Links for Friday, December 29, 2017: food swamps, happiness from QI, and the persistence of ineffective treatments

So long, food deserts. Helloooo, food swamps

...food swamps had about four unhealthy options for each healthy one. Food swamps were a strong predictor of obesity rates—even stronger than food deserts were. The relationship between food swamps and obesity was especially strong in areas where people lacked both their own cars and access to public transportation.

See primary paper here.

Bob Badgett has thoughts on happiness and quality improvement

The Dunning-Kruger effect (which applies to docs) is the phenomenon in which difficulty in recognizing one's own incompetence leads to Inflated self-assessment. That is, the worse you are at your job, to some extent, the higher you rate your ability to do that job. Uplifting stuff when we think about management. 

Why do doctors keep recommending treatments that don’t work?

Tough question that Eric Patashnik does a good job of summarizing in a manageable length. We're all victims of our own status quo bias:

In the US, even modest reforms to use taxpayer money to fund research to learn what treatments work best, for which patients, have engendered controversy. Republicans famously charged that the establishment of the Patient-Centered Outcomes Research Institute (PCORI) through the Affordable Care Act, would lead to the creation of “death panels.” The politicians made that argument even though the agency only funds studies and was given no authority to make policy decisions or payment recommendations. PCORI has yet to have a significant impact on clinical practice. It faces a sunset date of 2019, and its future remains unclear.

Should a pharmacist be a bigger part of your practice?

Conflict of interest disclosure here: I receive some grant funding indirectly that works to get pharmacists and docs into collaborative practice agreements (CPAs).

But if the video above makes you think your practice ought to be using more pharmacy brainpower, take a look at the video below on how to establish a CPA:

Follow-up on medical school rank and narcotic prescriptions

I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting. 

1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.

2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.

 3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.

4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.

I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.

But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):

UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here: http://bit.ly/2uLk2lY

Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this: 

Check the footnote. *slaps forehead*

So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it. 

The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via marginalrevolution.com

Links to health for Wednesday, August 9, 2017: Laennec and his stethoscope, rich people love endurance sports, the health of elite athletes, and mythical drug expiration dates

After Rene Laennec invented the stethoscope, he encouraged other doctors to make their own.

This is reminiscent of the way Banting and Best handled insulin: 

"...the first “sale” of insulin was for just $3 (Canadian), not for a vial, but the very intellectual property of the drug itself. Frederick Banting, Charles Best, and James Collip, the team that first discovered and refined insulin therapy, agreed to receive $1 each in exchange for giving their patent rights to the Board of Governors of the University of Toronto in 1923.

This was a bold move, and not without controversy at the time, according to an article posted by the University of Toronto Centre for Innovation Law and Policy. At the turn of the 20th century, it was considered beneath scientists and universities to patent medical innovation at all. However, Banting and company believed that they needed to patent their formulation of insulin to stop pharmaceutical companies from rushing to patent an inferior, less potent form of the drug. The university immediately gave pharmaceutical companies the right to manufacture insulin, royalty-free, and to improve upon the formulation and patent any subsequent improvements."

If only we saw such responsibility and modesty from drug manufacturers now.

But back to Laennec: it is strange that we continue to venerate the stethoscope 200 years after its invention, especially when we have rapidly evolving, already far superior equipment in the form of handheld ultrasound. As the folks at 99 percent invisible note, docs no longer routinely carry reflex hammers or pinwheels, but they still overwhelmingly carry stethoscopes. I do not. You can't auscultate an adrenal tumor, you know what I'm saying? Bedside ultrasounds are the future, period. They'll just reach full market penetration sooner in the US than in developing countries.

Why do rich people love endurance sports?

Brad Stulberg pontificates on why endurance sports are so popular among high-income people. 

"...data collected in 2015 by USA Triathlon shows that the median income for triathletes is $126,000, with about 80 percent either working in white-collar jobs—professions such medicine, law, and accounting—or currently enrolled as students."

Once upon a time, and still for a shrinking older population, golf was the sport that signaled wealth. But now, with the fuzziness that surrounds the measurement of effectiveness in the knowledge economy, endurance sports give white-collar workers a simple, quantitative way to measure progress. You run/swim/bike/ski faster or slower than you did the last time, period. And the pain doesn't hurt (pun intended):

“By flooding the consciousness with gnawing unpleasantness, pain provides a temporary relief from the burdens of self-awareness,” write the researchers. “When leaving marks and wounds, pain helps consumers create the story of a fulfilled life. In a context of decreased physicality, [obstacle course races] play a major role in selling pain to the saturated selves of knowledge workers, who use pain as a way to simultaneously escape reflexivity and craft their life narrative.” 

Link from marginalrevolution.com

Related: Are elite athletes healthy?

Answer: it's complicated.

The myth of drug expiration dates

A pharmacist finds a cache of drugs, unopened, all 30-40 years past their expiration date. He has them tested by a toxicologist. The result? All of the drugs--all of them--are still useable.

Congressman Earl Blumenauer (and his sweet bow tie) wants to reform the Farm Bill

Link from foodpolitics.com