Monthly Archives: November 2011

PSA Screening and Prostate Cancer

Making health policy involves many different aspects of life:  scientific evidence of a highly predictive diagnostic test, reasonable price, competing resource demands, comfort and convenience of a test, seriousness of the disease being detected, impact of the disease on the individual and the population, etc.

Anyone who’s been involved in health policy debates will recognize that, except for predictive value of the test and actual cost of the test, both of which can be determined somewhat objectively, all of the rest of the items listed above are laden with values (and one can argue even arriving at the predictive value involved significant calls on various values in doing the studies).   Evidence-based medicine only provides information, it doesn’t provide a support of values and how they will be applied in society.

Rather than reproduce some of the less-than-obvious arguments about screening for prostate cancer here, those interested can find more information in Paul Menzel’s and my recent posting on the Oxford University Press blog website.


Can you remember…

…everything you did 15 years ago? I’ve gone to meals with younger colleagues with whom I haven’t had a prior acquaintanceship and two years later forgotten we had had lunch, and even who they were, mostly because we didn’t have a significant ongoing relationship at a time when so much was going on in my life.

Just yesterday I was in touch with a friend who is a family physician in Florida. I had coincidentally met a woman who was moving to my friend’s town and she was looking for a family physician. I recommended my friend and gave her his work phone number. When I was writing to my friend two weeks later I remembered the referral, but couldn’t remember the circumstances under which I had met the woman, nor could I remember her name. This wasn’t a matter of my bad memory, as much as the constant and intensive bombardment we have of data, much of which ends up being contextually forgotten because of its relatively trivial nature (trivial related to the daily meaning of our personal lives).

In this context, I can understand if Herman Cain doesn’t remember a woman with whom he had a meal and then allegedly made unwanted advances toward so many years ago. I’m not justifying or condoning his actions if he indeed did inappropriately touch her; that would be reprehensible. But if he forgot who she was, I could understand. I met with many entrepreneurs in the 1990s during my early venture capital days. Had meals or coffee with them. But I didn’t invest in their companies and don’t remember them now.

While I’m not justifying his actions, I also wouldn’t suggest that if he is “not remembering” because he is lying to avoid responsibility that would be inappropriate also, and further not justifiable.

The questions are, “How far back and how significant does one’s contact with someone have to be to be held accountable now for those distant actions? What is a reasonable balance – time, distance, maturity – to which we should be held blameworthy (or praiseworthy)?”

Lying vs. Reporting Child Abuse

Joe Palazzolo is a reporter for the Wall Street Journal. On November 8, 2011 he reported on the legal issues related to the Penn State scandal. In his article, “Child-Abuse Reporting Law is Challenge to Prosecutors” he states:

Some observers wonder why lying to a grand jury about knowledge of child-abuse allegations carries a stiffer punishment than failing to report them in the first place.

This is, to some extent, a parallel issue to why we prioritize treatment over prevention. If there is any doubt that we do, read chapter 1 of Paul Menzel’s and my recently published text, Prevention vs. Treatment: What’s the Right Balance? (Oxford University Press, 2011).

To answer Palazzolo’s quandary, in essence we consider breaching trust in testimony more harmful to society than preventing harm to children. The first preserves the integrity of our society. The second should preserve the integrity of individuals. Sometimes we prioritize one over the other, sometimes not.

Note that this is an explanation of how society has made legislation, not a justification. Most legislation is made linearly, not comparatively. Nobody sat down and said, “Is child abuse more or less important than lying?” The juxtaposition of the two occurs now because of the peculiar circumstances and conditions of the Penn State case. Is it the right balance? Will the Pennsylvania legislature see this juxtaposition and take action to either reduce penalties for perjury, or increase penalties for failing to report child abuse? Only those in Pennsylvania who vote and could put pressure on their legislatures will determine that question. It would be interesting to know, however, if the same relative penalties exist in most other states. Any lawyers out there who can research the questions?

Wealth and Conflicts of Interest

Carl Bialik’s column in the Wall Street Journal this past weekend (Nov. 12, 2011) discusses the “Income Ladder’s Sticky Steps.”  He tackles the difficult question of assessing mobility, showing how defining the strata may change the conclusions that can be reached, including issues such as (1) What age groups should be included? (2) How do you handle natural progress of careers; older employed folks usually make more than they did when they were younger because their careers progress? (3) Would we be better tracking longterm earnings, as there can be natural fluctuations from year-to-year?

These have important implications when trying to look at economic progress.  For example, the Occupy Wall Street folks claim they are the 99% who are below the chasm of the 1% highest earners.  Of course they are – the 99 out of 100 people will be in the 99% by definition.  Except for celebrity guests of the Occupiers (who likely are in the 1%), those with the time on their hands to protest will be in the 99%.

Bialik states, without making further comments, “And none of the income measures explicitly includes wealth, which is distributed more unequally than income.”  This is an important statement.  Bialik is not the only one who recognizes but does not deal with the issue of wealth.  In Conflicts of Interest in medicine and health care wealth is at least partially ignored.  How?

Most conflict of interest disclosure requirements for authors in journals or speakers in continuing medical education events include provisions to disclose relationships with companies or other interests.

The International Committee of Medical Journal Editors states:  “Conflict of interest exists when an author (or the author’s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties).”

The American Council on Continuing Medical Education (ACCME) states:

2.1 The provider must be able to show that everyone who is in a position to control the content of an education activity has disclosed all relevant financial relationships with any commercial interest to the provider. The ACCME defines “‟relevant‟ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

In the ACCME’s case financial relationships are defined as “…those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.”

How does this normally exhibit itself in CME speaking activities?  In my experience the moderator of a session will state “so-and-so discloses that (s)he owns stock in [Drug] Company” or “so-and-so discloses that she has been paid an honorarium by [Device] Company” and it is left at that.  As we know, disclosure doesn’t fix the conflict, it merely reveals it.   Loewenstein notes related to the physician-patient relationship,

Disclosure may give the adviser a “moral license” for strategic exaggeration in the adviser’s best interest. (“I told her I had a conflict—now, I can recommend the surgery.”) Having disclosed a conflict of interest, moreover, advisors may feel compelled to give advice in an extra-forceful fashion.

This may be similar for the speaker-audience relationship, “I [the speaker] have disclosed my conflict, now I needn’t worry about it, or I may feel free to discuss it even more than if it were hidden.”

However, the key question that needs disclosure is “What does this relationship mean to the speaker and how has it influenced his/her presentation of information?”  Simply knowing that someone has been paid an honorarium or owns stock in an enterprise doesn’t tell the audience if such ownership is meaningful.  More importantly, what does that represent in terms of one’s income or wealth?  If the speaker has net worth of $100 million, owning $10,000 of stock likely is relatively meaningless.  On the other hand, if the speaker’s net worth is only $200,000, that $10,000 of stock may be critical for how she wants to please either the commercial interest (to get more stock or honoraria) or the audience (to purchase more of the product offered by the commercial interest).

(As an aside, at a recent Harvard University Program in Ethics and Health conference conditional cash transfer payments to encourage health promoting activities in second world countries was discussed.  As I recall, levels of payments had to approach 20-30% of annual income to get behaviors to change substantially.  This, of course, differs from findings related to physician behavior, which is influenced by small pharmaceutical company gestures.)

So, while ignoring wealth as the denominator of disclosure is usually done, we should consider the issue as a much more important measure.  Further there likely is some interactive relationship between meaningful financial ownership (wealth) and income.  Income fluctuations may have little meaning if the amounts are small, or if one has equilibrium with a lifestyle that is fully supported by drawdowns on existing wealth (not requiring additional annual wealth through income or increases in, for example, stock value).

Because of the complexity of the interaction of wealth, income, and meaningful bias/influence the leading medically-related institutions are moving to requiring disclosure of any financial relationship between an author/speaker/influencer and a commercial interest.  This makes sense, in that research indicates that we often don’t let data get in the way of our biases, which can easily come from financial self-interest, and that even small conflicts can result in unconscious bias.   Until we have more reliable data on the relationship between wealth and income this is probably prudent, but also recognizably excessive.

How to find the right balance?  More easily done when more research is completed.

Hello and Welcome!

Welcome to Halley Faust Comments.

Many of our contemporary issues are conflicted by personal self-interest, commitment biases, incorrect information, and unbalanced consideration of alternatives.  For example, we often use the best of our traditions to compare the worst of others’ traditions – an unfair (and perhaps unjust) evaluation.

I’ll use this blog to discuss various events and ideas, particularly as they impact health care, prevention, and the Middle East.  I am a moderate in American politics – eschewing the extremes we seem to see more of lately.  My posts will pick up on contemporary issues and ideas and try to put out a balanced view, or at least point out where balance is missing.

I hope you’ll find my comments of value.  And I invite your comments on mine.

In the meantime, Happy Thanksgiving.

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