The Accad and Koka Report

By Michel Accad and Anish Koka

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The podcast that makes sense of health care

Episode Date
Ep. 50 Thieves of Virtue: How Bioethics Stole Medicine
Did bioethics emerge to defend the interests of patients or to rationalize the needs and actions of the state and its corporate allies?  Are bioethicists too complacent about their grasp of economics?  Do they have sufficient understanding of the complexities of medical decisions to weigh in on them? Are Hippocratic ethics so inadequate that they needed to be replaced by ever-morphing "Kantian" ethics?  A fascinating discussion with our guest, Tom Koch, a man whose resumé and whose many books read like great adventure stories. Professor Koch is an author, journalist, historian, philosopher, and educator. He holds an inter-disciplinary PhD in medical cartography, ethics and medicine  He has taught medical ethics to medical students at the University of Toronto.  He is a consultant in gerontology.  And he has written numerous books both for an academic audience as well as for the general public.  His books include Cartographies of Disease, Ethics in Everyday Places, The Wreck of the William Brown, and the volume that will be the focus of our discussion today, Thieves of Virtue: When Bioethics Stole Medicine. GUEST: Tom Koch, PhD.  Website LINKS: Tom Koch.  Thieves of Virtue: When Bioethics Stole Medicine.  MIT Press. 2011 (Amazon link) Tom Koch. Ethics in Everyday Places: Mapping Moral Stress, Distress, and Injury.  MIT Press. 2017 (Amazon Link) RELATED EPISODES: Ep. 29 Why Hippocrates Still Matters WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Dec 13, 2018
Ep. 49 Why Are We Insuring Primary Care? Lee Gross on the DPC Movement
"We're not going to ask permission to take care of our patients."  It is with this epiphany, that our guest on this episode became one of the pioneers and leaders of the most hopeful trend in health care today: the direct primary care or DPC movement. Dr. Gross shares with us how the light bulb went off in his mind that there is no good reason to insure primary care and, in fact, that insuring primary care hurts everybody: patients, doctors, and society.  He walks us through his success stories and the efforts he is leading at the state and federal level to remove regulatory barriers to direct care. Dr. Gross is the founder of Epiphany Health in North Port, FL, and is regularly consulted by lawmakers at the local, state, and national level.  He has offered testimony on behalf of the direct care movement for the US Health and Human Services Department, the US Congress, and for the White House.  He also serves as president of the Docs 4 Patient Care Foundation and he is the recipient of the 2016 HCA Frist’s Humanitarian Award and of the Beacon Award from the Free Market Medical Association for his leadership in healthcare reform. GUEST: Lee Gross, MD.  Twitter LINKS: Lee Gross.  Direct Primary Care Can Rein In America's Out-of-Control Healthcare Costs (in the Washington Examiner) Epiphany Health: Dr. Gross' practice website Doc 4 Patient Care Foundation's website US Department of Health and Human Services.  Reforming America's Healthcare System Through Choice and Competition (Report) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Dec 09, 2018
Ep. 48 Many Statisticians, Many Answers: The Methodological Factor in the Replication Crisis
In 550 BC, the Greek philosopher Heraclitus famously declared: “No man ever steps in the same river twice, for it's not the same river and he's not the same man.”  In this episode, we learn from our guest whether scientists can step into the same data pool and obtain the same research results twice. Brian Nosek is Professor of Psychology at the University of Virginia.  He is also the co-founder and Executive Director of the Center for Open Science, an organization dedicated to fostering transparency and collaboration in scientific research. In 2015, Professor Nosek and his team published in the journal Science a widely acclaimed and widely discussed paper that shed light on the extent to which psychological research findings may not be reproducible when the research is conducted anew. More recently, his Center conducted a unique project where a single data set was sent to be analyzed by about 30 independent teams of statisticians for the purpose of answering a single question.  The variability in the methods chosen and in the answers obtained was also perhaps sobering, if not perplexing. GUEST: Brian Nosek, PhD.  Profile and Twitter LINKS: Silberzahn R, Uhlmann EL, Martin DP et al. Many analysts, one dataset: Making transparent how variations in analytical choices affect results. (2018, Advances in Methods and Science in Psychological Research, open access pre-print here) Klein RA, Vianello M, Hasselman F, et al.  Many Labs 2: Investigating Variation in Replicability Across Sample and Setting. (2018, open access pre-print here) Open Science Collaboration. Estimating the reproducibility of psychological science. (2015 in Science, open access here) WATCH ON YOUTUBE: There is no video available for this episode.
Dec 04, 2018
Ep. 47 Drug Dosing: One Size Does Not Fit All
Patients come in all sizes and shapes, and with varying tolerance for complications and risk.  Is it plausible that a single dosing regimen can optimize treatment for everybody?  If not, what is keeping the pharmaceutical industry from endorsing a more dynamic and patient-centered drug dosing regimen? Our guest is Dr. David Norris, a physician, mathematician, and inventor.  David operates a scientific and statistical consultancy focused on methodology development for ‎precision-medicine applications. He developed Dose Titration Algorithm Tuning (DTAT), a methodological framework that conceives dose individualization as a seamless learning process, beginning in early-phase trials and continuing throughout the drug development process.  Before earning his M.D. at Brown University, he worked in diverse application areas including mathematical finance, operations research and systems engineering. GUEST: David C. Norris, MD.  Patreon and Twitter LINKS: Norris DC. Dose Titration Algorithm Tuning (DTAT) should supersede ‘the’ Maximum Tolerated Dose (MTD) in oncology dose-finding trials. F1000Research. 2017 (open access) Norris DC. One-size-fits-all dosing in oncology wastes money, innovation and lives. Drug Discovery Today. 2018 (open access) Norris DC. Precautionary Coherence Unravels Dose Escalation Designs. bioRxiv. 2017 (open access)  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 30, 2018
Ep. 46 Reforming Medical Education: Beyond the Usual Platitudes
The reform of medical education is a usually boring conversation that needs its own reform.  The discussion we have on this episode does just that.  It goes far beyond the usual proposals to tweak the curriculum and directly addresses the question of what it means to be a physician. Our guest is Dr. Adam Cifu, an award-winning medical educator and author.  Dr. Cifu is a Master in the Academy of Distinguished Medical Educators at The University of Chicago.  He has been selected as a Favorite Faculty Member by the graduating class of students 14 times.  He is the author of Symptom to Diagnosis a manual on diagnostic reasoning, and co-author with Dr. Vinay Prasad of Ending Medical Reversal: Improving Outcomes, Saving Lives, one of the blockbuster medical books of the last few years. GUEST: Adam Cifu, MD.  University of Chicago website and Twitter LINKS: Scott Stern and Adam Cifu, Symptom to Diagnosis: An Evidence-Based Guide (Amazon link) Vinay Prasad and Adam Cifu, Ending Medical Reversals: Improving Outcomes, Saving Lives (Amazon link) Michel Accad. Intolerable Laissez-Faire: The Early Years of the Mayo Clinic (Alert and Oriented blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 27, 2018
Ep. 45 Brain Death at the Bedside
We revisit the question of brain death, this time with a more practical focus.  What should doctors tell families of patients who fulfill neurological criteria for brain death?  Joining us on this program is Fred Rincon, MD, who is a Assistant Professor of Neurology at Jefferson University Medical Center in Philadelphia.  Dr. Rincon is a neuro-intensivist who, on a day-to-day basis, cares for patients with severe brain injury.  He also holds a Master's in Bioethics from the University of Pennsylvania. GUEST: Fred Rincon. Professional Website LINKS: Michel Accad.  Of Wholes and Parts: A Thomistic Refutation of Brain Death.  (Open Access, Linacre Quarterly) RELATED EPISODE: Ep. 35 Why Brain Dead Isn't Dead: An Introduction to Shewmon's Challenge  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 22, 2018
Ep. 44 Economic vs. Political Means to Healthcare: A Conversation with Jeff Deist
Economic knowledge should not be the sole province of technical experts, but it is—and we seem to accept the way it is.  The price we pay for this ignorance is that most people—including doctors—can easily fall prey to the political class and to the technocrats whose economic theory is generally far from sound. Our guest on the show is Jeff Deist, President the Mises Institute, an educational institution that promotes a very noble tradition of economic theory and political thought.  Prior to taking the helm of the Mises Institute, Mr. Deist was chief of staff to Congressman Ron Paul for many years and, in that capacity, gained special insights into healthcare "sausage-making" in Washington DC. GUEST: Jeff Deist. Mises Institute Website, Twitter and Podcast LINKS: Michel Accad.  Undue Aggregation Isn't Just for Economists. (Mises Institute Blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 18, 2018
Ep. 43 Doctors and Guns: Where Is the Lane?
Should doctors have something to say about guns?  If so, what should they say?  A position paper by the American College of Physicians, followed by a blog post and a tweet from the National Rifle Association, have set off a storm of controversy on the issue of medical professionals speaking publicly about guns and gun control. Our guest today is Pradheep Shanker, a radiologist based in Ohio and a prolific writer and conservative commentator who contributes regularly to a number of major national media outlets, including National Review, The American Spectator, Ricochet, and others.  He just published a piece entitled "Guns, Doctors, and Staying in Your Lane.” GUEST: Pradheep Shanker, MD. Twitter LINKS: Pradheep Shanker.  Doctors, Guns, and Staying in Your Lane.  (article in Ricochet) Reducing Firearms Injuries and Death in the United States: A Position Paper from the American College of Physicians (free access in Annals of Internal Medicine) NRA blog.  Surprise: Physician Group Rehashes Same Tired Gun Control Policies  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 15, 2018
Ep. 42 The Tyranny of Metrics: A Historian Weighs In
Bureaucratic appeal to measurement as a check on personal judgment rules the medical field but also permeates our entire culture.  Our guest is the author of a new book that comprehensively treats this unique phenomenon of modern life and brings a valuable historical perspective to the subject. Jerry Z. Muller is Professor of History at Catholic University of America in Washington DC, where he served as Chairman of the department from 2009 to 2015.  Professor Muller’s focus is on Modern European Intellectual History and History of Capitalism.  His book, The Tyranny of Metrics, was published earlier this year by Princeton University Press. GUEST: Jerry Z. Muller, PhD. Professional Website and  Twitter LINKS: The Tyranny of Metrics (Amazon)  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 12, 2018
Ep. 41 Healthcare Policy in the Crosshairs: The Hospital Readmissions Reduction Program
The Hospital Readmission Reduction Program is a recent policy designed to save the government money by imposing large financial penalties on hospitals whose readmission rates for certain medical conditions are found to be higher than the national average.  Could pushing policy levers on such a grand scale conceivably have negative unintended consequences?... Our guest is Dr. Ankur Gupta, author of a 2017 JAMA article that examined mortality rates in heart failure in the aftermath of the HRRP development and implementation.  Dr. Gupta is an interventional cardiology fellow at University of Texas Southwestern Medical Center in Dallas.  He holds and MD from the All India Institute of Medical Sciences (New Delhi) and an interdisciplinary PhD in statistics and computational fluid dynamics from the University of Alabama. GUEST: Ankur Gupta, MD.  Twitter LINKS: Gupta A, Allen LA, Bhatt Deepak, et al.  Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure. (Open Access in JAMA, 2017) Gupta A, Fonarow G.  The Hospital Readmission Reduction Program: Evidence for Harm. (in JACC: Heart Failure 2018) Khera R, Dhamarajan K, Wang Yonfei, et al.  Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia.  (Article from Dr. Krumholz's group in JAMA 2018, Open Access) Khera R, Dhamarajan K, Krumholz H. Rising mortality in patients with Heart Failure in the United States. (Counterpoint to Dr. Gupta's analysis in JACC: Heart Failure 2018)  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 08, 2018
Ep. 40 Practicing Medicine in Canada: Promises and Realities
What's the professional life of Canadian doctors really like?  Does the safety and stability of a single-payer system free them from business concerns and allow them to concentrate on patient care?  Or do the realities of central planning produce unexpected uncertainty and stress for patients and doctors alike? To help us gain a realistic understanding of the Canadian system, we have as our guest Dr. Shawn Whatley who currently runs a primary care practice in Ontario, Canada.  Prior to this position, Dr. Whatley worked for many years as an emergency physician and he is the author of No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments. Dr. Whatley is past-president of the Ontario Medical Association and he is a senior fellow at the MacDonald-Laurier Institute for Public Policy in Toronto.  He also publishes a highly trafficked blog where he shares insightful and humorous comments about healthcare in Ontario.  In other words, he is the perfect guest to inform us about the realities of healthcare in Canada. GUEST: Shawn Whatley, MD.  Blog and Twitter BOOK: Shawn Whatley.  No More Lethal Waits: 10 Steps to Transform Canada's Emergency Departments (Amazon) LINKS: Milton Friedman at the Mayo Clinic speaks on Free Markets in Healthcare (YouTube, 9 minutes) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Nov 03, 2018
Ep. 39 Freedom of speech regained: How NIFLA v. Becerra could impact medical practice
A recent US Supreme Court decision has struck down the "professional speech doctrine" which was elaborated by lower courts to justify restricting or regulating the activities of anyone offering advice or counsel to another individual.  This decision may have far reaching implications across a number of human activities, including health care. To help us understand this decision and what effects it might have, we have as our guest Mr. Paul Sherman, senior attorney at the Institute for Justice and an expert in constitutional cases protecting the First Amendment, economic liberty, property rights and other individual liberties. GUEST: Paul Sherman.  Website and Twitter LINKS: Paul Sherman. Occupational Speech and the First Amendment. (Free access in Harvard Law Review) Paul Sherman and Robert McNamara. NIFLA v. Becerra: A Seismic Decision Protecting Occupational Speech. (free access in Cato Supreme Court Review) Parmet WE, Berman ML, and Simth JA.  The Supreme Court’s Crisis Pregnancy Center Case — Implications for Health Law.  (Open Access in New England Journal of Medicine) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 29, 2018
Ep. 38 Sally Pipes: The case against single-payer healthcare
Support for a single-payer healthcare system in the United States seems to be growing inexorably.  Before we resign ourselves to the inevitable fate of "Medicare-4-All," it may be prudent to remind ourselves or understand better the arguments against a single-payer system Our guest on this episode is Sally Pipes, president and CEO of the Pacific Research Institute, a San Francisco-based think tank dedicated to promoting free market principles across a variety of fields, including education, health care, and the environment.  Ms. Pipes is widely published on healthcare issues and a regular contributor to GUEST: Sally Pipes.  Website and Twitter LINKS: Sally Pipes. The False Promise of Single-Payer Health Care (Amazon) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 25, 2018
Ep. 37 Hospital sham peer review: what doctors need to know
Peer review by colleagues is an important process by which doctors who misbehave or malpractice can be held accountable and, if necessary, prevented from harming patients.  Unfortunately, the process can also be used in bad faith, and many physicians are completely unaware of how career-destroying traps can be set up under the guise of peer review, compromising even the most caring and competent of doctors. Our guest is Lawrence R. Huntoon, MD, PhD, a world expert on the topic of "sham" peer review.  Dr. Huntoon is editor-in-chief of the Journal of the Association of American Physicians and Surgeons and he leads the organization's Committee to Combat Sham Peer Review. GUEST: Lawrence R. Huntoon, MD, PhD LINKS: Sham Peer Review: Resources for Physicians (Association of American Physicians and Surgeons, includes Physician's Hot Line) Articles by Dr. Huntoon: Abuse of the “Disruptive Physician” Clause (2004) Sham Peer Review and the Courts (2006) Sham Peer Review: the Poliner Verdict (2006) The Psychology of Sham Peer Review (2007) Sham Peer Review: the Unjust “Objective Test” (2007) Sham Peer Review: The Fifth Circuit Poliner Decision (2008) The Insulting Physician “Code of Conduct” (2008) Tactics Characteristic of Sham Peer Review (2009) Sham Peer Review: Disaster Preparedness and Defense (2011) Sham Peer Review: Recognizing Possible Early Warning Signs (2011) Sham Peer Review: Abuse of the P.U.L.S.E. Survey (2012) Sham Peer Review: The Psychology of Obedience and Social Influence (2012) Retaliation Against Physician Whistleblower: the Shocking Case of Dr. Michael Fitzgibbons (2013) Sham Peer Review: New Tactics and Pitfalls for Employed/Exclusively Contracted Physicians (2015) Sham Peer Review: the Shocking Story of Raymond A. Long, M.D. (2015) Sham Peer Review: Outrageous and Unjustified Immunity (2015) Sham Peer Review and the National Practitioner Data Bank (2017) Risk Factors for Sham Peer Review (2018) Sham Peer Review: Violations of Due Process and Fundamental Fairness (2018)  WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 20, 2018
Ep. 36 Conversation with a clinical trialist
The life of a clinical trialist involves juggling multiple demands.  Beyond the purely scientific questions are the clinical interests of the patient and the personal demands on the physician. Our guest on this episode is Ajay Kirtane, MD, Associate Professor of Medicine at Columbia University Medical Center in New York.  In this conversation with Anish Koka, Dr. Kirtane shares his professional journey and his perspective on one of the most surprising and hopeful clinical trials in recent times, the COAPT trial of mitral valve repair in patients with congestive heart failure. GUEST: Ajay Kirtane, MD.  Website and Twitter LINKS: Stone G, et al.  Transcatheter mitral valve repair in patients with heart failure. (in New England Journal of Medicine, 2018) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 16, 2018
Ep. 35 Why brain dead isn’t dead: An introduction to “Shewmon’s Challenge”
One of the most fundamental questions that a doctor may be asked to answer is the following:  Is this man or is that woman dead?  And one would think that any substantial controversy regarding the determination of death would feature prominently in the medical curriculum and in basic medical textbooks.  Instead, such discussions and debates have been relegated to narrow specialty medical and philosophical journals, and most practicing physicians are remarkably unaware about the state of knowledge on this question. Our guest on this episode is D. Alan Shewmon, MD, Professor Emeritus of Pediatric Neurology at UCLA. His work, comprising decades of well-documented clinical observations and reflections, is now known as "Shewmon's challenge," a compelling rebuke to the principal arguments put forth to defend the concept of brain death. GUEST: D. Alan Shewmon, MD.  List of scholarly publications on PubMed. LINKS: Shewmon DA. Chronic "brain death":  Meta-analysis and conceptual consequences. (in Neurology, 1998). Shewmon DA, Holmes GL, and Byrne PA.  Consciousness in congenitally decorticate children: A self-fulfilling prophecy.  (Open Access, in Developmental Medicine and Child Neurology, 1999) Shewmon DA. Truly reconciling the case of Jahi McMath.  (in Neurocritical Care, 2018) VIDEOTAPED LECTURE: The Case of Jahi McMath: A Neurologist's View.  (Starts at 41:53 mark.  Part of the 2018 conference at Harvard Medical School, Defining Death: Organ Transplantation and the 50-year Legacy of the Harvard Report of Brain Death.) Rachel Aviv.  What does in mean to die?  (article on the case of Jahi McMath in The New Yorker, 2018) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 11, 2018
Ep. 34 Free-market solutions in a world of third-party payers
The arcane procedure patients must follow to file out-of-network claims is an important obstacle for a more widespread embrace of a third-party free medical practice.  Could that process be made less daunting? Our guest is Vatsal G. Thakkar, MD, Clinical Assistant Professor of Psychiatry at the NYU School of Medicine, as well as op-ed contributor to Doximity and The New York Times.  He is the founder and CEO of Reimbursify, a startup in the out-of-network reimbursement space. GUEST: Vatsal Thakkar, MD, Doximity profile Company: Reimbursify LINKS: Vatsal Thakkar. The Illicit Perks of the M.D. Club (Op-Ed in The New York Times) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 07, 2018
Ep. 33 Moving mountains: The folly of population medicine
In a matter of a couple of decades, the concepts of population health and population medicine have taken center-stage in healthcare, displacing the traditional aim of medicine and distorting the doctor-patient relationship. Our guest today is your co-host, Michel Accad, who highlights the errors of the population health theory as revealed in his recently published book Moving Mountains: A Socratic Challenge to the Theory and Practice of Population Medicine. GUEST: Michel Accad, MD:  Twitter LINKS: Michel Accad.  Moving Mountains: A Socratic Challenge to the Theory and Practice of Population Medicine Accad, M.  Population health:  At odds with person-centered health care (Editorial in the European Journal of Person-Centered Healthcare) WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Oct 02, 2018
Ep. 32 Sexual harassment and bias in medicine: Will metrics help?
In the wake of the #MeToo movement, a sweeping report was recently published by the National Academies of Science, Engineering, and Medicine detailing 30 years of research on the sexual harassment of women in academia.  In addition, reports of discrimination and evidence of a pervasive "pay gap" between men and women are also coming to the surface. Our guest is Jane van Dis, MD, an obstetrician-gynecologist who recently co-authored a perspective in the New England Journal of Medicine on the occasion of the NASEM report.  Dr. van Dis sheds light on the report and highlights what future steps must be taken.  She is the co-founder of Equity Quotient, a data-analytics firm that provides workplace assessments of gender culture to help organizations create equitable work environments. GUEST: Jane van Dis, MD:  Twitter LINKS: Choo E, van Dis J, and Kass D.  Time's Up for Medicine? Only Time Will Tell (New Engl J Med) NASEM Report: Sexual harassment of women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Sep 29, 2018
Ep. 31 Is moral injury the cause of physician burnout?
Physician burnout has attained epidemic proportions.  It is highest among all professions and new research indicates that doctors commit suicide at a rate that is twice that of the general population, leading to a loss of approximately one physician per day.  And it’s not only doctors who are at risk.  Patients too may suffer the consequences, as medical errors have now been linked to the issue of physician depression and burnout. The true causes of this epidemic remain hotly contested but our two distinguished guests have recently published a highly provocative essay whose thesis has resonated with many doctors. Wendy Dean is a psychiatrist who is senior vice-president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine.  Simon Talbot is an Associate Professor of Surgery at Harvard Medical School in the Brigham Hospital’s division of plastic surgery. GUESTS: Wendy Dean, MD:  Twitter Simon Talbot, MD: Professional profile LINKS: Wendy Dean and Simon Talbot.  Physicians aren't 'burning out.'  They're suffering from moral injury.  (In STAT News, July 26, 2018) Website: End Moral Injury WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Sep 23, 2018
Ep. 30 Beyond EBM: Case-based reasoning and the integration of clinical knowledge
Can anyone question evidence-based medicine and not be considered some kind of fringe lunatic?  Fortunately it's possible, as will be demonstrated by our guest, Mark Tonelli, professor of medicine from the University of Washington, and one of the earliest, most thoughtful, and most articulate academic critic of the EBM dogma. Dr. Tonelli holds a BA in philosophy form the University of Colorado in Boulder and a medical doctorate from the University of Colorado in Denver.  He is the author of numerous peer-reviewed articles and book chapters on various aspects of medical science and medical philosophy.  His critique of EBM and his proposal for "case-based reasoning" are both cogent and compelling. GUEST: Professor Mark Tonelli's faculty Website LINKS: Mark Tonelli. The limits of evidence-based medicine. (Video of Grand Rounds lecture, University of Washington, 2016) Tonelli MR.  Integrating evidence into clinical practice: an alternative to evidence-based approaches. (pdf of paper in J Clin Eval Pract 2006) Tonelli MR.  The philosophical limits of evidence-based medicine. (pdf of paper in Acad Med 1998) Accad M and Francis D.  Does evidence-based medicine adversely affect clinical judgment? (BMJ 2018) NOTE: Dr. Tonelli will kindly make a copy of his book chapter on case-based reasoning available upon request.  You may contact him via his professional website above. WATCH ON YOUTUBE: Watch the episode on our YouTube channel.
Sep 19, 2018
Ep. 29 Why Hippocrates still matters
For most doctors, Hippocrates is a quaint figure of the past with hardly any relevance to the modern practice of medicine.  We may label him as the “father of medicine,” but we have no idea what really connects us to him.  We may occasionally and sanctimoniously proclaim “first, do no harm!”  but we ignore the origin and real significance of that phrase. Some of us may have taken some modified version of the Oath of Hippocrates upon graduating from medical school, but few of us think of it as a serious pledge with any real consequence for our day-to-day practice.   And, over the last decades, most bioethicists have openly set aside the Hippocratic tradition, deeming it inadequate to help us deal with the moral quandaries that arise in the age of scientific medicine. So, is there are any reason, besides historical curiosity, to become familiar with Hippocrates, let alone take him seriously?  To help us sort this out we have a distinguished guest who is the author of a brand-new book entitled Hippocrates’ Oath and Asclepius’ Wound: The Birth of the Medical Profession, published by Oxford University Press.   GUEST: Professor Thomas Cavanaugh's faculty Website LINKS: Thomas A. Cavanaugh. Hippocrates' Oath and Asclepius' Wound. (Oxford University Press) Thomas A. Cavanaugh.  Double Effect Reasoning: Doing Good and Avoiding Evil. (Oxford University Press) Michel Accad.  Physician-assisted dying: A deadly choice for the medical profession. (Alert & Oriented blog) Michel Accad.  On the deactivation of implantable devices. (Alert & Oriented blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Sep 16, 2018
Ep. 28 Jeanne Lenzer: The case for tougher medical device regulation
Are doctors patsies for the medical device industry?  Are patients put in harm's way for lack of tough standards on new device approvals?  We examine the question with Jeanne Lenzer, award-winning investigative journalist and author of The Danger Within Us: America's Untested, Unregulated Medical Device Industry and One Man's Battle to Survive It. GUEST: Jeanne Lenzer's Website and Twitter LINKS: The Bleeding Edge (documentary) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Sep 13, 2018
Ep. 27 The coronary heart disease pandemic: a medical historian’s perspective
Coronary heart disease remains shrouded in mystery as to its causes and natural history.  Our guest is Dr. William Rothstein, Professor Emeritus of Sociology at the University of Maryland, who has just published The Coronary Heart Disease Pandemic of the Twentieth Century: Emergence and Decline in Advanced Countries.  This fresh look at the patterns of coronary mortality rates throughout the world over the last 8 decades calls into question received notions about this disease. GUEST: William G. Rothstein LINKS: William Rothstein. The Coronary Heart Disease Pandemic of the Twentieth Century: Emergence and Decline in Advanced Countries William Rothstein.  Public Health and the Risk Factor: A  History of an Uneven Medical Revolution Accad, M and Fred HL.  Risk-Factor Medicine: An Industry Out of Control? (in Cardiology) Michel Accad.  The Public Health Myths of Cardiovascular Disease Prevention (a piece I wrote 10 years ago on the Alert & Oriented blog, which touches on many of the themes discussed on this episode) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Sep 09, 2018
Ep. 26 Scientific gatekeepers in the age of Twitter: A journal editor’s perspective
Are medical journals still needed in the age of the internet and social media?  Our guest is Brahmajee Nallamothu, editor of the journal Circulation Cardiovascular Quality and Outcomes.  We have a wide ranging conversation, covering everything from the financial incentives of publishing, ideological biases in medical journals, the peer review process, the Twitter effect, and a new editorial position of independent troller! GUEST: Brahmajee Nallamothu Twitter and Profile LINKS: The following articles are all Open Access articles in Circulation Cardiovascular Quality and Outcomes Robert W. Yeh.  Academic cardiology and social media: Navigating the wisdom and madness of the crowd Michael Thompson.  Science and social media: Debating the effects of readmission penalties RELATED EPISODES: Ep. 23 Buying doctors with lunches: Fact or fiction? WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Sep 05, 2018
Ep. 25 Exposing medical students to free market ethics and principles
US medical schools overwhelmingly support centralization of healthcare and health care decision-making.  That is not a surprise since, over the decades, academic institutions have greatly benefited from healthcare policy. Because centralization of health care is detrimental to the doctor-patient relationship, students who begin their training motivated by a genuine desire to practice medicine in a meaningful and personal way can easily fall into disabuse or disillusion or may adopt a more cynical attitude toward their profession. Our guest today is Beth Haynes, medical director of the Benjamin Rush Institute, a non-profit organization dedicated to offering medical students an alternative perspective on healthcare and its possibilities by exposing them to free-market principles and ethics, centered on the supremacy of the doctor-patient relationship. LINKS: Benjamin Rush Institute website and student-led podcast Will Craghead and Daniel McCorry.  Direct Primary Care: Improving Medical Students Interest in Primary Care. ("White Paper") RELATED EPISODES: Ep. 10 Free market medicine is ethical, workable, and unstoppable Ep. 22 Free markets in  healthcare : objecting to the objections WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Sep 02, 2018
Ep. 24 Making the case for Medicare-4-All
For an increasing number of Americans today, a single payer system seems to be the only conceivable next step in the cataclysmic and ruinous history of our healthcare system.  Our guest today is Adam Gaffney, MD, a longtime supporter of a single-payer system and president-elect of Physicians for a National Health Program.  He has kindly agreed to be subjected to our objections. GUEST: Adam Gaffney: Twitter and website WATCH ON YOUTUBE: Watch the episode on our YouTube channel RELATED EPISODES: Ep. 22 Free markets in healthcare: objecting to the objections Ep. 10 Free market medicine is ethical, workable, and unstoppable
Aug 29, 2018
Ep. 23 Buying doctors with lunches: fact or fiction?
Do medical journals apply scientific standards selectively?  On the subject of the effect of pharmaceutical lunch gifts on physician behavior, all that may be required from a paper is that the conclusions drawn be compatible with the expected narrative—even if the data presented suggests the opposite.  Joining us are Rafael Fonseca and John Tucker who shared with us their eye-opening analysis of a recent article published in JAMA Internal Medicine and the fascinating reaction to their analysis from journal editors and from the community at large. GUESTS: Rafael Fonseca, MD: Twitter and Website John Tucker, PhD: Twitter LINKS: Rafael Fonseca and John Tucker. Are doctors bribed by Pharma: A critical analysis of a recent study by Hadland and colleagues (In The Health Care Blog). Rafael Fonseca and Jeffrey Singer.  Politics, Confirmation Bias, and Opioids.  (Cato Institute blog) Rafael Fonseca. How physicians interpret research funding disclosures. (New England Journal of Medicine) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 26, 2018
Ep. 22 Free markets in healthcare: Objecting to the objections
Many ardent supporters of free markets still believe that healthcare is an exception where government intervention is, for some reason, necessary.  Our guest on this episode is Roman Zamishka, a financial analyst and medical school applicant who authored a witty and carefully constructed article titled "A Libertarian's Case Against Free Markets in Healthcare." The piece garnered a lot of positive comment on The Health Care Blog where it was published.  Mr. Zamishka kindly agreed to be cross-examined about the points he made. GUEST: Roman Zamishka: Twitter LINKS: Roman Zamishka.  A Libertarian's Case Against Free Markets in Healthcare. (In The Health Care Blog). Caption-generator video meme: Hitler reacts to 8 years of the ACA WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 22, 2018
Ep. 21 Inside the Swiss healthcare system with Dr. Fouradoulas
The Swiss healthcare system is frequently proposed as a model for the rest of the world to emulate.  Our guest is Marc Fouradoulas who practices medicine in Zurich, Switzerland. He is a board-certified internist who holds a Master’s degree of advanced studies in managed health care and health economics from the Winterthur Institute of Health Economics, School of Management and Law, in Zurich. GUEST: Marc Fouradoulas, MD: Twitter LINKS: Marc Fouradoulas.  The Swiss Healthcare System: A Model for the US? (Alert and Oriented blog) Marc Fouradoulas.  From Direct Democracy to Centralization: The Swiss Healthcare Experiment (Mises Wire) Michel Accad.  An Economic History of the American Healthcare System. (Alert and Oriented blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 18, 2018
Ep. 20 How healthcare systems scapegoat physicians: the Bawa-Garba case
Hadiza Bawa-Garba was convicted of involuntary manslaughter by a British court for her role in the care of a patient in a hospital setting fraught with system failures.  Our guest is Dr. Saurabh Jha who returns on the show to share his insights on this case.  Dr. Jha trained in the NHS but practices in the United States as Assistant Professor of Medicine at University of Pennsylvania Perelman School of Medicine.  He is intimately familiar with the details of the Bawa-Garba case and has recently returned from London where he attended the most recent legal proceedings in the physician's appeal of the General Medical Council's decision. GUEST: Saurabh Jha, MD: Twitter LINKS: Saurabh Jha.  To Err is Homicide in Britain: The Case of Dr. Hadiza Bawa-Garba (The Health Care Blog). Saurabh Jha.  If Hadiza Bawa-Garba Worked in the US She Would Still Be a Doctor. (The Guardian) Saurabh Jha.  The Doctor Who Thwarted the Charge of the General Medical Council (The Health Care Blog) Saurabh Jha.  Dr. Jonathan Cusack versus the General Medical Council (The Health Care Blog). Ganfyd site entry of the Bawa-Garba case, with all the relevant facts and court documents. WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 12, 2018
Ep. 19 Public reporting: necessary evil or harmful fake news?
Public reporting of outcomes aims at improving quality but has also harmed patients and doctors alike.  Can any good come out of it?  Our guest on this episode is Dr. Robert W. Yeh, Associate Professor of Medicine at Harvard Medical School and Director of the Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center in Boston.  He is an expert on the outcomes of outcome reporting. GUEST: Robert W. Yeh, MD: Twitter Papers by Dr. Yeh and colleagues on public reporting: paper suggesting an association between public reporting of PCI mortality and lower rates of PCI especially for high risk patients, and higher mortality for MI patients overall. - paper showing that after New York removed cardiogenic shock patients from public reporting of PCI, PCI rates went up and shock-related mortality went down. - study showing that hospitals identified as PCI mortality outliers tend to be the large hospitals with CT surgical programs where complex patients are referred. In addition, after being identified as outliers, hospital appeared to improve mortality without worsening risk avoidance. - a survey of interventional cardiologists in public reporting states on the extent to which reporting programs have changed their and their colleagues practice. RELATED LINKS: Anish Koka. The High Cost of Public Reporting (published in "The HealthCare Blog") RELATED EPISODES: The dangerous business of public reporting. WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 11, 2018
Ep. 18 A doctor fights against CON laws
Our guest on this episode is Dr. Gajendra Singh, a well-respected surgeon who decided to provide affordable ultrasound, CT, and MRI imaging to his community.  A few months into his endeavor, he was confronted by his state's "certificate of need" laws telling him that providing affordable healthcare was illegal.  His response: to sue the government. GUEST: Gajendra Singh, MD: Twitter and E-mail LINKS: Dr. Singh's Forsyth Imaging Center: Website and Facebook Page "Healthcare Favoritism:" The Mercatus Center at George Mason University's analyses on Certificate of Needs Laws Article featuring Dr. Singh on Dr. Singh featured on the Institute for Justice's website RELATED EPISODES: Free Market Medicine is ethical, affordable, and unstoppable. WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Aug 04, 2018
Ep. 17 Hope in the fight against MOC
Our guest this week is Dr. Wes Fisher who is leading the fight against the American Board of Internal Medicine and its self-serving tactics to force thousands of physicians to comply with the onerous Maintenance of Certification Program. We learn of Wes' new initiatives that stand a realistic chance of turning the tide against the quasi regulatory monopoly of the board-certifying agencies. GUEST: Westby Fisher, MD website and Twitter LINKS: GOFUNDME link to raise funds to complete the pre-litigation investigation. PRACTICING PHYSICIANS OF AMERICA A grassroots organization co-founded by Dr. Fisher. WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jul 29, 2018
Ep. 16 The EHR will see you now
Our guest is Twila Brase, RN, PHN, Executive Director of the Citizen's Council for Health Freedom.  We discuss her freshly released book that reveals the ugly truths about the electronic health records and what can be done to escape from this modern day Panopticon. GUEST: Twila Brase, RN, PHN website and Twitter LINKS: Big Brother in the Exam Room: The Dangerous Truth About Electronic Health Records WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jul 22, 2018
Ep. 15 Lethal regulation: The 1962 FDA amendments
Our guest is Dr. Mary Ruwart, scientist, ethicist, and author of a new book that examines the history of the last 6 decades of drug regulation and highlights the unintended consequences on the 1962 amendments to the FDA.  Her meticulous research is an eye opener for anyone interested in health. GUEST: Mary Ruwart, PhD website and Twitter LINKS: Death by Regulation: How We Were Robbed of a Golden Age of Health and How We Can Reclaim It WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jul 15, 2018
Ep. 14 EBM “India-style,” with Dr. Anupam Singh
We took the EBM controversies to India and consulted with Dr. Anupam Singh, Assistant Professor of Medicine at SMC in Ghaziabad.  He offered a very sound and intelligent perspective on the proper role of clinical trials and clinical judgment in medical care. GUEST: Dr. Anupam Singh's Twitter and ResearchGate profile LINKS: The EBM Wars: Manufacturing Equipoise (part 1) The EBM Wars: When Evidence has a Price – The ECMO Trials (Part 2) The Evidence Crisis: Causal Inference--Don't Be a Chicken (part 3) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jul 10, 2018
Ep. 13 A buffet of blood pressure guidelines
We have fun discussing the controversies about blood pressure guidelines with our guest, Dr. Swapnil Hiremath, Assistant Professor of Medicine at the University of Ottawa and Co-founder of NephJC, a highly successful Twitter-based journal club.  Dr. Hiremath sits on the Canadian blood pressure guideline committee and shares his insights about the question of BP management. GUEST: Swapnil Hiremath's Twitter NephJC Journal Club WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jun 30, 2018
Ep. 12 John Mandrola: The case for “Less-Is-More”
We explore the "less-is-more" movement with Dr. John Mandrola, one of its most articulate and popular champions.  We discuss the problem of practices that have no scientific justification and the conundrum of out-of-control costs.  What is the best way to curtail unwarranted therapies?  Should there be more top down regulations or is it possible that more health care freedom will lead to less utilization? GUEST: John Mandrola's website John Mandrola's Twitter WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jun 24, 2018
Ep. 11 The case against shared decision-making
Shared decision-making (SDM) has become a sacred cow of medical ethics almost overnight.  What's more, doctors are now being forced to practice it in order to get paid for certain procedures.  We review the history of this concept and why it is contrary to a sound doctor-patient relationship. LINKS: Merchant F., et al. Mandating shared decision-making (JAMA) Presidential Commission: Making Medical Decisions. (Kennedy Center for Bioethics at Georgetown University) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jun 16, 2018
Ep. 10 Free-market medicine is unstoppable
We have a terrific interview with G. Keith Smith, co-founder of the Surgery Center of Oklahoma and of the Free Market Medical Association.  Keith gives us an overview of his pioneering experience and clearly makes the case that free markets are ethical, workable and, ultimately, unstoppable. LINKS: Surgery Center of Oklahoma (Twitter: @SurgeryCenterOK) G. Keith Smith's blog Free Market Medical Association WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jun 09, 2018
Ep. 9 Jade eggs and Francis Bacon
We discuss a blog post by obesity therapy guru Jason Fung in which he pushes back against "debunkers" and self-appointed guardians of "science-based medicine."  We look at the question of science and pseudo-science and how it bears on actual medical care. LINKS: Jason Fung: Debunking the Debunkers David Gorski: An Unholy Combination of Methodolatry and Quackery Michel Accad: Is Medicine a Scientific Enterprise? Jade Eggs for Healing WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Jun 02, 2018
Ep. 8 The dangerous business of public reporting
We discuss the background policies the effects of public reporting of outcomes on the behavior of physicians and the reactions to a paper that was just published on this topic.  Anish shares a real life experience of a patient of his who was a tragic victim of these misguided healthcare policies. LINKS: Blumenthal et al.  A Survey of Interventional Cardiologists’ Attitudes and Beliefs About Public Reporting of Percutaneous Coronary Intervention (JAMA Cardiology) Anish Koka. The High Cost of Public Reporting (published in "The HealthCare Blog") WATCH ON YOUTUBE: Watch the episode on our YouTube channel
May 26, 2018
Ep. 7 “No tears for you!” say the pharmascolds
We discuss a tweet and a paper claiming that pharmaceutical companies don't even need to produce effective drugs anymore.  All they need is "an effective marketing campaign" and billions of dollars in annual sales soon follow.  This is a very dubious claim on the face of it, but Anish did some investigating of his own. LINKS: Schwartz, LM, and Woloshin, S.  A Clear-Eyed View of Restasis and Chronic Dry Eye Disease WATCH ON YOUTUBE: Watch the episode on our YouTube channel
May 19, 2018
Ep. 6 “Real ACOs have never been tried!”
We take to task healthcare policy wonks who lament that the government can no longer mandate hospital systems to participate in new "value-based" payment schemes.  These alternative payment plans have been a disaster from the get-go, but it seems that central planners never lose hope. LINKS: Levy, S. Bagley N, and Rajkumar R. Reform at Risk: Mandating Participation in Alternative Payment Plans. WATCH ON YOUTUBE: Watch the episode on our YouTube channel
May 12, 2018
Ep. 5 Saurabh Jha: Normal is fuzzy
We have a free-wheeling and fun conversation with Dr. Saurabh Jha on the philosophical question of "what is normal."  The conversation was prompted by an editorial by John Ioannidis who thinks that "Big Data" could help clinicians get a handle on the vexing problem of normal values.  We discuss the merits of that idea. GUEST:  Twitter: @RogueRad LINKS: Saurabh Jha: Artificial Intelligence in Radiology John Ioannidis: In the Era of Precision Medicine and Big Data, Who Is Normal? (JAMA) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
May 06, 2018
Ep. 4 The Alfie Evans case: lessons for doctors
There precise rationale invoked by the courts to prevent Alfie Evans' parents from transferring the child out of the UK is widely misunderstood.  In many ways it worse than what many people imagine.  We discuss this chilling case and the ethical doctrine that informs the courts' decision. LINKS: Royal College of Paediatrician's guidelines: Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice. Michel Accad: Charlie Gard, disproportionate care, and assisted suicide Anish Koka: The price of progress Michel Accad: The body language of assisted suicide WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Apr 28, 2018
Ep. 3 Should doctors protect their turf?
We discuss a “white paper” jointly written by Jeffrey Flier, former dean at Harvard Medical School, and Jared Rhoads, from the Dartmouth Institute, calling for some deregulation of the apparatus that rules the supply of physicians and their scope of work.  We touch on the question of safety, patient sovereignty, alternatives to licensing, and whether protectionism is ever a legitimate option. LINKS: Jeffrey Flier and Jared Rhoads.  The US Health Provider Workforce (Mercatus Center website) Michel Accad: An Economic History of the American Healthcare System (Alert and Oriented blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Apr 24, 2018
Ep. 2 Francis and Accad on EBM
We have a fun chat with Professor Darrel Francis, from Imperial College in London and the UK's National Heart and Lung Institute.  Dr. Francis takes the "pro" side and Michel the "con" side in regards to evidence-based medicine. GUEST: Darrel Francis' Twitter handle and website WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Apr 21, 2018
Ep. 1 Confessions of a pharma-fed doctor
After an opinion piece in JAMA Internal Medicine once again showed the influence of drug company payments on physician practices, Anish comes clean about his relationship with Big Pharma.  We discuss that potential conflict of interests but place it in the context of broader COIs in health care that no one ever talks about. LINKS: Mitchell et al. Pharmaceutical Industry Payments and Oncologists’ Selection of Targeted Cancer Therapies in Medicare Beneficiaries.  (JAMA Internal Medicine) Michel Accad, The Pharma-Fed Doctor (Alert and Oriented blog) WATCH ON YOUTUBE: Watch the episode on our YouTube channel
Apr 14, 2018