Why High-Class People Get Away With Incompetence


In season four of NBC’s “Parks and Recreation,” Paul Rudd plays a wealthy businessman named Bobby Newport who runs for city council because he’s looking for something “easy” to do. He is asked during a debate how he’d fix the town. His answer: “I have no idea.” Still, the audience goes wild, much to the frustration of his rival, Leslie Knope.

It’s funny because it’s relatable. Sooner or later, we all may encounter a Bobby Newport. What is it about an elite upbringing that seems to make people feel qualified for tasks where they have little experience? This is one of the questions that inspired a study published Monday in The Journal of Personality and Social Psychology.

The researchers suggest that part of the answer involves what they call “overconfidence.” In several experiments, they found that people who came from a higher social class were more likely to have an inflated sense of their skills — even when tests proved that they were average. This unmerited overconfidence, they found, was interpreted by strangers as competence.

The findings highlight yet another way that family wealth and parents’ education — two of a number of factors used to assess social class in the study — affect a person’s experience as they move through the world.

“With this research, we now have reason to think that coming from a higher social class confers yet another advantage,” said Jessica A. Kennedy, a professor of management at Vanderbilt University, who was not involved in the study.

Studying social class is tricky. First there’s the matter of definitions. “Most people would say they are middle class,” said Peter Belmi, a professor at the University of Virginia’s Darden School of Business and a lead author of the study. But how can that be?

Even researchers who specialize in social class struggle to agree on the weight to give income, family wealth, professional prestige and other factors.

Previous work has found that many people can correctly gauge a stranger’s family income bracket and mother’s education level within 60 seconds. But what exactly they are responding to is not well understood, said Rebecca Carey, who studies social class and identity at Northwestern University’s Kellogg School of Management.

The study consisted of four experiments. Class was defined multiple ways each time.

The first experiment involved about 150,000 small-business owners in Mexico applying for a loan. In addition to providing their income and education level, they were asked to select a rung on a ladder, representing their place relative to others in Mexico.

As part of the loan process, they took a memory test. (The real-life task was designed to try to predict whether a person would default on a loan.) For the purposes of the study, participants were also asked to estimate how well they thought they did compared with others. Higher-class people generally performed better than others — but not to the degree they assumed they did, researchers found.

The disparity between upper-class people’s estimated performance and actual performance was more dramatic in a later study involving 230 University of Virginia students.

This time, social class was measured by students’ assessment of how they saw themselves relative to others in the United States, their parents’ income and their parents’ education. Researchers found that students of higher social classes failed to outperform their peers in a trivia exercise. But once again, most were certain they had.

In an attempt to understand the implications of overconfidence, the researchers constructed a mock job interview. The students were asked the same question and videotaped. A group of strangers then watched the videos and rated the candidates. The selection committee generally opted for the same people who’d overestimated their trivia abilities. Overconfidence was misinterpreted as competence.

Ms. Carey was unconvinced by how much the faux-job interview experiment demonstrated about real life. She also had some concerns about the findings from the first of the four experiments, which she believed relied too heavily on the participants’ own sense of social class standing.

“But what they do very consistently show is that social class is tied to overconfidence,” she said. Other studies have also shown that people who are overconfident are perceived as more competent. Ms. Carey suggested that it could be that “in a lower-class context, the cost is higher if you are wrong when you make a mistake.”

And not all class groups value “faking it until you make it,” Dr. Belmi said. “I grew up in the Philippines with the idea that if you have nothing to say, just shut up and listen.”

Researchers said they hoped that the takeaway was not to strive to be overconfident. Wars, stock market crashes and many other crises can be blamed on overconfidence, they said. So how do managers, employers, voters and customers avoid overvaluing social class and being duped by incompetent wealthy people? Dr. Kennedy said she had been encouraged to find that if you show people actual facts about a person, the elevated status that comes with overconfidence often fades away.

“We may also need to punish overconfident behavior more than we do,” she said.



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The Health 202: Large employers don’t want Medicare-for-all


THE PROGNOSIS

Medicare-for-all advocates argue enacting their plan would lift a heavy burden off employers to provide their workers with health-care coverage, which is the way 180 million Americans get their insurance.

But large employers are just fine with being the suppliers of insurance and don’t want to give up that role, according to an association that represents them.

Overwhelmingly they would like to continue doing it,” Jim Klein, president of the American Benefits Council, told me. “They think they’re doing a good job.”

The American Benefits Council — which represents the country’s largest employers including Walmart, ExxonMobil and Apple — hasn’t joined the large industry coalition of insurers, pharmaceutical makers and hospitals who are vigorously fighting every iteration of Medicare-for-all proposals coming from Capitol Hill (we’ve written about that partnership here).

But its leaders are plenty skeptical of the prospect of a single-payer system, stressing it would upend the way most people in the United States get their coverage and potentially subject employers to big new taxes so the government could pay for the whole thing.

“I think they’re very concerned about sort of a blank check which the government would be filling in the blank, in terms of cost,” Klein said of his members.

The future of employer-sponsored coverage is one of the stickiest questions raised by the Medicare-for-all debate. The shortcomings — and merits — of the system got a lot of airtime during last month’s Medicare-for-all hearing at the House Rules Committee and probably will be part of the debate at a similar hearing House Budget Chairman John Yarmuth (D-Ky.) has scheduled for Wednesday.

Just look at how some of the Democrats running for president have recently danced around the issue.

Sens. Cory Booker (D-N.J.) and Kamala Harris (D-Calif.) are co-sponsors of the latest Medicare-for-all bill from Sen. Bernie Sanders (I-Vt.), which would upend the country’s health insurance system, replacing virtually all private plans with a generous set of benefits provided by the federal government. But both candidates have tried to take a softer stance on what would happen to workplace coverage.

—“I stand by supporting Medicare-for-all, but I’m also that pragmatist that, when I’m chief executive of the country … I’m going to find the immediate things that we can do,” Booker told CNN’s Jake Tapper this month.

“Because I’m telling you right now, we’re not going to pull health insurance from 150 million Americans who have private insurance who like their insurance — my union friends, brothers and sisters, who have negotiated for their health insurance,” Booker added.

—Sen. Kamala Harris (D-Calif.) told Tapper last week “that’s not what I meant” when he asked her to clarify previous comments in which she said she supports eliminating the private insurance industry.

“I support Medicare-for-all but I really do need to clear up what happened on that stage,” Harris said. “It was in the context of saying let’s get rid of all the bureaucracy.”

— Yarmuth poured cold water on the idea of Medicare-for-all being law anytime soon, despite the hearing he’s holding on the issue this week.

“A lot of people, I think, co-sponsored Pramila’s bill for the same reason they co-sponsored H.R. 676; it was the metaphor for Medicare-for-all,” Yarmuth told my colleague Dave Weigel last week. Yarmuth was referring to the House bill proposed by Rep. Pramila Jayapal (D-Wash.).

“Now, people have seen some of the details and said, ‘Okay, we need to look at this.’ There doesn’t seem to be much of a sense of urgency because it’s not going anywhere,” Yarmuth added.

Rep. Donna Shalala (D-Fla.), former Health and Human Services secretary under President Bill Clinton, is also a Medicare-for-all skeptic:

Perhaps these Democrats recall President Barack Obama’s infamous “if you like it, you can keep it,” pledge, where Obama learned the hard way what happens when people lose insurance they wanted to keep. Obama repeatedly promised people they could retain coverage they liked under his 2010 Affordable Care Act. When around 4 million people got notices their plans were being canceled — because they weren’t ACA-compliant — the administration came under heavy fire. The website PolitiFact dubbed Obama’s promise its “Lie of the Year” in 2013.

Yet employer-sponsored plans are still far from perfect. In fact, many health policy wonks have said many of the problems with health insurance in the United States stem from people getting it through the workplace instead of shopping for it on their own.

Costs are a big problem for both employers and their workers. For years, employers have grappled with rapid health-care cost inflation, resulting in higher monthly premiums and annual deductibles. Last year, health benefits for the average employee at a large company cost more than $13,000, according to a Mercer survey of employer-sponsored plans.

In response, employers have trended toward high-deductible plans or asked their workers to contribute more to their monthly premiums. Some have also invested in workplace wellness programs, in hopes of creating a healthier, lower-cost workforce.

“It puts a huge burden on employers,” House Rules Committee Chairman James McGovern (D-Mass.) said at his committee’s Medicare-for-all hearing.

Then there’s the issue of portability — the problem created when people change jobs and are forced to also change their health plan. This can be especially costly for those with chronic health conditions, who can’t afford any gaps in coverage and may find themselves having to satisfy an annual deductible for the second time in one year.

Yet to those enmeshed in the system, such as large employers, overhauling the whole thing is a daunting prospect. While health-care costs continue to rise, employers are more fearful of having to help fund the expensive single-payer system proposed in the Sanders and Jayapal bills.

Sanders argues his Medicare-for-all plan would be net cheaper for employers. He has proposed charging them either 75 percent of what they’re paying for each of their employees enrolling in Medicare-for-all or a 7.5 percent payroll tax, whichever is higher.

This would result in a net savings for employers, Sanders argues. Large employers don’t appear convinced.

Klein said the council isn’t opposed to expanding Medicare to more people — perhaps through adding a public option to the marketplaces — and stresses that it’s deeply interested in reining in cost growth.

But he said employers don’t want a health insurance overhaul, arguing they spend more than $4 on health benefits for every dollar the government loses by exempting the benefits from taxes.

“Our employers are not calling for Uncle Sam,” he said.

AHH, OOF and OUCH

AHH: In a Saturday night Twitter missive, the president signaled the recently signed Alabama abortion law that virtually bans abortions in the state goes too far, though he insisted he is “strongly pro-life.”

The president didn’t directly refer to the newly signed Alabama bill, which makes performing abortions a felony except in cases where a pregnany is a risk to a woman’s health. Nor did he cite other measures in Republican-led states to restrict abortion.

Instead, the president said he supports three exceptions to such abortion restrictions, in cases of rape, incest, and when the mother’s life is at risk, writing that his view is “the same position taken by Ronald Reagan,’” our Post colleagues Amy Goldstein and Seung Min Kim report.

But Amy and Seung Min note that Reagan wasn’t as conservative on abortion as Trump made it sound. “In aligning with the memory of the popular GOP figure, Trump disregarded that Reagan had, as California governor, signed a liberal abortion law. And as president, Reagan nominated to the U.S. Supreme Court the first female justice, Sandra Day O’Connor, who voted to uphold Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide, in later challenges to the ruling.” (The Post’s Alex Horton has more on how the president’s tweets and the comparison to Reagan bend reality here.) 

— Trump would hardly be the first Republican to signal concern about the Alabama law. Sen. Mitt Romney (R-Utah), explicitly said he was opposed to the law and Senate Majority Leader Mitch McConnell (R-Ky.) said he has long supported exemptions for rape, incest or when a women’s life is at risk.

“I don’t support the Alabama law,” Romney said in an interview Sunday on CNN. “I believe that there ought to be exceptions. I’m pro-life, but there ought to be exceptions for rape and incest and where the life of the mother is at risk.”

Romney also criticized what he described as “extreme” views of the issue being represented in recent state abortion legislation.

“You’re seeing laws on both sides of this argument that are in the extreme. And whether it’s New York and Virginia, or whether it’s Alabama and Missouri, people have gone to the — to the wings, if you will,” he continued. “I don’t think that’s productive. I think something much more toward the center makes a lot more sense.”

On Friday, Republican National Committee Chairwoman Ronna McDaniel said she would prefer such a law to include some exemptions. “Personally, I would have the exceptions,” McDaniel said in a CNN interview. “That’s my personal belief. But we are a party that is a broad tent. If you agree with us 80 percent of the time, I want you to be a Republican. We don’t have a litmus test as to whether you can belong to our party.”

OOF: A Republican Missouri state lawmaker apologized after he said some rape cases are “consensual” during remarks about an antiabortion measure.

State Rep. Barry Hovis, who spent three decades with the Cape Girardeau Police Department, was speaking on the state House floor about a measure that would ban abortions in the state at eight weeks. He was talking about sexual assault cases he came across as a police officer.

“Let’s just say someone goes out and they’re raped or they’re sexually assaulted one night after a college party — because most of my rapes were not the gentleman jumping out of the bushes that nobody had ever met,” Hovis said. “That was one or two times out of a hundred. Most of them were date rapes or consensual rapes, which were all terrible.”

Hovis later told The Post that he misspoke and he believes there is “no such thing as consensual rape,” as our Post colleague Orion Donovan-Smith reports. “I’m not trying to make excuses,” Hovis said. “Sometimes you make a mistake and you own up to it.”

OUCH: A new report from independent nonprofit FAIR Health found mental health care – including claims linked to depression, anxiety and other conditions – makes up an increasing number of private health insurance claims.

“There were notable increases in those claims among young people, who accounted for a disproportionate share of mental health claims. Experts said the findings could reflect increased access to treatment — but cautioned that it’s difficult to determine the factors at play,” Stat’s Megan Thielking reports. “The report’s findings among adolescents and young adults were particularly striking. Mental health claims also rose among young people, which the report defined as age 22 or younger. The report also found that young people accounted for a growing share of the claims for major depressive disorder. In 2007, young people accounted for 15% of all claims tied to serious depression. By 2017, they accounted for 23%.”

Another notable finding from the report was that claims related to generalized anxiety disorder increased 441 percent among people ages 19 to 22 from 2007 to 2017, and claim lines for behavioral health diagnoses spiked 108 percent during that time. 

Study authors examined insurance claims related to behavioral health care, which includes mental health care and treatment for substance abuse, specifically assessing individual claim lines for use of treatment services or procedures.

HEALTH ON THE HILL

— Protect Our Care, a leading ACA-advocacy organization led by top Democratic operatives, is today launching a new seven-figure ad campaign to bolster lawmakers in 20 congressional districts.

The campaign is meant to help those House Democrats hold on to their seats in 2020 by helping educate voters about what they have accomplished to address health care.

“Two years ago, the Republican Congress voted for health care repeal — gutting protections for people with pre-existing conditions, slashing coverage and raising premiums and prescription drug costs for millions of Americans,” Protect Our Care Chair Leslie Dach said in a statement sent to The Health 202. “Now President Trump and his allies are trying to do the same thing in court. The Democratic health care Congress is working to protect health care for people when they get sick and lower costs for hard working Americans. We’re going to make sure that despite the clutter and noise of Washington, constituents know when their Member of Congress stands up for health care and fights to lower costs and improve care.”

Most of the 20 districts included in the campaign are those of lawmakers who flipped Republican seats in 2018, including Rep. Angie Craig (D-Minn.), a former medical device company executive who flipped a Republican seat; Rep. Lauren Underwood (D-Ill.), who flipped a Republican district that was held by former Rep. Randy Hultgren; as well as Reps. Ann Kirkpatrick (D-Ariz.), Lucy McBath (D-Ga.), Jason Crow (D-Colo.), Abby Finkenauer (D-Iowa), Cindy Axne (D-Iowa), Jared Golden (D-Maine), Conor Lamb (D-Pa.), Dean Phillips (D-Minn.), Elissa Slotkin (D-Mich.), Haley Stevens (D-Mich.), Andy Kim (D-N.J.), Susan Wild (D-Pa.), and Colin Allred (D-Tex.).

— Sen. Bernie Sanders (I-Vt.) became the latest 2020 Democratic contender to pledge to nominate only Supreme Court justices who support the landmark Roe v. Wade abortion ruling. Sen. Kirsten Gillibrand (D-N.Y.) has done the same.

During an interview on NBC’s “ Meet the Press,” host Chuck Todd asked Sanders whether he would have a “litmus test” for judges. Sanders also condemned the new Alabama abortion law.

“I believe what they did in Alabama is unbelievable. Other states are doing it – the idea that women in this country shouldn’t be able to control their own bodies is beyond belief,” he said. “If you’re asking me would I ever appoint a Supreme Court justice who does not believe in defending Roe vs. Wade, who does not believe that a woman has the right to control her own body, I will never do that.”

— And here are a few more good reads: 

REPRODUCTIVE WARS

TRUMP TEMPERATURE

Behind the scenes, Pence has developed his own sphere of influence in an agency lower on Trump’s radar: Health and Human Services.

Politico

AGENCY ALERT

MEDICAL MISSIVES

STATE SCAN

OPIOID OPTICS

DAYBOOK

Coming Up

  • The House Armed Services Subcommittee on Military Personnel and the House Veterans’ Affairs Subcommittee on Health will hold a joint oversight hearing on military and veteran suicide on Tuesday.
  • The House Ways and Means Subcommittee on Health holds a hearing on surprise medical bills on Tuesday.

SUGAR RUSH

Stacey Abrams and four Democratic women running for president appeared in a Fair Fight Action video on social media, rallying against antiabortion laws:

Check out Saturday Night Live’s cold open:





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How much should we–and can we–pay for gene therapies? Find out at ISPOR 2019 – Healthcare Economist


The 2019 International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual Meeting has kicked off in New Orleans. One interesting Panel that I am moderating is titled “How much should we – and can we- pay for gene therapies?” I am serving as the moderator and the panelists on this issue panel include:

  • Anupam B. Jena, MD, PhD. Ruth L. Newhouse Associate Professor, Department of Health Care Policy, Harvard Medical School.
  • Jeremy Schafer, PharmD, MBA. Senior Vice President, Precision for Value.
  • Ramesh Arjunji, PhD. Senior Director, Blobal HEOR & RWE, AveXis.

The topic is described as follows.

Issue: As the first gene therapies enter the market, they offer the potential to
stop the progression of previously incurable diseases, such as leukodystrophies
and sickle cell disease. At the same time, high pricing and uncertain longterm
benefits have caused insurers and policymakers to question the value of these
therapies. Current prices of launched treatments range from over $300,000 USD
to $850,000 USD per treated patient, with future gene therapies expected to cost
in the millions. Even if value can be established at these price points, financing
these treatments poses significant challenges to insurers. Affordability, future
innovation, and patient access depend on the identification of pricing and
payment mechanisms for gene therapies that meet the diverse needs of
patients, insurers, manufacturers, and others.

OVERVIEW: This panel will debate the standards by which gene therapies should be priced and will explore opportunities for novel pricing and payment mechanisms. Jason Shafrin will moderate the panel and will provide an overview of the current and future landscape for gene therapies, framing key questions: What role should cost-effectiveness analyses play in determining appropriate price points? What approaches should be used to account for the uncertainty in valuing expected long-term benefits? How should insurers bear the costs of
treatments that generate long-term benefits to patients and potentially to different, future insurers? Anupam Jena will review the role of innovative pricing mechanisms and budget thresholds from an academic economist’s perspective. Jeremy Schafer, as head of a payer advisor team and as a former payer, will reflect on the real-world budget constraints of insurers and the need for protections to ensure against continued health care cost growth. Ramesh Arjunji will represent the manufacturer’s perspective and will discuss the unique
considerations for rare disease innovation and the impact on patients of access
restrictions.

The panel takes place at 5pm in Room 278-282. I hope to see you there!





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Maternity Leave for Sponsored Runners


Welcome to the Running newsletter! Every Saturday morning, we email runners with news, advice and some motivation to help you get up and running. Sign up here to get it in your inbox.

Did you know that sponsors can cut the pay of female runners if they’re pregnant?

And that those female runners can also lose their health insurance?

On Mother’s Day, The New York Times’s Opinion section released a powerful video in which sponsored female runners say they risk losing their pay if they become pregnant. And it is already prompting announcements of policy changes at several companies.

The runners say that they must choose between competing and having a family — and if they decide to do both, they are pushed into returning to competition as soon as possible by policies that treat their pregnancies like injuries.

Lindsay Crouse, a senior staff editor for Op-Docs who produced the video and also wrote a companion piece to it, said she had heard of these kinds of policies when she reported a story about pregnant professional marathoners in 2014. Some of the runners “had whispered to me off the record because the details of contracts were completely confidential,” she said. She found that being a mother while still running on a professional level “wasn’t that it was hard to do but there were also financial costs.”

When she saw Nike’s marketing campaign around Colin Kaepernick, whom they sponsor even though he’s not on an N.F.L. team right now, she got to thinking back to what she heard in 2014. Alysia Montaño, who was sponsored by Nike but is now with Asics, was willing to talk about it on the record, along with Kara Goucher and Phoebe Wright (Montaño has since also discussed it on “CBS This Morning”).

Crouse did a Q. and A. on what’s happened since the video and story were released. It’s also drawn a wide range of comments, from the American marathon record-holder Deena Kastor tweeting to send sponsors pink cookies declaring “The company is having a girl!” to make the sponsor feel valued, to Ivanka Trump tying it to paid family leave.

Brooks announced that it was adding a policy to support female athletes. Noting that it had not yet had one of its sponsored athletes start a family, the company wrote on its blog: “We want to be clear: Brooks will not reduce its female athletes’ pay or terminate a contract due to pregnancy or postpartum recovery.”

And the sports hydration company Nuun, a sponsor of both Montaño and Goucher, announced that “we will proactively and enthusiastically introduce a new clause in our contracts that explicitly formalizes our ongoing support of all female athletes throughout the duration of our term timeline, including through pregnancy.”

Burton Snowboards also announced that it was changing its contracts to includes language that protects women during and after pregnancy.

And Friday night, The Wall Street Journal reported that Nike had adopted a policy last year to stop cutting runners’ pay because of pregnancy and that such protection would be written into the terms of future endorsement deals.

I don’t think they’ll be the only companies to take a stand, especially if they want to stay competitive to attract top female runners. Runners don’t promote their sponsors only when they’re competing, but everywhere, especially if they have a large social media presence.

No one’s really talked about the issue before, said Crouse, because runners are still independent contractors who make money by one or multiple sponsorships.

“There’s no union. There’s no way for people to organize,” she said. “Maybe getting the public to talk about it from the top down could start that conversation that doesn’t seem to be happening from the bottom up.”

What do you think? And let’s keep it civil, folks — arguments have flared on both sides of this issue, and you are entitled to your opinion. But if you’re reading this in your email it’s still pretty early — maybe wait until you and I have both had our morning coffee before you tweet at me about it. I’m on Twitter @byjenamiller





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Why taking a daily aspirin to prevent heart attacks and stroke is not right for many people



For decades, millions of patients have been taking a daily aspirin in an attempt to prevent hearts attacks and strokes. But in March 2019, the American College of Cardiology and the American Heart Association released guidelines declaring healthy adults with an average risk for heart disease receive no overall benefit from a daily aspirin.

In simple terms, aspirin, or acetylsalicylic acid, is now “low-value medical care.”

The term has been coined to classify tests and medications that are ineffective and provide no benefit to a patient’s medical care. Instead, low-value care can actually expose patients to harm, shift the focus away from beneficial care and result in unnecessary costs to the patient and the health-care system.

Since entering medical school almost 10 years ago, and now as a practicing family doctor, I have noticed this ever-growing need to identify and move away from low-value medical care.

In the case of aspirin, research shows that average-risk patients are exposed to higher risks of bleeding and led to falsely believe aspirin is the best form of primary prevention.

The best protection is regular exercise, a healthy diet and avoiding smoking.

Slow to respond

Convincing doctors to stop making low-value care recommendations may be a slow and difficult task. History tells us doctor and patient expectations may be sluggish to respond to this new information.

It’s no secret health-care systems are slow to integrate new research into clinical practice. A landmark study from the early 2000s showed there is a time lag of 17 years before research is implemented into regular care.

Changing clinical practice also goes beyond integrating new information. It requires unlearning and de-adopting outdated, ineffective clinical practices. And it’s this process that health systems particularly struggle with.

This partially explains why low-value health care continues to thrive — to the tune of $765 billion of unproductive expenditure in the United States in the year 2013 alone.

The ‘defensive medicine’ trap

Part of the challenge in unlearning is that it interrupts the status quo, both for doctors and patients. For instance, in previous decades, family doctors had all patients undergo a yearly physical exam and routine bloodwork. We thought this annual check would find diseases and make patients healthier.

Instead, research has shown annual exams are very low yield. They provide no health benefit for a large, healthy subset of our population.

But try convincing the doctors who invested years doing these exams — often booking patients in for longer, half-hour visits and believing they were providing a valuable service — to move away from this ingrained and fossilized method of medical care.

Studies looking into the complexity of unlearning among physicians highlight the inherent shame and loss of professional self-worth that occurs when previous practices are abandoned and considered obsolete.

Even more powerful is the impact that removing previous practices can have on patients. Our culture places a strong emphasis on the mantra “more is better.” More exams. More tests. More procedures.

When doctors refuse to provide care that was previously considered beneficial and important, the pushback from patients can be strong. As a family doctor, I often inform my patients that I don’t do annual checkups. Most are surprised and some become upset. I would be lying if I said I haven’t thought about just giving into patients’ demands to give them comfort and make my job easier.

Complicating the matter even more is how overusing health services allows doctors to protect themselves against malpractice lawsuits. This is known as “defensive medicine.”

Clinical judgment and reasoning are increasingly being replaced by algorithms. The absence of testing and intervention is getting harder and harder to justify — a reflection of how medicine has morphed into an expectation of being “a perfect science, rather than an imperfect, but well thought-out art.”

But the cost of defensive medicine is staggering. On average, the American health-care system spends $46 billion on care centered on medical liability.

Aspirin not the best option

Initiatives such as the international Choosing Wisely campaign are making efforts to try to curb low-value care by educating health-care providers and patients on the drawbacks and harms of over-testing and medical misuse.

The campaign has issued numbered lists of low-value processes specific to each medical specialty. It aims to break the “this is how it’s always been done” culture that can overwhelm medicine.

Yet, despite the launch of the campaign in 2012, little change has been seen in the practice habits of physicians.

While the evidence is clear that, for many average-risk patients, aspirin isn’t the best option in preventing heart attacks, convincing patients, doctors and health-care administrators of the same will be difficult.

The process of unlearning and disengaging from previous practices is hampered by a complex interplay of human emotion, individual expectation, legal liability, organizational structure and simple inertia.

Inderveer Mahal is a family physician and global journalism fellow at the Munk School of Global Affairs & Public Policy at the University of Toronto. This report was originally published on theconversation.com.



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Does your perceptions about your peers matter more than your peers’ behavior? – Healthcare Economist


It appears that not only does your friend’s behavior affect your behavior, but your perception of their behavior–independent from their actual behavior–affects your behavior. Want a concrete example of this? A paper by Amialchuk et al. (2019) finds the following:

Using a nationally representative dataset, we estimate the effect of misperception about friends’ alcohol, smoking, and marijuana use on consumption of these substances by youths in grades 7–12. Overestimation of friend’s substance use significantly increases adolescent’s own use approximately 1 year later, and the estimated effect is robust across specifications including individual‐level fixed effects regression. The effect size is bigger for boys than for girls. 

Would this indicate that parents should strictly patrol who their children are friends with do to peer effects? Or at least who their friends think are negative influencers? What are your thoughts?





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What Does It Really Mean to Be 6 Weeks Pregnant?


Now that several states have passed bills that effectively ban abortion after a fetal heartbeat can be detected, the new laws are raising a lot of questions about early pregnancy and miscarriage treatments.

The fetal heartbeat can typically be seen on an ultrasound at around six weeks into pregnancy, but many women have no idea they’re pregnant at that time. So when do women typically realize that they are pregnant? And how often are pregnancies unplanned? We’ll explain all of this and more.

It sounds odd, but doctors measure the beginning of a pregnancy as being the first day of your last period. Why? They’re tracking the length of pregnancy using a nearly 200-year-old calculation called Naegele’s Rule, named after Franz Karl Naegele, the German obstetrician who is credited with creating it in the 1800s.

Here’s how it works: To figure out when a woman will give birth, doctors start with the first day of the woman’s last menstrual period, count back three calendar months and then add one year and seven days to that date.

The rule is somewhat confusing, because conception usually doesn’t occur until around 14 days after the first day of your period, assuming you have a 28-day cycle (which many women do not for a variety of reasons). The reason doctors still use the last menstrual cycle as a benchmark is because it is difficult to know exactly when the sperm fertilized the egg.

So when doctors say a woman is six weeks pregnant, it typically means the embryo started developing about four weeks ago.

The heart, which can be seen flickering on an ultrasound, is still maturing and cannot be heard until several weeks later.

Perhaps this is the simplest way to say it: Six weeks pregnant is two weeks after a woman misses her period.

Georgia, Kentucky, Mississippi and Ohio have this year passed so-called heartbeat bills, which effectively prohibit abortion after six weeks, and other states are poised to follow in their footsteps.

Most notably, Alabama’s governor recently signed into law the nation’s most restrictive abortion bill, which bans abortions at every stage of pregnancy and criminalizes the procedure for doctors.

According to the American College of Obstetricians and Gynecologists, one of the biggest concerns of their members right now is about how to interpret the scope and application of these laws in their practice. In some instances, that extends beyond the delivery of abortion care to questions about miscarriage treatments like dilation and curettage, which removes tissue from inside of the uterus.

Women are also wondering how miscarriage will be interpreted under the law. But it’s not entirely clear because of the way the laws are written.

For now, abortion is still legal because these laws have not yet taken effect. In addition, the legislation is expected to be challenged in court because of the precedent set by the 1973 Roe v. Wade Supreme Court decision, which says abortion is legal until the fetus reaches viability, usually at 24 weeks.

While there isn’t clear data as to when women typically find out that they are pregnant, Dr. Dana R. Gossett, the vice chair of obstetrics and gynecology at the University of California, San Francisco, said that in her practice she often sees women who don’t realize they are pregnant until after the six-week mark.

“Typically, clinical symptoms like fatigue and nausea don’t start until after six weeks,” Dr. Gossett said, though there are some women who are more sensitive to early pregnancy symptoms.

What’s more, women with irregular menstrual cycles might find it “especially challenging” to discover that they’re pregnant right away, Dr. Gossett said. “What are they supposed to do? Check pregnancy tests every four or five weeks?”

Dr. Sarah Horvath, a family planning fellow at the American College of Obstetricians and Gynecologists, agreed.

“Unless a woman is actively trying to get pregnant, she is unlikely to know that she is pregnant at six weeks,” she said.

Nikki Young, 42, who lives in Riverview, Fla., said she and her husband were surprised to discover eight years ago that she was pregnant.

“It was mixed feelings,” she said.

At the time, their second child was only about 1-year-old and she wasn’t actively monitoring her period.

“I didn’t really keep track of it that closely,” she recalled. But then, one day she noticed she was spotting and realized she had missed her period entirely. A home pregnancy test and a visit to the doctor confirmed that her third child was on the way.

Nearly half of pregnancies in the United States are unplanned.

A 2016 study published in the New England Journal of Medicine examined the rate of unintended pregnancy in the United States from 2008 to 2011 and found that 45 percent of pregnancies in 2011 were not planned. That’s 2.8 million unintended pregnancies, of which more than 40 percent would end in an abortion.

While the rate of unintended pregnancies declined from 2008 to 2011, the number of women who sought abortions for their unintended pregnancies changed very little. And in 2011, just like in 2008, unintended pregnancy remained most common among women and girls who were poor and those who were cohabiting.

“Lower-income women, rural women and women with limited access to health care will be disproportionately affected by these laws,” Dr. Horvath said. “Women of means will be able to travel to other states, or other countries, just as they did before Roe v. Wade.”



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