What Ought We do? (Normative Ethics)
Normative Ethics is the area of philosophy dedicated to describing what is wrong and how we go about deciding so1. To arrive here, we have to assume some form of moral motivation, and accept some form of Metaethics that we have previously discussed. For example, if we want to be Utilitarians, we have to assume that there IS a reason to act morally AND we have to assume the Metaethics of Objectivism. Normative theories are compatible with only some Metaethical theories, so it’s worth checking whether a Normative theory that sounds correct is compatible with the metaethics you have decided upon.
Utilitarianism
A theory we have all heard about, and a word people use WAY too much, Utilitarianism is the ethical concept that maximizing good (in the form of pleasure/happiness) for the most people IS the greatest good. In the words of Commander Spock, “The needs of the many, outweigh the needs of the few, or the one.” It is a form of Consequentialism, the idea that the ENDs (rather than the means) are what should be used to judge a moral action. So for Utilitarianism, the END of “maximized good” is what we care about to determine the morality of an action2. This is a rather simple and, in some ways, intuitive method of judging morality. If I take an action that saves millions of lives, such as discovering insulin, that seems pretty good! If I do something that saves one life at the cost of many others, like ignoring all my patients for one who I like more, that seems bad. But as we will see, it is not so simple!
Pros
Let’s start with the benefits of Utilitarianism. There are two main types, ACT and RULE Utilitarianism. We will explore both here.
-ACT Utilitarianism
Bentham, the grandfather of this theory, thought that if we can create a “hedonic calculus” to weigh what action is best in a situation, and we have a net positive, then this outcome is morally desirable. This is ACT Utilitarianism3. Each action has a weight we can measure, based on the type of pleasure, the intensity of pleasure, the length of pleasure, etc. Then, you subtract the suffering from it, and decide via math if the action is good. This thought process is used in medicine frequently. When you spend a certain amount of time in a patient’s room, you are weighing if you can get to all of your other patients in time and give them good care as well, and whether you’ll have to stay later because of it and not be able to feed your dog in time. You are weighing the good of extra time with one patient (an ACT) against the consequences of doing so, and measuring the overall good.
-RULE Utilitarianism
John Stuart Mill, the prodigy who followed in Bentham’s footsteps, saw some problems with ACT Utilitarianism and decided to come up with RULE Utilitarianism. This system prescribes rules to follow on a broader scope, not allowing room for individual variance like in ACT Utilitarianism. Instead of saying, “This patient needs X amount of time”, you would say, “each patient gets 30 minutes total.” The appeal here is that people do not have room to make biased or poorly calculated incorrect judgements, and because we can apply broad-based laws on a systemic level to impose this “good,” thus avoiding justifying horrible actions “for the greater good” (we will see examples of this in the Cons section)3.
Essentially, a Utilitarian gets these two main options, ACT or RULE, with the goal of maximizing the good/pleasure for the greatest number of people.
Cons
Machiavelli, a man considered by many (but not all) to be a bad person, is famous for stating that “the ends justify the means,” something many fear about Consequentialist theories such as Utilitarianism.
-ACT Utilitarianism
Although there is seeming appeal to ACT Utilitarianism, it has some large flaws that need to be discussed. The largest hole in the theory is that of how we calculate actions. This “hedonic calculus” is impossible to create;and even if it did exist, how would you employ it for each action before you take them? But even if this was not an issue, we are faced with some serious moral dilemmas. If you have a patient who is healthy, should you kill them to harvest their organs for 8 other patients who are slowly dying? It would seem that this ACT is justified because 8 people’s suffering has ended, and only one person is lost. The intensity of those 8 people’s pleasure from being alive is massive, but the suffering of the dead person is quickly resolved because they are no longer alive. This not only seems wrong, but undermines the physician-patient relationship because no patient would ever feel “safe”, creating suffering for every patient under your care in the long term. You could argue that this threatens to throw off the calculus, creating more suffering long-term, and thus would no longer be justified. But then arises the question of how you would predict this, or calculate this? As you can see, it begins to unravel from multiple angles3.
-RULE Utilitarianism
Enter John Stuart Mill, who created RULE Utilitarianism to deal with these issues. As we have seen, the dissemination of a RULE avoids the individual discretion that can lead to an inability to calculate things. It also would allow us to make a rule that “no organs can be harvested from live patients,” which avoids the dilemma seen above, where that individual action may create more good but threatens long-term relationships and abuses the current patient you have. At first blush this seems great, but it is criticized as “collapsing into ACT Utilitarianism.” The series of rules or laws we create regarding what actions are/are not okay at its core seems to be ACT Utilitarianism. Another strong critique is that it allows the converse to be true for moral acts. Yes, we can make a rule that says “never harvest organs,” but we could make a rule that says “always harvest organs,” and RULE Utilitarianism would support this if we say this is the greatest good. You might think that this wouldn’t be good because it is causing suffering, and couldn’t be a rule. Maybe, but if we did it specifically to a population with nobody to grieve for them, and saved people with large social circles, the pleasure would surely outweigh the suffering. We can go either way depending on what we decide, which makes RULE Utilitarianism in some ways more dangerous than ACT Utilitarianism3.
-What is Pleasure?
One critique I saved for its own area is the argument over what is pleasure. This applies to both forms of the theory as a problem. How do we define this? And how do we decide that this is what is good? Even if it is good, why does maximizing overall pleasure mean it is the right thing? When I have a few too many drinks I’m much happier, so should I get drunk every night? There are answers for these attacks, but it’s worth pondering if you think these issues are not truly recoverable.
Let’s Sum It Up
One of the most common Normative Ethical theories, Utilitarianism is a simple and broad-sweeping ethical theory that offers easy guidance and an answer to the feeling that our actions’ ENDs seem to carry a lot of value. We can divide it into RULE Utilitarianism and ACT Utilitarianism, depending on if we want to focus on calculating the individual ACTs pleasure creation vs. broad-sweeping RULES and their overall pleasure creation. Although they seem simple and valuable on face-value, there are some large weaknesses that are exposed when explored further, some that threaten to make medicine a dangerous field to practice, risking exploiting patients under a moral justification of removing their autonomy, beneficence, and justice. This doesn’t mean they are wrong, but the Utilitarian has to come with some strong answers to solve glaring holes we can see.
Now that we have explored Utilitarianism, a form of Consequentialism, we are going to flip to the other side of Normative theories with Deontology, a theory that considers the action itself to hold morality, regardless of consequences. I hope to see you then!
References
]]>One topic in preventative medicine that I find interesting is colorectal cancer (CRC) screening. CRC is the third most common cancer diagnosis and the second most common cause of death from cancer in the general population.2 CRC screening is relevant starting at age 45 for most people. Many modalities of CRC screening exist, with colonoscopy considered the gold standard and other options including sigmoidoscopy, fecal immunochemical tests (FIT), and fecal occult blood tests (FOBT). However, none of these modalities are feasible unless you have basic access to health care, a private bathroom, clean running water, and more. As I consider the national screening guidelines, it seems clear to me that there is more nuance when applied to the homeless population, given already established disparities in access to care.
Hoping to become more familiar with CRC in people experiencing homelessness, I turned to the literature. Limited studies exist on the topic but the literature available highlights concerning disparities. Recent studies have found that people experiencing homelessness have increased mortality from CRC and are diagnosed with more severe stages of CRC than those in the general population.3-4 Regarding screening, studies in the US have identified significantly lower rates of CRC screening in the unhoused population compared to the general population, with differences of up to 25% depending on the study, although these may still underestimate the true disparity.5-10
Why is that? Is it because CRC screening may not be a priority for patients among other more pressing health and social needs? Are barriers to care or lack of private spaces to complete bowel prep or stool tests the issue? Would it be futile to screen for CRC since obtaining the needed treatment may be infeasible?
Limited studies exist on perceptions of cancer screening among the homeless population. Two studies that explored this found that unhoused individuals actually had positive attitudes towards cancer screening in general, were concerned about cancer, and considered cancer screening to be a priority, despite established barriers to screening.5,11 This suggests that unhoused individuals may in fact value screening, and that attitudes towards screening seem less likely to be the driving factor of disparities.
The disparities in CRC screening rates may therefore be more attributed to barriers to screening. The existing literature suggests that multiple barriers to CRC screening exist, a fact that many of us who have worked with this population would not find surprising. These include lack of stable housing, access to consistent care, private bathrooms, transportation, accompaniment to appointments, communication methods, and mental health conditions.8-9,12-16 Interestingly, lack of provider counseling about CRC screening was also found to be a barrier, likely due to providers’ perceptions and implicit bias of patients’ need, willingness, or ability to complete screening.8-9,13-14,17
Several interventions to address barriers to CRC screening are proposed in the literature, including increasing access to stable housing and private bathrooms, employing patient navigators and case workers, encouraging FIT or FOBT for primary screening rather than colonoscopy, improving patient education, mitigating provider misconceptions, addressing risk factors in the population, and implementing policy and societal changes.5,8,11,13,18,19 Stable housing represents the most overarching barrier as it leads to a sequelae of related social determinants of health, and efforts to address housing insecurity first may be most beneficial. Interventions to improve screening and outcomes require significant buy-in from multiple stakeholders. For providers, assessing the potential benefits of screening based on individuals’ circumstances and engaging in shared decision making are key. Ultimately, our healthcare system should strive to meet people where they are at and needs significant improvement to ensure more equitable care.
Link to the full literature review:https://docs.google.com/document/d/1NUvjeFm1PQw2ajHZLaSs3SQUMfIbACLfU4ZPxKEBuBM/edit?usp=sharing
Note: This was an independent project completed for educational purposes and does not aim to make any universal claims. The contents of the literature review are not to the quality standards of a systematic review that may be found in a peer-reviewed journal.
This case got me thinking about the concept of health equity and the myriad of barriers that patients face when accessing healthcare. We have been taught about this topic multiple times during the first two years of medical school, and third year is the time to see it in action. Sometimes, however, the healthcare system fails to address these barriers, which is when advocacy on our part becomes an integral part of the job.
In this case, it was a relief to see this patient become comfortable in interacting with us, his healthcare team, and other patients as he no longer worried about waiting for a video interpreter to help him; rather, an in-person interpreter was available at all times. Also, allowing periodic use of a personal phone in place of a landline telephone was important in facilitating communication between the patient and his family.
Health literacy is another aspect of communication that usually presents as a limiting factor for patients who do not speak English or come from a lower socioeconomic status (SES)/education background. In this case, the patient was a construction worker with limited health terminology and an added layer of a language barrier. While the use of simplified medical terminology usually bridges the communication gap between healthcare professionals and patients, it was more difficult to explain psychiatry terminology in ASL. For example, many times the patient described episodes of anxiety as “nerves,” which was initially difficult to comprehend until it was clear “nerves” simply referred to his symptoms of anxiety. Similarly, when describing the diagnosis of psychosis to the patient, the interpreter had to spell out the word first and then the psychiatry team explained the meaning to him directly. For that, the team and I spent multiple afternoons checking on the patient, sitting down with him, and explaining terms with the in-person interpreter available.
On his last day prior to discharge, the patient requested to speak with the team and myself. On a white board, the words “THANK YOU” in bold letters were written, along with him moving his hands in sign language indicating the same words as a form of appreciation. Although this patient’s experience was the first of many for me as a third-year student, it was one of the memorable experiences that inspire me to continue working on advocating for patients with disabilities and other healthcare disparities. This patient’s experience is not far from many other experiences I witnessed, and that makes me hopeful that we can make a positive impact in healthcare by caring about health equity and providing each patient the care they need.
For you the reader, I hope this story reminds you about the importance of health equity, understanding what it means, and applying it in the future on your journey to become a physician. I hope you remember this when you are treating a refugee patient with limited English and understanding of the American healthcare system, when you are taking care of a hospital patient from a lower SES who does not comprehend all the medical terminology used to describe their complex medical history, and when your patient tells you that they cannot follow up with surgery for tumor resection as they cannot afford the sliding scale fee (all of which are experiences I have witnessed myself).
]]>The visuals and descriptions in these texts predominantly feature ailments as they appear on lighter skin. This leads to a skewed perception of disease presentation, especially evident in dermatology. In this field, the appearance of conditions like rashes, lesions, or infections can vary significantly between darker and lighter skin tones. The failure to represent these differences adequately can lead to misdiagnosis or delayed treatment for Black patients. Such oversights can have serious, even life-threatening consequences.
Beyond skin conditions, the absence of Black representation cuts across various medical disciplines, from cardiology to oncology. This lack of diversity reinforces a narrow, biased view of medicine. It inadvertently positions white patients as the norm and marginalizes the experiences and health issues of Black individuals. Even the word cyanosis – which is used to denote a lack of oxygen in the body – assumes light skin as the default as darker skinned patients do not turn blue when they are oxygen deprived. It also fails to account for the unique socio-cultural and genetic factors that might influence the health of Black patients. This oversight ignores the broader context of systemic racism and social determinants that disproportionately affect their health outcomes.
This educational gap has dire implications in a healthcare system already riddled with racial disparities. Black patients often receive lower quality care and face higher mortality rates for numerous conditions. This disparity is exacerbated by a healthcare workforce that is not adequately trained to recognize and effectively treat conditions in Black patients. Such a gap perpetuates a cycle of inequity and mistrust in the medical system.
To remedy this, a comprehensive revision of medical curricula is imperative. Such a revision should go beyond the mere addition of images of Black patients. It should involve a fundamental rethinking of how medical education is structured. This change would ensure healthcare providers are prepared to competently serve a racially diverse population. It entails integrating a wide range of clinical presentations across different ethnicities and skin tones. It includes training in understanding the social and cultural contexts that impact health.
Additionally, the medical community must confront and actively work to dismantle the implicit biases that such a lack of representation fosters. This involves a commitment to ongoing education in cultural competence and anti-racism. Healthcare professionals need to be equipped to provide care that is not only clinically effective but also culturally sensitive and equitable. The inclusion of Black patients in medical textbooks is not a mere token of diversity. It is an essential step towards reducing systemic biases in healthcare and ensuring equitable care for all patients.
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]]>One of the most common complications of discectomy surgery is disc reherniation. The lumbar disc herniation recurrence rate post-discectomy ranges from 5-15% and is a large driver of reoperation.4
Disruption of the annulus fibrosus, the dense collagen structure that surrounds the proteoglycan-rich nucleus pulposus can occur following trauma or age-related spinal degeneration.5 Traditional microdiscectomy doesn’t involve repair of the annulus, which has led researchers to explore options for repair of the annulus fibrosus following microdiscectomy using combinations of adhesives, mesh devices, and tissue repair systems.6
A research group in the Departments of Orthopedics and Bioengineering at University of Pennsylvania published a research article in Science Translational Medicine in November attempting to address the shortcomings of the current state of technology surrounding annulus fibrosus repair. This was a combined in vitro and in vivo study to determine the efficacy of a nanofiber patch device with tension-activated microcapsules in its ability to repair the functionality of the annulus, while simultaneously reducing the downsides of inflammation due to the procedure.7
The tension-activated repair patches (TARPs) used in this study are designed to integrate into normal tissue using a scaffold-like nanofiber structure that can mimic the dynamic stability of the annulus fibrosus. Built into this scaffold are pockets of microscopic capsules that are designed to be released in response to tension and deformation.7 Inside the mechanically-activated microcapsules (MAMCs) is anakinra, a biologic drug that blocks the receptor for IL-1β, a key mediator of the inflammatory response.8
The homologous structure of the nanofiber patches, combined with the microcapsules of anakinra, showed great promise in the in-vitro results of the study. Through serial tensioning tests, the researchers found that drug delivery rate can be altered with small changes in the microarchitecture of the repair patches. They also discovered that MAMC-delivered anakinra inhibited the upregulation of matrix metalloproteinase-3 and lipocalin-2, demonstrating that anakinra attenuates catabolic signaling caused by IL-1β.7 Decreasing the downstream effects of IL-1β could potentially reduce back pain associated with disc injury, as well as preventing re-herniation.
Once the in-vitro study was complete, the researchers transitioned into an in-vivo study using a goat cervical spine model for annulus fibrosus tear, since goats have cervical spine morphology similar to humans. The researchers induced a full-thickness annular tear in the C2-3 and C3-4 levels of 8 goats, and then repaired one level with either the TARP+anakinra, or the TARP+control. The adjacent level was used as a nonoperative control.7
The researchers then used imaging and histological studies to assess the tissue at 4 weeks postoperatively. Overall, the TARP procedure helped retain the nucleus pulposus, reinforced the annulus fibrosus, and prevented disc-wide remodeling and tissue necrosis that’s seen following annular tear and disc herniation. The TARP+anakinra prevented inflammatory remodeling at the site of TARP implantation, which is a common reaction to foreign body implantation. The drug’s delivery also showed via histological analysis, as well as imaging, that disc architecture was similar to uninjured controls.7
The promise lies in the potential to restore the tensegrity of the dense annulus to pre-injury levels, while also preventing the inflammatory response associated with tissue injury and foreign body implantation. These findings suggest a potential solution to address the limitations inherent in traditional discectomy surgery.
Although these data are promising regarding the development of technology involved in annulus repair, there are many limitations of this technology that would likely manifest when translated to clinical use.
First, the TARP must be sutured in place, which presents many technical challenges, in addition to the added risks of increased operative time. Second, this study used a model for anterior disc herniations of the cervical spine due to the easy access in the animal model that they used. The vast majority of disc herniations occur in the posterolateral aspect of the intervertebral disc, where the annulus lacks structural support.9 The added technical challenge associated with accessing this area of the spine may lead to challenges that outweigh the benefits of the technology.
The last consideration to be made involves the researchers’ model of disc herniation. The protocol required direct repair with the TARP immediately following the induced annular tear. It is important to highlight that most individuals attempt conservative measures (i.e. physical therapy or injections) before progressing to surgery, however, this model could be most useful in the population of patients with acute spinal cord injury following disc herniation. The data in these patients suggest early operation is preferred,10 and could be applicable to the conditions of the study highlighted in this paper.
Regardless, the findings out of UPenn’s orthopedics department are promising for the technology surrounding annular tear repair following discectomy. Further studies are imperative before making assumptions about the application of this technology in humans.
Aljoghaiman M, Martyniuk A, Farrokhyar F, Cenic A, Kachur E. Survey of lumbar discectomy practices: 10 years in the making. J Spine Surg. 2020;6(3):572-580. doi:10.21037/jss-20-519
Daly CD, Lim KZ, Lewis J, et al. Lumbar microdiscectomy and post-operative activity restrictions: a protocol for a single blinded randomised controlled trial. BMC Musculoskeletal Disorders. 2017;18(1):312. doi:10.1186/s12891-017-1681-3
Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine (Phila Pa 1976). 1996;21(15):1777-1786. doi:10.1097/00007632-199608010-00011
Shimia M, Babaei-Ghazani A, Sadat BE, Habibi B, Habibzadeh A. Risk factors of recurrent lumbar disk herniation. Asian J Neurosurg. 2013;8(2):93-96. doi:10.4103/1793-5482.116384
Tenny S, Gillis CC. Annular Disc Tear. In: StatPearls. StatPearls Publishing; 2023. Accessed November 24, 2023. http://www.ncbi.nlm.nih.gov/books/NBK459235/
Choy WJ, Phan K, Diwan AD, Ong CS, Mobbs RJ. Annular closure device for disc herniation: meta-analysis of clinical outcome and complications. BMC Musculoskeletal Disorders. 2018;19(1):290. doi:10.1186/s12891-018-2213-5
Peredo AP, Gullbrand SE, Friday CS, et al. Tension-activated nanofiber patches delivering an anti-inflammatory drug improve repair in a goat intervertebral disc herniation model. Science Translational Medicine. 2023;15(722):eadf1690. doi:10.1126/scitranslmed.adf1690
Lopez-Castejon G, Brough D. Understanding the mechanism of IL-1β secretion. Cytokine Growth Factor Rev. 2011;22(4):189-195. doi:10.1016/j.cytogfr.2011.10.001
Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. In: StatPearls. StatPearls Publishing; 2023. Accessed November 24, 2023. http://www.ncbi.nlm.nih.gov/books/NBK441822/10. Badhiwala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021;20(2):117-126. doi:10.1016/S1474-4422(20)30406-3
Or perhaps, mental and behavioral health’s relationship to technology hasn’t progressed quite as quickly as our own has. From its first addition in 1952 the Diagnostic and Statistical Manual of Mental Disorders, more affectionately known as the DSM, has attempted to perform the difficult task of standardizing the definitions and criteria for psychiatric conditions, including addictions. While such an effort is absolutely necessary, the challenge of trying to encompass all psychiatric ailments in a way that gives a framework for healthcare providers and patients alike to understand and communicate about the infinitely complex mess that is mental health is daunting. But because it undertook the challenge regardless of its difficulty, it has become the definitive lens through which healthcare and society at large view mental and behavioral disorders.
As such, with the most recent revision being published in 2022 (DSM-VTR), it would be reasonable to assume that contemporary behavioral addictions, especially related to the use of technologically oriented mediums, are reflected appropriately. Right? Or at least improved compared to its 2013 (DSM-V) publication? For crying out loud, that was back in Taylor Swift’s Red era.
I’m sure you see where this is going. Unfortunately, the DSM can be slow to adjust to the world around it. After all, homosexuality was included as a psychiatric disorder all the way up until 1974. If you were to look at the addictions that the DSM currently includes, you’ll find numerous descriptions and qualifiers of substances. However, when it comes to behavioral addictions, you will only find one, and that is gambling disorder. Look a little deeper, and you can find several more listed under Section III, the designated section for conditions requiring more research but that are not officially recognized. One of these Section III conditions is internet gaming disorder. That’s it. No mention of social media, no mention of internet usage at large, all while studies have clearly shown the issues of these mediums. Whether it’s social media usage contributing to anxiety disorders and comparison culture (especially in teenage girls) or pathological video game playing leading to neglected responsibilities and personal care (especially in teenage boys) there is no doubt that there is a point where these behaviors can cross over into addiction and become a problem. Yet the DSM remains non-committal to their existence.
The problem may not lie with the DSM at all, but in our research criteria used to qualify these disorders. We can use internet gaming disorder as an example of this, as it resides in the middle of its journey towards full recognition. It first appeared in the DSM-V in 2013, mostly arising from new research that had been performed in America as a result of previous research coming out of Asian countries. Researchers, just like all of us, had noticed an increase in video game usage across society. In fact, current estimates show that at least 1 person in 2/3rds of American households plays video games, and over 160 million adults play some sort of internet based video game. However, these studies used wildly different criteria to define, diagnose, and categorize pathological video game usage.
Herein lies the problem. The DSM lies between a rock and hard place, the rock being research clearly showing a problem with excessive participation in these behaviors, and the hard place being consistent research measures that can actually build a body of evidence that merits a formal disorder. If every study measures it differently, how can the field be sure that they are even studying the same thing? For this reason, internet gaming disorders inclusion in the DSM’s Section III back in 2013 was vital in that it gave a specific criteria from which future studies could standardize their own. As such, it appears to be on track to formal recognition in the next revision. Recognition means more research, which means more funding, which means better treatments and patient outcomes.
How we make standardized criteria more research friendly is difficult to say. One idea is a general classification of something akin to “behavioral addiction disorder” with basic addiction criteria that could apply to all behaviors and give researchers a basis to unify their studies and push topics forward towards more specific recognition. While not currently in place, it could be a great place to start. If nothing else, it has the potential to bring these patterns and findings in individual studies into a more centralized location, all with the long term goal of being formally recognized.
That way, at least when people Google things like “Is gaming/social media/internet addiction real?”, they won’t be met with the research equivalent of a shrug.
Alavi SS, Ferdosi M, Jannatifard F, Eslami M, Alaghemandan H, Setare M. Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views. Int J Prev Med. 2012 Apr;3(4):290-4.
Griffiths MD, van Rooij AJ, Kardefelt-Winther D, Starcevic V, Király O, Pallesen S, Müller K, Dreier M, Carras M, Prause N, King DL, Aboujaoude E, Kuss DJ, Pontes HM, Lopez Fernandez O, Nagygyorgy K, Achab S, Billieux J, Quandt T, Carbonell X, Ferguson CJ, Hoff RA, Derevensky J, Haagsma MC, Delfabbro P, Coulson M, Hussain Z, Demetrovics Z. Working towards an international consensus on criteria for assessing internet gaming disorder: a critical commentary on Petry et al. (2014). Addiction. 2016 Jan;111(1):167-75. doi: 10.1111/add.13057.
Petry NM, Zajac K, Ginley MK. Behavioral Addictions as Mental Disorders: To Be or Not To Be? Annu Rev Clin Psychol. 2018 May 7;14:399-423.
Rehbein F, Kliem S, Baier D, Mößle T, Petry NM. Prevalence of Internet gaming disorder in German adolescents: Diagnostic contribution of the nine DSM-5 criteria in a state-wide representative sample. Addiction. 2015;110(5):842–51.
What do you as the physician, or maybe the physician-to-be, do when your patient says, “Lung cancer? Me? How could that be? I’ve never smoked!” Those were the words of Dr. Alice Lee, an emergency physician in Mesa, AZ, and Clinical Assistant Professor at UACOM-P.
Unfortunately, Dr. Lee is not a unique case. When we first stumbled upon Dr. Lee’s remarkable story of her battle against lung cancer, we were surprised to hear about a rising trend of a very specific cohort of lung cancer patients that she is a part of: the Asian American female nonsmoker.
Lung cancer is the leading cause of cancer-related deaths in the US and worldwide and a leading cause of cancer mortality among the Asian American population.1 Although the number one risk factor for lung cancer is smoking, 10-20% of lung cancers in the US are in non-smokers. And if you were to look closely at the Asian American females diagnosed with lung cancer, 57% are never smokers.
In recent years, scientific evidence has shed light on the alarming rise in the incidence of non-small cell lung cancer (NSCLC) among non-smoker Asian females. Studies have identified mutations in the EGFR and ALK genes as significant drivers of NSCLC in non-smoker Asian females, contributing to a higher susceptibility to the disease.3 Epidemiological data has also revealed a higher prevalence of EGFR and ALK mutations in the Asian population compared to other ethnic groups, underscoring the importance of tailored screening and treatment approaches.3,4 This concern prompts a reevaluation of lung cancer prevention and early detection strategies, emphasizing the need for increased awareness, genetic testing, and targeted therapies to address this specific and growing public health issue.
Currently, the United States Preventive Services Task Force (USPSTF) recommends annual lung cancer screening with low-dose computed low-dose computed tomography (LDCT) for individuals aged 50 to 80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years.5 However, these guidelines do not capture the specific risks faced by the Asian American Native Hawaiian Pacific Islander (AANHPI) population, especially this cohort of non-smoker Asian females, putting them at higher risk of a later diagnosis. There is a need to advocate for more inclusive and targeted recommendations that address the unique challenges and risk factors faced by various communities, including AANHPI individuals.
Dr. Lee was one of the very few, fortunate patients to be diagnosed at the disease’s early stages and receive curative treatment. She was treated with a right upper lobe lobectomy in May of 2021 and continues treatment with Tagrisso, a specifically targeted therapy against EGFR-positive NSCLC that was identified on genetic testing. However, many are not as fortunate.
A story we would like to highlight is that of the late Dr. Patricia (Trish) Hom, MD, MPH, who passed away at the young age of 40. Just three days after finishing her rigorous OB-GYN residency at Harbor-UCLA, Dr. Hom was diagnosed with Stage IV ALK-positive lung cancer. No longer able to practice medicine, Dr. Hom became an advocate for lung cancer research and became a member of the UCSF’s Female Asian Never Smokers (FANS) study, collecting data from Asian American women in the Greater Bay area and investigating the factors leading to lung cancer in this population.
Across the country, there is another study being conducted at NYU Langone called the New York Female Asian Nonsmoker Screening Study (NY FANSS) with a similar objective. It also offers up to three annual and free low-dose CT scans (LDCT) to screen for lung cancer in Asian American female non-smokers. Both studies hope to identify new prevention methods as well as early diagnosis and treatment options for Asian women. However, this is only the beginning of uncovering the nuance of this glaring cancer health disparity.
The battle against undiagnosed lung cancer within the AANHPI population is a silent but critical one. Both Dr. Lee’s and Dr. Hom’s stories have inspired and motivated us to raise and spread awareness regarding the risks of NSCLC in this Asian American female nonsmoker population. We hope to address the challenges, advocate for change, and ultimately save lives by empowering patients to take control of their health through early screening and preventive measures.
We are excited to announce that Dr. Alice Lee will be giving a talk in November to share more about her inspiring journey and raise awareness about undiagnosed lung cancer in the AANHPI population. We invite everyone, from medical professionals to community members, to attend this event and join us in our mission to make a difference in the fight against lung cancer.
For some background, my CCE clinic recently was purchased by a large healthcare group who is slowly infiltrating outpatient care across the nation. The clinic was told that it would make things more efficient and increase patient care, a beautifully wrapped lie. The clinic now embodies the growing and underdiscussed problems in outpatient care, as nationwide private practices are being bought up and turned into money pumps, which, unsurprisingly, is not optimistic regarding its effect on patients2.
Whether it’s depersonalized call centers, exploiting patients to increase billable treatments, or maximizing the patient per day ratio, outpatient healthcare has become a machine through which patients are fed and cash is outputted, further driving doctors from people-healers to health-dealers: “I can fix you… for a price.”
Let’s start with the problem of call centers, an inherent part of corporatization of any industry. The most obvious issue is that this distances patients. Beyond being rude, it affects the patient’s healthcare by making them less likely to engage with the system. By perceiving they aren’t cared for, they are less likely to go in at all, undermining prophylactic care and encouraging them to wait until their condition worsens. Call centers also damage the patient-physician relationship. Any poor experience surrounding the office will be reflected onto the practitioner, regardless of the actual encounter. This means that even if patients are showing up to their appointments, they are less likely to do what the doctor asks, trust them, or refer others. A double-whammy, as not only is trust key in treating cautious patients, but word of mouth helps good doctors spread their practice. Lastly, call centers create a barrier to healthcare. From phone quality to call center background noise to the ineptitude of the personnel, I struggled to contact the office. Now imagine being 65, hearing impaired, and without our healthcare knowledge. This type of patient has little chance of getting taken care of timely or well. And this is the demographic who needs it most.
But it’s not just the call centers, as they’re only part of the money grabbing process, and certainly not the worst. The second issue is the exploitation of our patients. For example, my CCE’s new EMR alerts me every time a patient could be diagnosed or medically treated with something billable. Ignore overdiagnosis or overprescription, forget about side-effects of drugs that can be worse than the condition — all big companies want is more billables to bump the bottom line. Disappointing yet unsurprising, those who have been paying attention to this growing giant have also seen this vulgar behavior.3,4 Such blatant pimping of a vulnerable population manipulating both their sick status, as well as their reliance on physician advice.
Last and possibly worst, patient facetime has dropped off. Companies love to use the guise of it being because there is a doctor shortage, but the reality of shorter appointments is that it allows for more total money accrued per day. That caring relationship so necessary for a good diagnosis and patient trust? Gone. At our clinic we keep 15-minute appointments. Enough time for half an interview, a quick flash of light in their eyes, maybe listen to a heartbeat, and diagnose them with a good billable. At least a call center allows for possible treatment, and overprescribing can solve some problems. But what happens when your appointments are so short that you barely have time to introduce yourself? No relationship. Missed problems. Misdiagnosis. Collateral damage is abundant, but those patients will have no option but to return for treatment, so they’ll pay anyway. We are not alone either, as Braun et al. found a substantial increase (anywhere from 4.7% – 17%) in patients seen in dermatology private equity practices despite there being no increase in procedural volume1. This is not healthcare, or even sickcare: it is sick-maintenance, because that’s what keeps them coming back. To make matters worse, our patients know what’s going on, but tell me that everyone is being bought out and nobody else treats them differently. Companies have strong-armed this vulnerable population into accepting inferior treatment.
The final question then is, with these drawbacks, why are clinics like my CCE selling out? Do the practitioners not care? They do care, but they also are being put in an impossible situation, as their small private practice is thrown into the sea with the sharks circling. The first practices to sell didn’t have an ethical dilemma, but the remaining ones left must decide between financially competing against these growing giants, or selling and hoping that their new private equity overlord is somehow better than others. And who can blame them for taking lump-sums of cash? The financial instability of the pandemic left many in a precarious situation, while the pressures that lead to the practice of poor medicine are only now coming to light5. Perhaps some were simply unwise, but it’s too late to focus on that, we are now in damage control.
Detached and cold, modern healthcare has become a machine for wealth that doesn’t care about its patients’ feelings as it prioritizes net worth over human worth via distancing, exploitation, and rushing. What a horrible picture to look at, especially since we join medicine to help others. But this is exactly why we should look at that ugly picture. We have a war on two fronts, both in- and outpatient, and we can’t afford to only look at one, or assume the other to be better because there aren’t ridiculous stories of a $10,000 ER visit. This is the rise of the Clinic Cartel, and if we don’t pay attention, it’ll be too late.
Braun RT, Bond AM, Qian Y, Zhang M, Casalino LP. Private Equity In Dermatology: Effect On Price, Utilization, And Spending. Health Aff (Millwood). 2021 May;40(5):727-735. doi: 10.1377/hlthaff.2020.02062. PMID: 33939519.
Borsa A, Bejarano G, Ellen M, Bruch J D. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review BMJ 2023; 382 :e075244 doi:10.1136/bmj-2023-075244
Konda S, Francis J, Motaparthi K, Grant-Kels JM; Group for Research of Corporatization and Private Equity in Dermatology. Future considerations for clinical dermatology in the setting of 21st century American policy reform: Corporatization and the rise of private equity in dermatology. J Am Acad Dermatol. 2019 Jul;81(1):287-296.e8. doi: 10.1016/j.jaad.2018.09.052. Epub 2018 Oct 5. PMID: 30296541.
Matthews S, Roxas R. Private equity and its effect on patients: a window into the future. Int J Health Econ Manag. 2023 Dec;23(4):673-684. doi: 10.1007/s10754-022-09331-y. Epub 2022 May 23. PMID: 35604628; PMCID: PMC9125965.
Zhu, Jane M, and Daniel Polsky. “Private Equity and Physician Medical Practices — Navigating a Changing Ecosystem.” The New England Journal of Medicine 384.11 (2021): 981-83. Web.
Functioning as brokers between drug payers, manufacturers, and dispensers (pharmacies), they became a major force in the late 1980s with a business model that forced drug manufacturers to engage in price competition in drug categories that were, at the time, dominated by multiple, similar brand-name drugs.
So why did Ohio Attorney General David Yost call PBMs “modern gangsters,” and accuse them of having “absolutely destroyed transparency, scheming in the shadows to control drug prices on all sides of the market,” in a lawsuit earlier this year? PBMs play a critical role determining the price patients pay at pharmacies, and which medications they can access through their health insurance. Yet, how they negotiate these prices, and what they receive in return is information kept strictly behind closed doors.
Unpacking how PBMs influence healthcare access and cost is critical to understand why PBMs are such a vilified entity in health politics, so much so that both Republican and Democratic lawmakers support legislative reform.
For many consumers purchasing pharmaceuticals, their checkout price has little to do with the drug’s actual retail price. Often, they are charged a copay amount that is entirely dependent on the formulary tier that drug is placed on under their health plan. Thus, one way for pharmaceutical manufacturers to drive up sales for their prescription drugs is through influencing how their products are placed on health plans tiers.
PBMs negotiate “rebates” with manufacturers to secure their spots on formularies, but little is known how these rebates are negotiated or if these savings are actually translated to insurers, employers and consumers–as PBMs claim.
PBMs insist that this “bargaining” is necessary since the United States government plays little role in negotiating with drugmakers compared to other countries. These rebates are not publicly disclosed, leaving some to believe they’re just a way for PBMs to drive up their profits by taking advantage of their ability to set the rules drug makers and buyers have to play by.
The three largest PBMs, CVS Caremark, Express Scripts and OptumRx, manage 80% of all prescriptions in the U.S. CVS owns health insurer Aetna. Cigna purchased Express Scripts and United Healthcare purchased OptumRx. These mergers have further convoluted keeping track of how money is exchanged, and who stands to gain from formulary placements.
The oft-cited ideal used to justify our market-based health care system, where price competition drives innovation and keeps costs value based, seems further obscured considering how PBMs ultimately determine what medications are accessible to patients based on these secretive rebates.
There are concerns that this rebate system enables PBMs to favor placing drugs strategically on their formularies based on how much manufacturers can pay them, rather than more affordable alternatives. My previous article, “How Pharmaceutical Monopolies Cost Us All,” discussed how AbbVie’s biologic Humira enjoyed patent exclusivity beyond the 20 years normally given to drug developers through various mechanisms. Since 2016, five biosimilars were approved by the FDA but did not enter the market due to AbbVie’s aggressive litigation dedicated to protecting its exclusivity.
Now, seven years later, biosimilars for Humira are finally available and have the potential to save our healthcare system 9 billion dollars. The United Kingdom, Denmark and Poland have moved over 90% of their patients on Humira to biosimilars since their introduction in 2018. Kaiser Permanente expects to save $300 million in just this year from switching most of its Humira patients to Amjevita, which is 55% cheaper.
Considering the clear economic benefits to other health systems, why has most of the U.S. market seen such a slow uptake of Humira biosimilars? Perhaps it has to do with two of the three main PBMs, Express Scripts and OptumRx placing the significantly cheaper biosimilars in the same tier as Humira.
Coherus BioSciences’s biosimilar, Yusimry, listed for $995 ends up as the same cost to doctors and patients as Humira’s $6600, providing little incentive to switch. It is unknown what this means for future biosimilar manufacturers considering entering the market, but their viability depends on being able to sustain market shares. This seems futile when AbbVie is warning PBMs that if Humira is not offered on the same tier as biosimilars, it will cease paying them rebates.
Tactics like these are why both PBMs and large pharmaceutical companies benefit from finger pointing at each other whenever they are faced with political pressure from policymakers. Yet for the first time, Congress seems poised to pass legislation addressing some controversial aspects of the PBM industry. There is no illusion that this legislation will finally untangle the healthcare system that leaves us with higher prices for prescription drugs than anywhere else in the world. Nonetheless, it’s a start to draw light on an industry that has thrived from remaining deliberately obscured.
]]>While the pressures of this time of year challenge us, it truly is a special thing to not only go through the process of learning – not just about anatomy and block material, but also about ourselves and just how much we can accomplish when given the opportunity. The same goes for another rite of passage more ubiquitous than the back-to-back exams unique to the COM-P MS1 experience. One that I, and my fellow second-year medical student (“MS2”) classmates have come to face: the big, bad exam.
Step 1.
It feels fitting to have a clap of thunder and lightning cued up anytime someone brings up the first exam in the series of arduous licensing exams taken throughout the journey to become a MD. Regardless of the theatrics that come with acknowledging its existence, it is also the time of year where MS2s find themselves suddenly void of much clinical interaction after many months of community clinical experiences (CCE). As I said my own goodbyes to my CCE preceptor and staff with cupcakes and the exchanging of farewells/thank you cards, I watched as the family medicine practice I grew to adore was suddenly pulled from my grip and handed to the next MS1 in line.
Although many of us continue to have clinical experiences interspersed during the MS2 year, the coinciding pressure of Step 1 looming over our shoulders allows for fewer chances to engage with patients and “real life” medicine. As such, I find myself feeling somewhat hollowed out. Without a little sprinkle of patient interaction, I sometimes feel that the light at the end of the tunnel grows a little hazier.
Still, we stop by the third floor doctoring suites every other week to learn, to work with standardized patients and assure them that their chief complaints are valid – and more importantly, that their experiences are valid. There’s a mnemonic (like many other concepts in our textbooks and lectures) that we use to empathize with our patients: the NEURS.
In my mind, it’s a sacred concept – to empathize with a patient and encourage them to explore vulnerability with us, and in doing so, to establish a patient-(soon to be) physician relationship. Name and Explore the emotion, Understand, Respect, and Support the patient.
As I reflect back on my first year, while my classmates and I sat with our standardized patients during our earliest doctoring sessions and struggled to remember what each of the letters stand for, I remember why they serve as scaffolding on how to learn about our patients.
The NEURS framework is the foundation for the patient-physician relationship on which we all learn to stand on, strengthening it over time. As we begin to see patients outside of the walls of COM-P, many of us try our NEURS-ing skills on our own patients. The intent of the NEURS still stands, and as we progress through our journey, we begin to shape our own methods to hone in on the unique lived experiences of our patients.
As many of us momentarily pull away from the clinical realm with the priority of Step 1, I long for the opportunity to connect with patients. The likelihood of my annual wellness patient remembering my “how are you doing emotionally?” is fairly low, however, that does not stop me from thinking about how they trusted me enough to share their space of vulnerability, even if for just a moment. Although the hiatus from clinical medicine is brief, the knowledge and subsequent connections are forever – the case for the NEURS is just another rite of passage, whether we learn its value as an MS2, or as a PGY-20.
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