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Cavalcade of Risk #123: Exam Season

January 25, 2011 7 comments

 

After the initial enthusiasm of the start of medical school fades away, as excitement for the distant future is replaced with the quotidian routine of classes, lab, and review sessions, the realization finally settles in: we’re, um, expected to know all of this?

Most students at medical schools across the country respond to this challenge in the same way, living their lives by a simple, two-word credo that serves to guide their acquisition of knowledge. While I can’t say I show the same fervent devotion to it that many others do, it’s indisputably a part of medical school culture, and is certainly a useful mindset to have when it comes time to study for exams. It is in celebration of that spirit that I present to you today:


Cavalcade of Risk #123:  High-Yield Edition


The Basics


Risks and probabilities are important aspects of clinical medicine. How well are medical schools teaching future doctors to process statistics and other research information from the clinical literature? What does it mean for the quality of future physicians? Jin Packard, a New York Medical College student blogging at Low-Yield Med, draws from his own experiences to argue that the level of training is “nothing shy of a disgrace.” I went one step further and called it a straight-up failure.

Darwin of Darwin’s Money brings us back to the basics, with a clear, concise explanation of how to compare sums of money across time (i.e. “present value” and “future value”). A dollar today is worth more than a dollar in 10 years. Darwin explains the “how” and “why.” Understanding this sort of calculation, and the sorts of assumptions embedded in it, is integral to understanding so much of finance, insurance, and economics. This is a great post to use to learn it, or for a quick refresher.


Health Insurance

Jeff Rose, blogging at Good Financial Cents, features a guest post summarizing the major changes to health-related Flexible Spending Accounts that took effect at the beginning of the New Year. The highlights are the need to get prescriptions for OTC drugs, restrictions on what kinds of stores can accept FSA debit cards, and higher penalties for breaking the rules. All in all, it’s become much more difficult to use FSA money to pay for over-the-counter medications and other health expenses.

Closing out an “ACO ‘orgy week’ of postings” (his words, not mine!) at the Disease Management Care Blog, Dr. Jaan Sidorov takes a look at a recent Medicare demo of these new-fangled, orgiastic Accountable Care Organizations. While, as he says, “ACOs are arguably the only good long term answer to controlling costs, reportedly by making doctors and hospitals play nice with each other and participate in downstream savings,” he wonders why “they, compared to managed care insurers, any less likely to withhold costly care.”

Louise, blogging at Colorado Health Insurance Insider, discusses the proposal by a Colorado legislator to remove the cap on tax-deductible contributions to Health Savings Accounts in the name of sensible health reform. She argues that while this would be a boon to higher-income families who could thus contribute more money to HSAs (and thus shelter more income from taxes), it would do nothing to expand access to health care for those at lower ends of the income scale.

There are consumer protections, and then there are consumer protections. I point out an unusual pair of health policy stories from the past week: on one hand, PPACA supporters warning Republicans not to mess with the new law’s “consumer protections”; on the other hand, healthcare lawyers pointing out that for the law’s vaunted ACOs to have a decent chance of success, many existing “consumer protections” in healthcare may have to be gutted. I ask what the juxtaposition of these two implies about the moral necessity of the healthcare regulatory apparatus as a whole.


Other Insurance

Ryan at CashMoneyLife provides a quick, easy-to-digest rundown on life and viatical settlements, with attention paid to the risks and benefits for both buyers and sellers of life insurance policies in these transaction. These settlements allow life insurance policyholders to “cash out” some fraction of the policy’s face value, and investors to (maybe) make a profit when the policy pays off. Ultimately, while acknowledging that they are not evil and have their roles to play in the insurance marketplace, he concludes that these certainly “aren’t right for the majority of people out there.”

Free Money Finance touts the merits of umbrella insurance policies: they’re relatively inexpensive for the coverage that you get; and that coverage can come in really handy when one lawsuit could be all it takes to exhaust the coverage that your home and auto policies provide. As he points out, “even if your assets are low, your future earnings are probably not,” and both are fair game in a lawsuit.

Hank Stern of InsureBlog fame dissects some finance/insurance “wisdom” posted at an AOL personal finance website. He wasn’t too impressed with their list of “Seven Insurance Policies That Aren’t Worth The Money,” finding that there wasn’t much “profound wisdom to be had.” It’s worth remembering the need to keep your wits about you when reading financial advice on the Internet… or anywhere else, for that matter.

The Digerati Life makes the case that consumers should generally avoid buying the type of insurance that they’re most often offered: extended warranty programs. They’re often costly, and may duplicate coverage provided by your credit card. The proposed alternative is to save the money that would have been spent on these warranties as a personal “warranty fund” of sorts.


Non-insurance risk management

While prognostications about financial markets are dime-a-dozen, some of them still make for interesting reads. This interview with a Canadian asset manager, conducted by Arjun Rudra and posted at InvestingThesis, is one of them. The discussion touches upon prospects for gold, the likelihood that QE2 will succeed, interest rates, emerging markets, and the Canadian dollar (with a bearish outlook on most of these).

Circumcision has been shown to dramatically reduce the risk of males contracting HIV from heterosexual sex. The government of Swaziland has begun a mass circumcision campaign in the hopes of reducing HIV incidence. Jason Shafrin, the Healthcare Economist, discusses why such an effort might actually increase HIV incidence: moral hazard.

At some point afterI grow up and become a doctor, I will be sued. When that happens, I want a defence like the one described (with illustrations) by David Williams at the Health Business Blog. A patient died shortly after an operation to replace a stenosed bicusoid aortic valve. The plaintiff argued that the operation was performed improperly, and that the replacement valve chosen was of an incorrect size. The defence argued the opposite, supported by the visual aids that David has posted, and obtained a verdict in their favour.

Julie Ferguson of Workers Comp Insider sends along a wreck of a video (literally) accompanied by advice for truck operators looking to avoid mismatches between the height of their vehicle and the clearance of that rapidly-approaching underpass. Along with the usual advice to plan your route and heed signage about clearance, it’s also recommended to check in advance with local/state departments of transportation for information about low underpasses… a source of information that many people (myself included) might not think of.


Content, NOS

It was a pleasure and an honour to host this edition of the Cavalcade of Risk! Now that you’re done with the best risk-related blog posts of the past fortnight, I’d like to invite you to poke around the rest of The Notwithstanding Blog, home to tales from medical school, health policy analysis, critiques of the academic medical zeitgeist, and the occasional bonus Canadiana. I think you’ll like what you see!

***

The next edition of Cavalcade of Risk will be hosted by Dr. Sidorov on February 9th.

Around the Mediverse: July 26, 2010

July 26, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • It turns out that one of the authors of the oft-cited research behind all the improbable claims about medical bankruptcies is none other than Consumer Financial Protection Agency leadership nominee Elizabeth Warren.  In two posts about two different pieces of her scholarship, Megan McArdle points out that nominee Warren’s relationship with … facts?  statistics?  economic reality? … can be tenuous.  Not the greatest news.  In another post sure to rile up the academic crowd, McArdle also advances an argument for the uselessness of tenure in the university environment.
  • Great Zs asks what happens when doctors adopt an “employee mentality” to the same degree as other healthcare workers.  Coyote explains the “employer mentality” behind the use of FICO scores in hiring decisions.

Around the Mediverse: July 8, 2010

July 8, 2010 3 comments

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • Some questions have emerged about Supreme Court nominee Elena Kagan.  Reason asks if she would ban books.  Bloggers at the Volokh Conspiracy touch on what is arguably Kagan’s political manipulation of a medical specialty society’s statement on abortion.  It should be said that the American College of Obstetrics and Gynecology comes out looking worse than the nominee.
  • Though the response to the Deepwater Horizon spill has arguably been insufficiently aggressive, here are two commentators who argue that children should be taught to better express and receive aggression.
  • What is a “scientific consensus?”  Reason’s Ronald Bailey takes on this issue.  Along the way, we stumble onto this gem of a web page explaining the relationship between animal models of carcinogenic toxicity and the actual exposure of humans to those substances.  Much more non-technical than I made it sound.  Do give it a read if only to attenuate your own “cancer panic” over some of those chemicals.
  • David Williams at the Health Business Blog reminds everyone that hospital visits should be BYOMD.
  • Two recent guest posts at KevinMD point out that the concept of the patient-centered medical home is probably way overhyped, given the current evidence “for” it.

Around the Mediverse: June 28, 2010

June 28, 2010 Leave a comment

The unusual delay since the last edition of “Around the Mediverse” means that this one features a higher-than-normal number of…

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • On the subject of evidence, Hit & Run discusses scientific denialism of both left- and right-wing political flavours.
  • The Placebo Journal Blog points out that government programs that enlist others to root out physician wrongdoing promise monetary rewards and bounties, whereas a new program that enlists physicians to root out drug company wrongdoing promises to pay whistleblowers… well, you’ll see.
  • Greg Mankiw reports that some Japanese men are too sexy for their equities, too sexy for commodities, too sexy for corporates… oh yeah…
  • Buy your own journalist!  Well, not really.  More like targeted micro-charity for investigative reporting.  I like this model better than the FTC’s.
  • What would “Around the Mediverse” be without a tale of ridiculous litigation?  The propofol litigation, however, could have real adverse consequences for those patients needing anesthesia now that one of its manufacturers has withdrawn from the US market.  See Great Zs, Overlawyered, and Skeptical OB for details.
  • Dr. Wes discusses some of the often-overlooked biases inherent to the way medical research is conducted, and what it might mean for the wide applicability of results.
  • MLRs, what are they good for?  David Williams and Reason have interesting, unorthodox takes on the question.
  • Rounding out this week’s selection, Dr. Rich has an unorthodox take on a hot-button issue… this one being the appropriate nature of the relationship between physicians and pharmaceutical companies.  It’s a perspective that I haven’t seen well-elucidated elsewhere, so it’s well worth reading the full thing.

Around the Mediverse: May 7, 2010

May 8, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • I like the idea of “concierge” medicine, even though there are many vocal opponents of the concept.  I reject their argument that it is necessarily something that will limit itself to the richest and best-off in society.  I present to you PartnerMD and Qliance.  Much more has been written on Qliance here, here, and here.
  • The Volokh Conspiracy had a series of eloquent posts on Harvard Law School’s Emailgate, all to be found here.
  • Economists like to say that their field is a science.  There’s some legitimate disagreement on that point.  There really shouldn’t be any such debate about the nature of such things as homeopathy and the anti-vaccine movement.  It’s unfortunate that there still is.  Megan McArdle discusses homeopathic WMDs in the first link, and Science-Based Medicine answers all of your anti-vaccine loaded questions in the second.
  • There’s been a lot of anger directed at Wall Street recently.  Someone there decided to direct a little bit back to the rest of us.  Enjoy!
  • Maggie Mahar at Health Beat Blog argues that our society is suffering from “cancerphobia” and an accompanying “epidemic of diagnosis.”  If I weren’t already persuaded of these points, this would have convinced me.
  • There’s always a lot of talk about Medicare and Medicaid, but this past week brought us talk from CMS.  Health Affairs conducted a roundtable discussion with past heads of CMS.  The transcript is fascinating; the conversation touches on political and funding dynamics within the agency and department, the mechanics of anti-fraud activities, the implementation of reform, how physicians were ignored, and how Don Berwick will fit within the agency.  From the CMS of the present, we get the Chief Actuary’s report on the PPACA, summarized by John Goodman.  It really does not look pretty.
  • InsureBlog discusses the travails of a health insurer offering a so-called 100% HSA/HDHP.  I have to wonder, from an economics point of view, whether people will be more judicious in their spending even though the money originally came from someone else (i.e. their HSA was topped up for them).  Endowment effects and whatnot.  If that is the case, and if the insurer can get the premium right to reflect the relative injudiciousness relative to “true” out-of-pocket spending, then this model could be a very real alternative to the current mainstream of first-dollar medical coverage.

Around the Mediverse: April 28, 2010

April 28, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • Going back to the subject of Congressional hearings, two bloggers at the Economist explain why Goldman Sachs and the financial services industry generally aren’t as evil as people seem to want them to be.
  • There’s been a lot of talk about reforming physician pay and medical organization, but not a lot of emphasis on new and innovative models of health insurance provision.  (As I discuss in this post, the PPACA will probably do more to ossify the present state of health insurance than anything else)  That’s why this post from the Health Business Blog, highlighting a value-based, market-oriented, real insurance offering in Fresno, CA is so heartening.
  • WhiteCoat brings us the story of a case in which a physician was sued, and settled, for malpractice.  It sounds pretty vanilla until you read that the physician was out of the country at the time the alleged malpractice was committed by a supervisee midwife who failed to contact the physician covering for the one who got sued.  Malpractice affects physician behaviour through fear more than it does through changing actual risk.  With stories like these, is it any wonder that the fear is still there?  Also on the subject of lawsuits is this post by Amy Tuteur that suggests liability concerns as a major driver of increases in C-section rates.
  • Scott Greenfield at Simple Justice is probably my favourite lawyer I’ve never met.  Two of his posts from this past month, taken together, explain the reasons for my own discomfort with the way the victims’ rights movement is playing out in the US and Canada.
  • Jason Shafrin at Healthcare Economist has made some pretty pie charts detailing the breakdown of Medicare and Medicaid expenditures on categories such as physicians, hospitals, drugs, etc.  While I knew intuitively that physicians constitute a small piece of the pie, it was still surprising to see it represented visually.  It also suggests a way to win over skeptics of various payment reforms:  if, as it seems, much of the cost of certain types of physician care is incurred downstream (as opposed to fees paid to the physician), then payment reform that seeks to lower overall costs by changing incentives should also be able to guarantee higher income for those types of physicians.  Call it gainsharing, maybe?

You’ll also notice that A Cartoon Guide to Becoming a Doctor has been added to my blogroll and to the links on the sidebar.  If you’re looking for more visual stimulation from your medblog collection, that’s a fantastic place to get it!

Around the Mediverse: April 21, 2010

April 21, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • Edwin Leap discusses one of the frequently ignored drivers of Emergency Department use:  other physicians.  To be fair, most of those other physicians would probably cite liability concerns, and most of those could do so legitimately.   Still, it’s something to keep in mind when looking at ED utilization patterns.
  • Megan McArdle and the WSJ Health Blog discuss the recent moves by some health insurers to reclassify expenses to satisfy new rules requiring minimum medical-loss ratios.  In my view, things like nursing hotlines and wellness programs are “medical” expenses moreso than “administrative,” but reasonable people disagree.
  • John Tierney gives us “7 New Rules to Live By” for Earth Day, demolishing pervasive myths about organic food, GMOs, and nuclear power.  I’ve been harping on about these for the last couple of years (especially the first two) to anyone who would listen, so it’s gratifying to see that my views on the issues aren’t completely crazy.
  • Coyote brings us an example of a proponent for creating another of my least favourite types of “rights:”  positive rights to someone else’s goods or labour.  In this case, the “right” being bandied about is an alleged “positive right to travel.”  The comment was made at a conference with no direct policy implications, but the existence of that thought at the higher levels of EU is terrifying (but unsurprising).

Also of note is the addition of Bittersweet Medicine, a relatively new addition to the mediverse, to the list of blogs that I follow and to the links over to your right.  Of immediate interest is the series on overrated medications (for instance, statins).  Hopefully there will be more of those in the future!

Around the Mediverse: April 14, 2010

April 14, 2010 1 comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • A letter to the editor of The Economist tells that “[t]he so-called precautionary principle is, in the words of risk-expert Bill Durodié, “an invitation to those without evidence, expertise or authority, to shape and influence political debates. It achieves that by introducing supposedly ethical or environmental elements into the process of scientific, corporate and governmental decision-making.”
  • Bob Centor points out that increasing medical school enrollment won’t be enough to solve projected future shortages of physicians, especially in primary care.  He looks at increasing the number of primary care residency slots and improving pay for primary care physicians and residents.  I would argue that this might not even go far enough:  if the slots are there, who’s to say they’ll be taken unless the job gets much better than it is now?
  • Eugene Volokh tells of litigation that arose after an accident victim was mistaken as dead many, many, many times.  I’m not one to second-guess decisions made under tricky circumstances (well, maybe I am), and I’m all for reducing “unnecessary medical tests” (whatever those are), but can it really hurt to double-check the pulse?
  • An alternate take on schizophrenia from a behaviourist perspective, entitled “Schizophrenia Is Not An Illness.”  Provocative?  To someone like me with only limited exposure to “traditional” approaches to mental illness, yes.  The three-part series makes some interesting points and is well worth the read.
  • In 1964, President Lyndon Johnson placed an order for new pants.  The tape and transcript of the phone call are … quite something.  Be warned that LBJ uses graphic language to describe the desired specifications of the pants being ordered.  He also belches without saying “excuse me,” and admits to carrying a knife to work.
  • A lot of health care revolves around providing reassurance and peace of mind (kinda like real insurance is supposed to, but that’s another topic for another day).  Sometimes that’s for the patient’s benefit and sometimes for the physician’s.  Oftentimes, it’s for both.  Of course, peace of mind can be an expensive thing to come by.   This story from ACP Internist illustrates this perfectly.
  • There exists a jurisdiction not too far from Florida that has recently imposed a health insurance mandate on some of the people present there.  Those subject to the mandate who don’t already have insurance will have to buy a product that doesn’t cover pre-existing conditions and features payout caps.  Guess where this is, I challenge you!
  • Don’t believe everything you read online, even from a somewhat-reputable source.  This is especially true when it’s AOL recommending “medical tests that could save your life.”  Or not.
  • Reason explains, in graphical form, a subject near and dear to my heart:  US immigration law.
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