Lilly after graduating from Rutgers. He went into sales because he thought it would be an opportunity to connect with clinicians at an intellectual level and discuss the science. Because that’s what a private-sector sales job is all about. Needless to say, he was somewhat disillusioned, especially upon finding that most of his salesforce colleagues weren’t scientists, but… salespeople. Go figure.

The presentation wasn’t irrationally hostile to pharm companies, though I might have caught the suggestion at the end that physicians have an “obligation” to vote the interests of their patients. He explained the many ways in which pharm sales people use the same techniques employed by salespeople in any industry: appeals to emotion backed up by data about the client that is never overtly mentioned.

The discussion was focused almost entirely on the prescriber-marketing interface; I was hoping for some evaluation of the appropriate nature of researcher-industry relationships, which is where (in my view) the controversy is much hotter. Nonetheless, it was an entertaining talk that explained the psychological basis behind all sorts of marketing techniques such as giving away free stuff…

Oh, right! Free stuff! AMSA might claim to be pharm-free, but a quick visit through their exhibition hall revealed a whole host of characters whose money AMSA was more than happy to accept in exchange for a booth. Some of these groups are more savoury than others.

Details to come… truly extraordinary.

Dr. Parenti:

• The 3% of the country who own 97% of the assets think that health insurance is a market in which to make money. The horrors! [capitalism is morally repugnant? not the most nuanced argument]
• The Gesundheit Institute [Patch Adams' facility] has never carried malpractice insurance and has never been sued. [Am I alone in thinking that there might be a causal relationship].
• The Gesundheit Institute is open to all sorts of “medicine:” homeopathy, naturopathy, ayurveda, reiki, and a few others I’ve never heard of.

Dr. Adams

• “Depression is not a mental illness. It is a pharmaceutical company diagnosis. Depression is simply a symptom of loneliness.”
• One of the scariest phrases in the world: “AMSA could lead the way on…”

Inspiration is easily muted by unrelated fringe beliefs. Would that the audience have been more critical.